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BACKGROUND- Breast reconstruction today is commonly performed using prosthetic implants, autologous tissue, or both. The decision as to which reconstruction to perform is based on a number of factors including patient desires, co-morbidities, body habitus, and surgeon preference. Although distinct advantages among techniques have been reported, there are no studies to date that provide an objective comparison between autologous and prosthetic reconstruction in terms of size, shape, contour, and symmetry. The following study reports the application of three-dimensional (3D) imaging to compare the post-operative results between patients undergoing unilateral prosthetic or autologous flap reconstruction. METHODS- This outcomes study represents a retrospective analysis of 60 patients who underwent unilateral mastectomy with either TE-implant (n=34) or autologous free TRAM or DIEP flap (n=26) reconstruction between 2007 and 2010 (performed by two senior authors, MC and NK). Key patient demographics and risk factors were collected (age, BMI, smoking history, history of radiation, and total number of reconstructive surgeries). The Canfield VECTRA system was used to obtain 3D scans of patients during pre and post-operative visits (mean post-op day 469 and 471 for the TE-implant and autologous groups, respectively). Using Geomagic software, 3D models were constructed and the following parameters were analyzed: total breast volume, maximum anterior-posterior (AP) projection from the chest wall, and global 3D compare. RESULTS- The TE-implant and autologous groups exhibited no significant differences in mean age, BMI, or total number of reconstructive surgeries (TE-implant: 52.2±9.9, 23.9±3.7, 3±0.9; autologous: 51.3±9.8, 25.8±4.1, 3±1.4; p>0.05). The total volume difference between the unaffected and affected breast in the TE-implant group was insignificant at 27.1±22.2 cc (439.2±143.2 cc vs. 466.3±169.3 cc; p > 0.05) similar to the autologous group: 16.9±25.2 cc (449.3±188.3 cc vs. 466.2±205.8 cc; p > 0.05). In both groups, the reconstructed breast had a larger volume compared to the contralateral unaffected breast. Both the TE-implant and autologous groups achieved anterior-posterior projections that were similar between the unaffected and the affected breast (TE-implant: 72.5±18.6 mm vs. 71.7±20.5 mm, autologous: 63.7±23.1 mm vs. 59.3±21.9 mm; p > 0.05). Lastly, both groups produced similar asymmetry scores based on global 3D comparison (2.24±1.5 mm difference in the TE-implant group, 1.9 ±1.3 mm difference in the autologous group) with no statistically significant differences among them (p > 0.05). CONCLUSION- 3D imaging demonstrates that both TE-implant and autologous reconstruction can achieve symmetrical surgical results relative to the unaffected breast with the same number of operations. Post-operative symmetry should therefore not be a primary consideration in the breast reconstruction algorithm, and should be based on other clinical parameters. The ability of 3D imaging to generate additional measurements of volumetric distribution and breast projection make it a promising method for further elucidating the effectiveness of these reconstructive techniques in achieving breast symmetry.