Surgeons performing breast reconstruction in previously augmented patients can either leave the preexisting implant in place and incorporate the implant into the reconstruction, or remove the implant, usually performing an implant exchange. The focus of this study is to identify indications for implant removal in previously augmented patients undergoing mastectomy with breast reconstruction. We performed a retrospective chart review of patients who underwent breast reconstruction from 1997-2007 at University of Alabama, Birmingham Medical Center. Of these patients, 54 had previous augmentation with silicone or saline implants. Twenty-two of these underwent bilateral breast reconstruction, making a total of 76 reconstructed breasts. Patients were followed for a mean of 2.1 years (range 0.1-5.1 years). The mean body mass index was 23.0 (range 18-30). Implants were explanted in all but one patient. Reasons for implant removal or exchange included subglandular position (n = 39), aged silicone implant (n = 50), rupture or leak (n = 24), implant exposure (n = 1), and infection (n = 1). Some patients had more than one reason for explantation. We recommend removal of preexisting implants for patients who have implants in a subglandular position, ruptures or leaks, site infections, implant exposures, capsular contractures, pain, indolent seromas, aged silicone implants, poor cosmesis, plans for or history of radiotherapy, and close proximity of tumor to implant. We also remove implants to respect patient preferences and to achieve symmetry in our reconstruction. Consequently, we find in our practice that most of previously augmented patients who undergo breast reconstruction will also undergo implant removal.