Skin-sparing mastectomy with immediate reconstruction has become popular with patients because, compared with delayed reconstruction, it improves the cosmetic result, reduces cost and anesthetic risk, and in one stage completes most of the surgical treatment that the patient will ever require for treatment of her breast cancer. In the past, reconstruction was often delayed because of an unwarranted fear of locoregional recurrence or because the patient, having to live for some time with a flat chest wall, would be more appreciative of her reconstruction. This concept is now considered unacceptable, and many women regard this attitude as evidence of a lack of concern for the psychological impact of mastectomy. Provided that the breast skin is not involved with or close to the tumor, we prefer to perform the mastectomy with removal of only the nipple-areolar complex and the tumor biopsy scar. The mastectomy is otherwise the same as a standard modified radical mastectomy with removal of all breast tissue and a level I-II axillary node dissection. Our preference is to use the transverse rectus abdominis myocutaneous flap with a microvascular anastomosis because it provides a better blood supply, reduces abdominal wall muscle sacrifice, and eliminates the bulge from tunneling required by a pedicled flap. Using the skin-sparing technique with immediate reconstruction in 545 patients with early-stage breast cancer, our overall incidence of regional recurrence was 2.6%. Of 95 patients who were followed for > four years, the recurrence rate was 4.2%. Regional recurrence after skin-sparing mastectomy is a function of the biology of the tumor and the stage of the disease and is not affected by the use of immediate reconstruction or skin-preservation mastectomy.