Nipple reconstruction employing both grafts and local flaps has historically been a staged procedure. This paper presents a one-stage procedure using a local flap with immediate tattoo that has the advantages of high patient satisfaction and low cost. The procedure can be performed in a minor surgery suite with local or no anesthetic in 15 to 30 minutes. In this series of 100 nipples there has been only one partial necrosis, which was easily corrected with a "boost" procedure. Only 8 percent of patients required revision procedures in the office, and there have been no infections or wound complications. Patient satisfaction and compliance have been excellent because the procedure is fast and easy with minimal morbidity. Modifications in technique are presented, based on the type of breast reconstruction (implant versus flap), local scarring, and size and color of the opposite nipple-areola complex.