Although reconstruction after mastectomy offers an opportunity for cosmetic rehabilitation that should make mastectomy more acceptable and contribute to overall rehabilitation, the procedure is relatively underutilized. The best cosmetic results usually come from breast conservation rather than from mastectomy and subsequent reconstruction, and most small (T0-T2) cancers can be treated by means of breast-conserving measures. The surgeon who is performing the mastectomy plays a key role in explaining reconstruction to the patient and encouraging her to consider the process. Surgeon- and patient-related factors contribute to under-utilization. Physician assessment of the results of reconstruction, particularly with use of implants, tends to be less favorable than that of the patient. Surgeons may overemphasize the inadequacies of the results and patients may be overwhelmed by the diagnosis and array of decisions that must be made. Immediate reconstruction poses little risk of treatment delay or limitation. Reconstruction after mastectomy does not interfere with follow-up for recurrence. Choices for reconstruction have been limited by the withdrawal of silicone implants from the market. The availability of reconstruction has encouraged the inappropriate use of mastectomy for low risk disease. Prophylactic mastectomies and reconstruction should be performed for appropriate indications. To be effective, prophylactic mastectomy must include the nipple areolar complex. The availability of genetic testing to define very high risk groups brings into question the adequacy of protection offered by this procedure. Whereas prophylaxis in humans for premalignant mastopathy appears to be nearly complete, mastectomy appears to offer little protection in a rodent carcinogen model. The effectiveness of mastectomy for prophylaxis in a genetically high risk human population is unknown.