In the past few years, endoscopic surgery has been applied to breast surgery to minimize the wound. We have performed endoscopic-assisted subcutaneous mastectomy and immediate breast reconstruction (EASM-IBR) since 2002. In later cases of EASM-IBR, we used a posterior approach to the breast tissue. EASM-IBR was performed in 21 cases. Ten patients underwent EASM by the advanced skin flap method, and 11 patients underwent EASM by the posterior approach. Surgical duration was 251 and 216 minutes, respectively. Intraoperative blood loss was 294 and 238 ml, respectively. Surgical duration tended to be shorter, and there was less bleeding with the posterior approach than with the advanced skin flap method. In the posterior approach, breast tissue is fully retracted through the wound as the dissection advances. It is a useful method for video-assisted surgery.