This breast cancer patient 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 reduction pattern to her skin to allow her to achieve elegant, but perky and youthful appearing breast mounds! She elected not to have nipples reconstructed because she loves how she can not wear a bra now and not worry about nipples constantly pointing out.