The purse string technique for reconstruction of the nipple and areola provides both a tension-free reconstruction of the nipple and areola as well as reliable projection behind both the nipple and the areola. This technique is based on the periareolar approach to mastopexy, which has been criticized for creating an unsightly “herniation” of the nipple and areola through the purse-string closure. This same tendency is used to advantage in this technique for nipple and areolar reconstruction. This is the first technique to address projection behind the areola which is typically absent with techniques employing a skin graft for the areola. Tension at the base of the nipple has been implicated in the long term loss of nipple height. This novel method eliminates the spreading tension of the breast mass on the nipple by protecting the nipple flap within the permanent purse string suture around the new areola. The technique has been used to reconstruct 172 nipples in 138 patients since 1996 by a single surgeon. It has been utilized on patients with implant based (22), latissimus flap (9) as well as TRAM flap (112) reconstructions. Effective projection of the nipple has been maintained in 80% of procedures for greater than 3 years with some late loss following intradermal tattoo. This approach to nipple and areola reconstruction has the advantage of simultaneously creating both structures with desirable projection behind the areola while maintaining a tension free closure on the central nipple flap.