Summary: The latissimus muscle continues to be a head to toe workhorse in free tissue transfer for coverage of large defects. Traditional full muscle harvest is performed in the lateral decubitus position which is frequently suboptimal or requires position change based on the recipient site and laterality. We present a multi-institutional case series of full muscle flap harvest from the supine position for a range of defects in 32 patients. The relevant operative setup and technique are described. In our experience, supine harvest has become the preferred open harvest technique compared to lateral positioning for both optimal exposure of the pedicle and reduction in operating time.