Background: Racial disparity continues to be a well-documented problem afflicting contemporary health care. Because the breast is a symbol of femininity, breast reconstruction is critical to mitigating the psychosocial stigma of a breast cancer diagnosis. Whether different races have equitable access to breast reconstruction remains unknown. Methods: Two thousand five hundred thirty-three women underwent first-time autologous versus implant-based reconstruction following mastectomy. Information regarding age, smoking, diabetes, obesity, provider, race, pathologic stage, health insurance type, charge to insurance, and socioeconomic status was recorded. Established statistics compared group medians and proportions. A backward-stepwise multivariate logistic regression model identified independent predictors of breast reconstruction type. Results: Compared with whites, African Americans were more likely to be underinsured (p < 0.01), face a lesser charge for reconstruction (p < 0.01), smoke (p < 0.01), have diabetes (p < 0.01), suffer from obesity (p < 0.01), live in a zip code with a lower median household income (p < 0.01), and undergo autologous-based reconstruction (p = 0.01). On multivariate analysis, only African American race (OR, 2.23; p < 0.01), charge to insurance (OR, 1.00; p < 0.01), and provider (OR, 0.96; p < 0.01) independently predicted type of breast reconstruction, whereas age (OR, 1.02; p = 0.06) and diabetes (OR, 0.48; p = 0.08) did not. Conclusions: African American race remains the most clinically significant predictor of autologous breast reconstruction, even after controlling for age, obesity, pathologic stage, health insurance type, charge to patient, socioeconomic status, smoking, and diabetes. Future research may address whether this disparity stems from patient preferences or more profound sociocultural and economic forces, including discrimination.