Having a history of BRCA positivity, this patient seeked Dr. Jacob Unger's opinion and experience with a need for bilateral mastectomy with reconstruction. She decided to undergo bilateral mastectomies and reconstruction. We performed a two stage reconstruction with pre pectoral based tissue expanders, followed by implant exchange and fat grafting. She had large, low breasts, so we performed a vertical reduction pattern to her skin to allow her to achieve elegant, but perky and youthful appearing breast mounds. She loves her new shape.