Breast reconstruction following mastectomy can be reliably undertaken using many different techniques. Although excellent cosmetic results can be achieved without contralateral balancing surgery, many unilateral breast reconstructions require a balancing procedure on the contralateral breast in order to achieve symmetry; the ultimate goal in breast reconstruction. This article attempts to summarise the existing literature on the plastic surgical management of the contralateral breast. It also outlines the multifactorial and complex issues involved in the planning and undertaking of such surgery with illustrative examples. The implications for future oncological management and radiological surveillance following the procedure are also discussed in brief.