Muscle sparing free TRAM flap / creation of nipple and tattooing of nipple areolar complex. 49 yo 5′ 6″ underwent skin sparing mastectomy and same time breast reconstruction using muscle sparing free TRAM flap. Second stage – creation of the nipple and tattooing of the nipple areolar complex. Note symmetry in shape and volume of breasts and overall proportion with body habitus with a nearly imperceptible healing of her incisions within a year of surgery. Her abdominal wall was repaired with both an in lay and an only mesh to minimize the chances of future abdominal wall bulging or weakness.