Nipple-sparing mastectomy (NSM) and reconstruction is challenging in ptotic patients with additional risk factors. Here, these problems are addressed with a staged strategy that extends NSM and reconstruction to patients with grade 3 ptosis and additional risk factors of diabetes, obesity, and macromastia. Three stages are used to perform a mastectomy, reposition the nipple, and reduce the skin envelope using the Wise pattern. This is followed by definitive implant placement in a final fourth stage. All patients successfully completed their reconstructions without a single instance of implant loss. Using a staged approach, NSM and reconstruction in high-risk ptotic patients is feasible. This is facilitated by using multiple surgical delays and insuring a well-healed skin envelope and optimal nipple position before any prosthetic device is placed.