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Over the last decade, there has been a 12% increase in prophylactic mastectomy (PM) per year. The aim of the study was to analyze complication rates and associated risk factors in patients undergoing PM and reconstruction.We reviewed patients undergoing PM (contralateral and bilateral) from 2010 to 2015 at a single academic institution. Data on patient characteristics and postoperative outcomes were obtained. Postoperative complications were categorized into minor and major groups. We compared complication rates between autologous and alloplastic reconstruction. Patient characteristics were assessed using univariable and multivariable models.Reconstruction after PM was performed on 390 breasts over the study period: 214 underwent autologous and 176 underwent alloplastic reconstruction. When comparing autologous and alloplastic reconstruction, significant differences were seen between the number of immediate breast reconstructions (96.3% vs 48.9%, P < 0.001, respectively) and 2-stage reconstructions (0.5% vs 44.9%, P < 0.001, respectively). The overall complication rate was 15.9%: 14.6% were minor complications, and 6.9% were major. Autologous reconstruction compared with alloplastic reconstruction had a lower incidence of minor complications (11.2% vs 18.8%, P = 0.036), breast infection (1.9% vs 13.1%, P < 0.001), and breast seroma (2.3% vs 7.4%, P = 0.018), respectively. Risk factors for complications included age (≥65), obesity, American Society of Anesthesiology class (≥3), smoking, hypertension, anxiety, tissue expander (with acellular dermal matrix), and implant-only reconstructions.In our study, autologous reconstruction appeared to have a better complication profile than alloplastic reconstruction. Clinicians may potentially use this information to guide preoperative counseling of women considering PM and reconstruction.