In women at high-risk for breast cancer, bilateral prophylactic mastectomy achieves a risk reduction of up to 95 percent. Provided that proper indications are adhered to and informed consent has been obtained, prophylactic mastectomy can be performed starting at the age of 25 years. As an option, in BRCA1/2 mutation carriers with hereditary breast and ovarian cancer, bilateral prophylactic ovarectomy and salpingectomy reduce the risk of breast cancer by 50 percent and the risk of ovarian cancer by 90 percent. In women of at least 35 years of age and without wish for child bearing, this means of surgical prevention is often suggested at present. The database on chemoprevention in premenopausal high-risk women remains to be defined and procedures are currently advised in conjunction with clinical trials only. As opposed to more radical ablative techniques, we favour subcutaneous mastectomy as a prophylactic means in women at high risk for breast cancer. It combines oncological safety and excellent aesthetic results if performed with the correct surgical technique. Both aspects are of fundamental importance to the often young and still healthy women with this indication who are confronted with the difficult decision for or against a prophylactic mastectomy.