Background: Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors' experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, -focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to-examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results. Methods: A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor. Results: The authors' cohort included 1647 patients. Overall, 2023 nipple- sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors' cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated. Conclusions: The authors' data suggest that proper patient selection and wellexecuted operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics.