Autologous breast reconstruction started with the use of a myocutaneous latissimus dorsi flap. The need for an additional silicone implant to obtain sufficient breast volume intensified the search for new flaps, resulting in the microvascular TRAM flap, which is currently considered the "gold standard" in autologous breast reconstruction. For patients who are not suited for this procedure or reject this treatment option, a modified extended latissimus dorsi flap was designed and used in 47 patients. Additional volume is obtained by including the scapular fat fascia, based on perforators from the cranial edge of the latissimus dorsi muscle. Flap survival was 100 percent in the series, and sufficient volume could be achieved in 42 patients. Main complications were seromas at the donor site (n = 9). The results demonstrate that in selected patients the extended latissimus dorsi flap provides an excellent alternative to a TRAM flap in reconstruction of small and moderate-sized breasts.