Purpose: The national obesity epidemic is contributing to an increased proportion of overweight and obese breast cancer patients. Little is known about use of breast reconstruction among the obese, the motivating factors driving this decision, and surgical satisfaction. Our purpose was to describe patterns and outcomes of reconstruction among an obese breast cancer population. Methods: We performed a 5 year follow-up survey of mastectomy-treated breast cancer patients from the Los Angeles and Detroit SEER Cancer Registries (response rate = 65%). The outcomes of interest were receipt of reconstruction, type of reconstruction, motivating factors for surgery, and satisfaction with the surgical outcome. Patients were divided into three BMI categories: normal weight (BMI<25), overweight (BMI 25-30), and obese (BMI>30). Chi-square was used for analyses. Results: Obesity did not appear to be a barrier to reconstruction. Of the 384 mastectomy-treated patients, approximately one-third were normal weight, one-third were overweight, and one-third were obese. About half of women in each weight category received reconstruction, and there were no significant differences in the timing of reconstruction. There was a trend for overweight and obese women to be more likely to receive a TRAM reconstruction compared to normal weight patients (42% and 39% vs. 24%, respectively, p=NS). Motivating factors for reconstruction appeared similar for normal weight, over-weight and obese patients: 43%, 47%, and 43% wanted to feel whole again; 48%, 48%, and 51% wanted to avoid a prosthesis; 32%, 40%, and 35% wanted to feel less self-conscious during sex; and 32%, 33%, and 31% wanted to overcome the constant reminder of cancer, respectively. Satisfaction with surgical outcomes was similar across BMI categories; however, obese patients compared to overweight and normal weight patients were more satisfied with clothing fit (33% vs. 28% and 15%, p<0.01) and more likely to feel sexually attractive (30% vs. 21% and 15%, p=0.01). Conclusion: Obesity did not appear to limit access to breast reconstruction in either the immediate or delayed setting and was associated with an increased use of autogenous tissue procedures. Motivating factors for surgery and surgical satisfaction were similar among BMI groups; and interestingly, obese women were significantly more satisfied with the reconstruction outcome regarding clothing fit and sexual attractiveness. Surgeons may find these data helpful when counseling the obese breast cancer patient.