This paper is focused on whether an immediate breast symmetrisation procedure is beneficial when a patient undergoes contralateral breast resection plus an immediate free flap reconstruction for breast cancer. Free abdominal perforator flaps (DIEP) generally offer the highest postoperative satisfaction rates in breast reconstructive oncology. Possibly because in recent decades the world experience has been primarily with these types of flap. However, like many other domains of oncological reconstruction, the holy grail of single stage completion of surgery has been difficult to achieve in breast oncological reconstruction. This is because many teams prefer to wait until the reconstructed breast has declared its finite shape and size before committing to a symmetrising procedure. This study compared a series of immediately reconstructed patients that had concomitant symmetrising surgery or did not. Although the immediate symmetrising group was much larger than the delayed group, patients were relatively well matched for age, BMI and neoadjuvant oncological treatment. This suggests the authors had not ‘cherry picked’ the patients that had received immediate balancing procedures. Moreover, there was no significant difference in mean operative times or postoperative complication rates. This adds weight to the argument that immediate symmetrisation and free flap reconstruction does not require significantly more operative resource, whilst maintaining a predictable postoperative course. Of particular interest is the significant decrease in revisional symmetrising procedures observed when a patient does have an immediate balancing procedure. This is an encouraging finding and something that patient groups will welcome. Oncological reconstructive surgeons aim for single stage solutions to difficult problems, yet, we are unsure if patients really do psychologically suffer from protracted surgical treatment well after a cancer cure. A constant reminder of one’s cancer, by way of multi-stage symmetrisation is logically something that we surgeons feel is surely undesirable to our patients. This is pitched against the ever increasing desire for a perfect result. We are yet to have robust objective patient reported outcomes (PROMs) to indicate if multi-stage symmetrisations result is a better, lasting result. This valuable study combined with PROMs will shed further light on how breast oncology evolves in coming years.