Skin sparing left mastectomy with same time TRAM flap Breast Reconstruction and right breast reduction, creation of left nipple and tattooing of the new nipple and areola. 47 yo 5′ 7″ had previous breast augmentation and lift elsewhere complicated by bilateral breast tissue loss requiring breast reconstruction. The breast tissue was first debrided by another surgeon and she was referred to me for the reconstruction. Her initial photos are post debridement and wound healing. She had lost the left nipple and significant amount of glandular breast tissue as well as skin on her left breast whereas on her right breast she had significant amount of fat necrosis and hardening including areas behind and including the right nipple yet sparing the overlying skin envelope. The patient underwent staged left breast reconstruction – using a tissue expander first placed under full muscle coverage for her left breast in order to stretch the tissues to later accommodate a breast implant and create the nipple. Whereas for her right breast – elected to patiently monitor the healing of the deep tissues in the ensuing months as we expanded the left breast. During her second stage, she underwent exchange of the left tissue expander and replacement with a 400 cc high profile silicone gel smooth round breast implant and same time creation of the nipple. At her right breast, she required a major debridement of the residual scar tissue preserving her existing nipple and replaced the debrided tissue with a 450cc high profile smooth round silicone gel breast implant to achieve the present symmetry and contour. She may further need minor retouching for optimal symmetry and tattooing of her new left nipple and areola.