Bilateral muscle sparing free TRAM flap breast reconstruction – delayed reconstruction post previous mastectomy at left and same time reconstruction post skin sparing mastectomy at right / creation of nipples and tattooing. 42 yo 5′ 8″ had history of left sided breast cancer and had undergone previous mastectomy without reconstruction. Patient had suspicious changes at her right breast and hence elected to undergo right mastectomy and same time bilateral breast reconstruction. Patient underwent skin sparing mastectomy at her right breast and had bilateral muscle sparing free TRAM flap reconstruction. Note much larger skin paddle required to resurface the missing skin post mastectomy at her left side hence the different shapes of the skin paddles between the reconstructed right and left breasts. Post op patient has full “D” cup breasts – in proportion to her body habitus with a tight and firm abdomen. Patient had an in lay and an on lay mesh repair of the abdominal muscle donor site. Second stage – underwent bilateral nipple reconstructions and tattooing of the nipple and areolar complexes. Note post op symmetry and contour complemented by a shapely abdominal contour.