Aim: Is to evaluate skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) by the use of mid- TRAM 
(Transverse Rectus Abdominis Myocutaneous) flap (instead of conventional lower TRAM flap) with its added novel 
modification of inclusion and evertion of the umbilicus,as this is hypothesized to optimize aesthetic and therapeutic 
outcome. 
Methods: 15selected patients with early stage breast cancer with a mean age of 43.8 years operated from jan.2003 through feb.2004 by SSMwithIBR by the use of mid-TRAM flap with inclusion of the umbilicus which is everted to simulate the lost nipple.patients were followed up for 6-12 months and data regarding operative time ,blood transfusion,time of hospital stay,local wound problems,flap necrosis,fat necrosis,abdomenal herniation,local recurrence and cosmetic outcome were reported 
Results: there were no mortalities or life threatening morbidities,an average of 4hours operative time,with only 1unit blood transfusion and10days hospital stay. Only 1case of partial flap necrosis and 1with minimal fat necrosis.No cases of local or distant recurrences or abdominal herniation.good to excellent cosmetic results with longstanding protruding nipples were obtained and in no case remedial surgery on contralateral side done to achieve symmetry. 
Conclusion: This approach is safe,reliable,emotionally less traumatizing with excellent cosmetic and therapeutic outcomes and should be considered an alternative approach for insitu and early breast cancers.