Skin-sparing mastectomy and immediate autologous breast reconstruction in the macromastic patient poses a challenge to the reconstructive surgeon. Elliptical incisions encompassing the nipple-areola complex create unsightly scarring across the superior aspect of the breast and require a large, often color-mismatched skin paddle to remain on the transposed flap. Periareolar incisions leave excessive skin envelopes with limited access to recipient vessels necessitating additional incisions. Wise pattern incisions have been reported, yet all approaches have created a buried free flap which then may no longer rely on conventional monitoring techniques of Doppler ultrasonography and clinical observation. Presented is a modified technique obviating these issues, which has evolved from an institutional experience of over 600 cases of free flap breast reconstruction. The mastectomy is performed via a Wise pattern incision, and a free TRAM is anastomosed to the thoracodorsal system. The inverted ‘T’ incision is closed over the TRAM. A new nipple-areola location is marked and excised from the apex of the closed mastectomy flaps. The TRAM is deepithialized entirely except for a skin paddle which rests directly below the new nipple-areola location, which is then brought out and sutured in place at this location. This modification allows for conventional free flap monitoring, a defined areola structure, no color-mismatched skin paddles outside of the areolar space, no unsightly scarring along the superior aspect of the breast, and technical ease for access to recipient vessels. From 2001 to 2002, we have successfully utilized this technique in five macromastic patients. Four patients had a balancing contralateral mammoplasty reduction performed simultaneously. There were no instances of free flap loss or of mastectomy flap necrosis. Complications included one axillary seroma requiring drainage and one abdominal incision cellulitis requiring hospital admission. This modified technique is safe, aesthetically pleasing, and of technical ease for free autologous breast reconstruction in the macromastic patient.