Breast reconstruction after mastectomy is becoming more common despite the general trend toward breast conserving therapy with lumpectomy and radiation. Reconstruction at the time of mastectomy can be done safely and eliminates the disadvantages associated with a second operation under general anesthesia. There are also some psychologic benefits to immediate reconstruction. Autologous reconstruction with flap tissue usually is preferred by the authors. In a woman with small breasts or when autologous tissue is not available, a prosthetic reconstruction is an acceptable choice. The authors prefer the use of textured saline implants in a submuscular position. Nipple and areola reconstruction is performed at least 3 months later as an outpatient procedure under local anesthesia. In 216 consecutive patients with immediate reconstruction, the patients with autologous reconstruction with transverse rectus abdominis or latissimus dorsi flaps ranked their level of symmetry as well as their level of overall satisfaction significantly higher than did the patients with prosthetic reconstruction. Similarly, the surgeons ranked the results from the autologous reconstructions higher. In the patients who underwent autologous reconstruction, 6% had necrosis of a significant portion of the flap. Prosthetic reconstructions were complicated by infections, hematomas, and chest-skin necrosis, resulting in removal of the implant in a total of 8% of the patients in this group. Thirty-four percent of the patients received adjuvant chemotherapy, and the reconstructive surgery did not result in a delay of the onset of this treatment. The authors conclude that breast reconstruction is a safe procedure with an acceptable morbidity when done either as an immediate or a delayed procedure. Patient satisfaction rates are high, particularly with autologous reconstructions.