59 year with carcinoma of the breast requiring bilateral total mastectomies. Due to the large size of the patients breast, the nipple and areola could not be saved. A breast reduction incision pattern (Wise Pattern) was used to provide access for the mastectomy and reduce the overall amount of skin. Immediate reconstruction was performed with tissue expander and aceullar dermal matrix (Alloderm). Second stage reconstruction was performed four months later with tissue expander to cohesive gel silicone implant exchange and autologous tissue fat grafting. A second round of fat transfer was performed in conjunction with nipple reconstruction. This woman is shown 4 months after her final surgery with excellent symmetry and shape. Her breast size and shape fit her frame well and appear natural. She will now undergo nipple areola tattooing.