Breast reconstruction completion is the goal of the reconstructive process. Reconstruction completion may be defined as breast mound creation allowing the use of clothing without prosthetics or the stigmata of mastectomy. Creation of the nipple areolar complex (NAC) may also be considered reconstruction completion because many women do not feel like it is their breast again until the NAC in place. In normal body mass index (BMI) patients undergoing breast reconstruction, perioperative complication risk is similar between implant-based and autologous reconstruction. This is not the case in the obese women where breast reconstruction operations are associated with increased risk of perioperative complications. We hypothesize that perioperative complications may affect the eventual completion of reconstruction in the obese women. Our aim is to determine whether reconstruction technique affects the achievement of reconstruction completion in the obese women. An Institutional Review Board–approved retrospective study of consecutive obese women (BMI ≥30) who underwent mastectomy and implant-based or autologous reconstruction over a 10-year period was performed. Patient demographics, comorbidities, oncologic treatments, reconstructive procedures, and their complications were analyzed. Two hundred twenty-five women with 352 breast reconstructions were included with mean follow-up of 27 months. Seventy-four women underwent 111 autologous breast reconstructions and 151 underwent 241 implant reconstructions. Mean age of included women was 52 years. Mean BMI in the autologous group was 33 and 36 in the implant group. There were no differences between groups in terms of age and presence of medical comorbidities. Active tobacco use was noted in 5.4% of the autologous group and 14.5% of implant patients (P = 0.47). Chemotherapy, radiation, and delayed reconstruction timing were more common in the autologous patients compared to the implant group (P = 0.01, P = 0.09, and P < 0.0001, respectively). Minor and major complications occurred more frequently in the implant group compared to the autologous group (P ≤ 0.0001). Breast mounds were completed in >98% of autologous cases compared to 76% of implant cases (P ≤ 0.001). NAC creation was completed in 57% of autologous patients and 33% of implant patients (P = 0.0009). The rate of successfully completing the breast mound and the NAC is higher in the autologous patient group (mound: odds ratio [OR], 3.32; 95% confidence interval [CI], 1.36–5.28; and NAC: OR, 2.7; 95% CI, 1.50–4.69) compared to the implant group. Occurrence of a major complication in the implant group decreases the rate of reconstruction completion (OR, 13.0; 95% CI, 4.9–34.1). Obese women undergoing implant-based breast reconstruction are more likely to have perioperative complications, and 24% of these patients fail to achieve mound completion. Obese women who undergo autologous breast reconstruction are more likely to achieve breast reconstruction completion (both mound creation and completion NAC reconstruction) when compared to obese women who undergo implant-based breast reconstruction.