Aim To evaluate the usefulness of mammographic surveillance for asymptomatic patients and as a problem-solving tool in symptomatic patients with reconstructed breasts. Materials and methods The imaging records over 4 years identified 227 patients with a history of breast reconstruction post-mastectomy due to cancer. Clinical and imaging records were reviewed to evaluate the use of imaging in the follow-up management of these patients. Results Records showed that 116 (51%) of the patients identified underwent surveillance mammography of the reconstructed breast, in which one recurrent cancer was detected in an autologous tissue flap reconstruction (0.86% detection rate of non-palpable recurrent cancer), with a recall rate of 4%. One other patient had interval recurrence diagnosed following presentation with pain. Mammography of the contralateral breast only was performed in 111 patients. Fifty-four patients (24%) presented on 78 occasions with symptoms relating to the breast reconstructions, most commonly lump or swelling. Half of these patient episodes subsequently found no significant abnormality, and a further 29% had fat necrosis revealed on imaging. Four recurrent cancers were diagnosed. Conclusion There is insufficient evidence for recommending routine surveillance mammography for non-palpable recurrent cancer in the reconstructed breasts. Ultrasound and mammography are useful imaging techniques in the assessment of reconstructed breasts in the symptomatic setting. Fat necrosis is the most common benign finding on mammograms of reconstructed breasts, both in the surveillance and symptomatic groups.