Background <p>Breast reconstruction is a fundamental procedure for patients with breast cancer. Reports suggest that autologous reconstruction provides greater psychological improvement and higher patient-reported satisfaction than implant-based reconstruction. However, objective evidence on psychiatric outcomes remains limited.</p> Objective <p>The study primary aim was to assess new psychiatric disorders in patients undergoing autologous versus implant-based breast reconstruction surgery.</p> Methods <p>A retrospective cohort analysis was conducted using the TriNetX Global Collaborative Network. Patients aged &gt;18 years who underwent breast reconstruction were divided into two cohorts: the first of patients who underwent autologous breast reconstruction surgery, and the second of patients who underwent implant-based breast reconstruction. Propensity score matching (PSM) was applied to balance demographic and clinical variables. Primary outcomes included new diagnosis of anxiety, depression, psychotic, mood, personality, eating, and behavioral disorders within 6 months to 5 years of surgery.</p> Results <p>After 1:1 PSM, both cohorts consisted of 14,805 patients. Within 5 years of surgery, the incidence of new psychiatric diagnosis was similar between autologous and implant-based cohorts. No significant differences were observed for anxiety (<i>p</i>=0.135), depression (<i>p</i>=0.366), personality disorder (<i>p</i>=0.61), mood disorders (<i>p</i>=0.991), psychotic disorders (<i>p</i>=0.52), and behavioral disorders (<i>p</i>=0.149). These findings were consistent across the measured timeframe.</p> Conclusion <p>Autologous and implant-based breast reconstruction are associated with similar long-term psychiatric risks. The previous reported advantages in patient-reported outcomes do not translate to objective psychiatric measures, therefore patient-centered discussions regarding needs, preferences, and candidacy should guide reconstructive decision making.</p> Level of Evidence III <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>