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Postmastectomy breast reconstruction (PMBR) has evolved dramatically since it was first described by Vincent Czerny in 1895. The increasing numbers of mastectomy procedures and improved patient survival have placed an increasing emphasis on the aesthetic and psychosocial outcomes, prompting surgeons to develop more sophisticated methods to reconstruct the breast mound. Significant improvements have been made to existing implant and autologous methods of PMBR in recent decades in an effort to reduce donor site morbidity and complication rates and improve cosmesis. The limitations of contemporary methods of PMBR have directed research toward more novel techniques such as autologous fat grafting and adipose tissue engineering. The present review discusses recent advances in the evolution of contemporary approaches to breast reconstruction and the future directions of PMBR using adipose tissue engineering strategies.