Beyond the Classic Latissimus Dorsi Flap: A Decision-Making Algorithm for Technique Selection in Complex Breast Reconstruction

Background: The latissimus dorsi (LD) flap remains a reliable option for breast reconstruction in irradiated, salvage, and non-microsurgical candidates. Despite the availability of multiple LD-based variants, practical guidance for technique selection remains limited. Methods: We retrospectively analyzed 40 consecutive LD-based breast reconstructions performed over 5 years at two Italian centers. Cases were categorized as classic LD, hybrid LD, extended LD, V-FALD, or KISS flap. Clinical variables, reconstructive setting, complications, and reoperations were described, and a decision-making algorithm was derived from institutional practice and literature integration. Results: The cohort was characterized by a high-complexity profile, with 36/40 patients (90%) exposed to radiotherapy and 22/40 (55%) treated in a salvage setting. Hybrid LD was the most frequently used technique, accounting for 23/40 cases (57.5%), followed by KISS flap in 6/40 (15%), extended LD in 5/40 (12.5%), V-FALD in 4/40 (10%), and classic LD alone in 2/40 (5%). Technique selection was primarily driven by skin-envelope adequacy, breast volume requirement, and the feasibility of a fully autologous reconstruction. Major complications occurred in 2/40 patients (5%), revision surgery occurred in 3/40 (7.5%), and no total flap necrosis was observed. Donor-site morbidity occurred in 10/40 (25%) of cases and was managed conservatively. Conclusions: LD-based breast reconstruction should be viewed as a versatile reconstructive platform rather than a single technique. A pragmatic algorithm may support surgical planning and help tailor the most appropriate LD variant to defect characteristics and reconstructive goals.