Muscle Sparing TRAM flap / creation of nipple & tattooing of areolar complex. Patient is a 60 yo with locally advanced Stage IIIC invasive lobular cancer of her right breast for she underwent Modified Radical Mastectomy, chemotherapy and radiation to her chest wall and axilla. Note the radiation induced skin changes. After completion of her cancer treatments, she underwent pedicled TRAM flap right breast reconstruction with same time symmetrizing left breast reduction. Several months later she also underwent creation of the right nipple and tattooing of the nipple and areolar complex.Note that besides the good contour shape and projection of the reconstructed breast, the previously irradiated appearance of the chest wall has also improved with time due to having a well vascularized flap (the TRAM flap) deep to the chest wall skin that aides in its healing and improving the blood supply or circulation of the overlying chest wall skin. In addition note the tight and firm abdominal wall contour as the abdomen is repaired with mesh to reinforce the core muscles’ strength and minimize the chances of having a lower abdominal wall bulging or a hernia in the future.