51 year old with breast cancer. She received chemotherapy before bilateral total skin and nipple sparing mastectomies. Immediate single stage direct to implant reconstruction was performed with cohesive gel silicone implants and acelullar dermal matrix (Alloderm). An extended periareolar incision was used for her reconstruction. The patient has good upper breast fullness and symmetry comparable to her natural breasts. She then underwent autologous tissue fat transfer (fat grafting) to the breast to improve symmetry and over contour. She is shown 4 months after her second surgery and is pleased with her results.