58-year-old female with breast cancer underwent bilateral prophylactic skin sparing mastectomy with immediate reconstruction. First stage reconstruction was performed with tissue expanders and acellular dermal matrix (Alloderm). A single horizontal mastectomy incision was used. She was fully expander during and after chemotherapy. The second stage consisted of placement of a permanent silicone implant with pocket revision for symmetry. She also received autologous tissue fat transfer (Fat grafting). She is shown 6 months after second stage reconstruction and is pleased with her results.