55-year-old female with breast cancer who underwent bilateral total skin sparing mastectomies is shown after breast reconstruction. A wise pattern skin excision (breast reduction incision pattern) was performed to reduce the amount of excess skin. Immediate first stage reconstruction using tissue expanders and acellular dermal matrix (Alloderm) was performed. The second stage consisted of placement of a permanent silicone implant with autologous tissue fat transfer. This woman is shown 5 months after second stage reconstruction and is pleased with her results.