Breast reconstruction has developed hand in hand with breast oncological resection. The Halsted radical mastectomy was an extensive surgery which left patients with a sunken chest wall and minimal excess skin coverage. Contemporaneous reconstruction techniques were suboptimal and multiple surgeons sought a more robust tissue option. The first half of the 20th Century found Ombredanne fashioning a new mound with pectoralis minor muscle while use of tubed pedicled flaps from the abdomen or buttock were pioneered by Gillies. None of these reconstructive options were widely adopted as they were lengthy multi-stage processes, expensive and associated with significant morbidity to donor and recipient sites. The modern breast implant was developed by Cronin and Gerow in 1963 who recognised the resemblance of silicone gel within a plastic bag to a women’s breast. Initially adopted for cosmetic augmentation, Synderman and Guthrie first reported its use for breast reconstruction in 1971. Changes to mastectomy practices which challenged long established Halsted principles enabled widespread implant reconstruction. The advent of skin and muscle sparing mastectomies provided plastic surgeons with flexibility regarding implant position within the subcutaneous or submuscular plane. Issues with capsular contraction and skin necrosis remained a frustrating issue with limited management options. However, the last two decades have witnessed innovative developments which help to shape the breast pocket, optimally position the implant and assess mastectomy skin vascularity to best optimise the success of an implant reconstruction.