Nipple-sparing mastectomy is an option for patients fitting oncologic criteria and may improve cosmetic outcomes of breast reconstruction. When anatomical limitations exist, we propose the use of free nipple grafting, akin to reduction mammaplasty. This study is a retrospective review of patients having a nipple-sparing mastectomy and immediate reconstruction using free nipple grafting (N = 36 breasts). Average graft take was 93.6% with no nipples having complete graft loss. Four nipples (11%) lost all projection and 4 nipples experienced significant hypopigmentation requiring tattooing (11%). For those ineligible for nipple-sparing mastectomy due to anatomical limitations, free nipple grafting is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties and, more importantly, saves women a subsequent operation for nipple reconstruction.