Skin-sparing mastectomy with immediate breast reconstruction has shown to be oncologically safe while providing dependable aesthetic results. However, flap inset into the skin defect of the excised biopsy site and nipple-areola complex often results in a patchlike effect and transverse scars. By keeping the mastectomy incision solely around the areola, all breast skin can be preserved. Thus, in immediate breast reconstruction with replacement of the nipple and areola by a small skin island from a deepithelialized TRAM flap or latissimus dorsi muscle flap, the scar is kept at the natural border between areola and breast skin. Reconstruction of the nipple-areola complex further helps to camouflage the incision line. This may result in the best possible aesthetic outcome after mastectomy to date. The technique has been used in 17 breast cancer patients (intraductal cancer, n = 5; T1/T2 ductal cancer, n = 13) with good to excellent results. No local or distant recurrences have been seen; however, mean follow-up time is short (10 months). As the procedure of choice, a free TRAM flap was performed in nine patients for immediate reconstruction. The other eight patients were too slim for an autologous reconstruction; therefore, a latissimus dorsi muscle flap with a small skin island and a silicone implant were used. There were no major complications in either group. In contrast to traditional skin-sparing mastectomy, all breast skin is preserved with the periareolar approach. Therefore, special surgical expertise is required to ensure tumor free margins, especially with respect to the skin overlying the tumor. If these requirements are met, excellent results in breast reconstruction are amenable with adequate oncologic safety.