Unilateral muscle sparing free TRAM flap / creation of nipple and areolar complex / tattooing of nipple and areolar complex. 44 yo 5′ 5″ had previous reduction mammaplasty where despite preoperative mammography, on pathological examination, the right breast specimen had cancer. She underwent left breast reduction skin flap sparing mastectomy and same time muscle sparing free TRAM flap reconstruction. Stage two – creation of the neo nipple and areolar complex and minor revisions at each breast. Stage three – tattooing of the right nipple and areolar complex. Note post op symmetry between the right and left breasts and tight abdominal wall contour. Patient had both an in lay and an on lay mesh repair of the abdominal donor site to achieve long term support and prevent future weakness or bulging of the abdominal wall.