We have discussed the major controversies in the reconstruction of the breast. As trends in cancer ablative surgery have shifted toward breast conservation techniques, the reconstructive choices available to the plastic surgeon have evolved. Advances in oncology, adjuvant therapy, and surgical techniques have changed the defects left following ablative surgery. Patient preferences have also changed, with a greater number of patients presenting to the reconstructive surgeon having already decided the timing and type of reconstruction they prefer. We must continually remind ourselves that the best and least controversial option is the one reached through appropriate consultation among patient, oncologist, and surgeons.