Post mastectomy breast reconstruction continues to evolve in both timing and technique; however, multiple surgical procedures are usually required. The purpose of this report was to determine the number of secondary procedures required to complete the breast reconstruction and factors that influence this process. All patients who underwent breast reconstruction at Emory University Hospital between 1975 and 2000 were reviewed. The end point and inclusion criterion was completion to nipple reconstruction. Secondary procedures were determined per patient for either unilateral or bilateral reconstructions, and defined as any surgical manipulation of the reconstructed breast, contralateral breast, or donor site. The cohort was stratified by timing and method of reconstruction. Additional variables included risk factors, radiation therapy, and complications. A total of 888 patients completed the reconstructive process (738 unilateral and 150 bilateral). The average number of secondary procedures was 3.99 for unilateral, and 5.54 for bilateral. Delayed reconstructions had a higher number of secondary procedures in both groups. Transverse rectus abdominus musculocutaneous flap reconstruction tended to have more secondary procedures than implant or latissimus dorsi with or without implant reconstructions. Radiation therapy increased the number of secondary procedures in unilateral (3.9 versus 4.6, P < 0.001) and in bilateral reconstructions (5.7 versus 6.4, P = 0.032). The number of secondary procedures also increased exponentially with the number of risk factors (0-4), and patients with any complication had a higher number of secondary procedures for unilateral (4.5 versus 3.6, P < 0.001) and bilateral reconstructions (6.4 versus 4.5, P < 0.001). Secondary breast and donor site procedures were used as an outcome measure to formulate comparisons. Autologous tissue reconstruction required more secondary procedures, likely in part to donor site revisions. Delayed reconstruction, the need for radiation therapy, any complication, and more risk factors significantly increased the number of secondary procedures required to complete the reconstructive process.