Objective After nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction, patients with significant ptosis are at increased risk for nipple-areolar complex (NAC) necrosis. Attempts to salvage the nipple using inferior dermal pedicles have yielded unsatisfactory results. This study aims to evaluate complications using 2 unique methods of breast reconstruction using either a Wise incision with dermal infolding or batwing incision after NSM. Materials and Methods A retrospective chart review was conducted on all patients who underwent NSM and immediate implant reconstruction using the methods described by a single surgeon between 2016 and 2022. Outcomes were assessed by comparing average complications rates. Result Seventy-three reconstructions were performed after NSM in patients with ptosis. Sixteen reconstructions used a prior technique, Wise pattern with inferior dermal flap. Thirty reconstructions used the Wise incision with dermal infolding, while 27 other reconstructions used a batwing incision. For the Wise with inferior dermal flap technique, NAC necrosis occurred in 43.8%. In the cases in which the newer techniques were used, NAC necrosis occurred in 11.1% in the batwing group and 10% in the dermal infolding group. Other complications measured were within acceptable percentiles between both groups. Aesthetic outcomes were acceptable for most of the cases involving NAC necrosis. Conclusions A batwing pattern incision or a Wise pattern with a broad, infolded dermal pedicle is a more effective method of immediate reconstruction after NSM in patients with ptosis according to these findings. Nipple-areolar complex necrosis continues to be a major complication that is important to discuss with patients. However, these methods offer patients with ptosis the benefit of preserving a native NAC while allowing for simultaneous skin reduction during an immediate reconstruction.