Importance: Although the development of persistent opioid use after surgical procedures has garnered much attention in recent years, large-scale studies characterizing patterns of persistent opioid use among patients undergoing plastic and reconstructive surgery procedures are lacking. Objective: To assess the prevalence of immediate and long-term postoperative opioid use after plastic and reconstructive surgery procedures. Design, Setting, and Participants: In this population-based cohort study, patients who underwent 5 classes of plastic and reconstructive procedures (nasal, eye, breast, abdomen, and soft tissue reconstruction) between January 1, 2007, and December 31, 2015, were identified using IBM MarketScan Commercial and Medicare Supplemental research databases. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year preoperatively and postoperatively, had a second anesthesia event within 1 year postoperatively, and filled an opioid prescription within the year prior to surgery. Main Outcomes and Measures: Analgesic prescription patterns in the immediate postoperative period. The primary outcome was rates of persistent opioid use (opioid prescriptions filled 90-180 days postoperatively). The secondary outcome was rates of prolonged opioid use (opioid prescriptions filled 90-180 days postoperatively and again 181-365 days postoperatively). Explanatory variables included patient demographics, procedure type, and relevant comorbidities. Results: Of the 466677 patients who met inclusion criteria, 96397 (45.3%) were men, and the mean (SD) age was 46.8 (17.7) years. Furthermore, 212387 (54.6%) of the patients filled prescriptions for postoperative analgesics, with 212387 (91.5%) of analgesic prescriptions filled being for opioids. Persistent opioid use occurred in 30865 (6.6%) patients (5.1%-13.5% across procedure classes), while prolonged opioid use occurred in 10487 (2.3%) patients (1.7%-5.6% across procedure classes). Patients who filled prescriptions for opioids in the perioperative period were significantly more likely to exhibit persistent (odds ratio [OR], 2.87; 95% CI, 2.80-2.94) and prolonged (OR, 2.90; 95% CI, 2.77-3.02) opioid use than those who did not fill perioperative opioid prescriptions, with the greatest odds for persistent use found in patients who underwent breast (OR, 4.36; 95% CI, 4.10-4.63) and nasal (OR, 3.51; 95% CI, 3.30-3.73) procedures. On multivariable logistic regression analysis, independent risk factors for persistent and prolonged opioid use included perioperative opioid use, procedure type, and prior-year mental health (depression and anxiety) and substance abuse diagnoses. Conclusions and Relevance: Given the significant risk of persistent opioid use after plastic and reconstructive procedures, it is imperative to develop best practices guidelines for postoperative opioid prescription practices in this population. Level of Evidence: NA.