Muscle sparing free TRAM flap / contralateral breast symmetrizing augmentation / creation of nipple areolar complex. 40 yo 5′ 6″ with right upper outer quadrant breast cancer underwent lumpectomy – given the resultant breast deformity preferred to undergo completion mastectomy and reconstruction instead of radiotherapy due to the worsening deformity expected post irradiation. Patient underwent a muscle sparing free TRAM flap with an in lay and an on lay mesh repair of the abdominal donor site. She returned to riding horses within eight weeks post op. Second stage – she underwent symmetrizing (left) breast sub pectoral augmentation with 200 cc moderate profile saline implant to achieve better symmetry and recreation of the left breast nipple and areolar complex.