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Background: American Indian/Alaska Native (AI/AN) breast cancer patients undergo postmastectomy reconstruction (PMR) infrequently relative to non-Hispanic White (NHW) patients. Factors associated with low PMR rates among AI/AN women are poorly understood. The authors sought to describe factors associated with this disparity in surgical care., Methods: A retrospective cohort study of the National Cancer Database (2004 to 2017) identified AI/AN and NHW women, aged 18 to 64, who underwent mastectomy for stage 0 to III breast cancer. Patient characteristics, annual PMR rates, and factors associated with PMR were described with univariable analysis, the Cochran-Armitage test, and multivariable logistical regression., Results: A total of 414,036 NHW and 1980 AI/AN women met inclusion criteria. Relative to NHW women, AI/AN women had more comorbidities (20% versus 12%; Charlson Comorbidity Index ≥ 1; P < 0.001), had nonprivate insurance (49% versus 20%; P < 0.001), and underwent unilateral mastectomy more frequently (69% versus 61%; P < 0.001). PMR rates increased over the study period, from 13% to 47% for AI/AN women and from 29% to 62% for NHW women ( P < 0.001). AI/AN race was independently associated with decreased likelihood of PMR (OR, 0.62; 95% CI, 0.56 to 0.69). Among AI/AN women, decreased likelihood of PMR was significantly associated with older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size >5 cm, positive lymph nodes), unilateral mastectomy, nonprivate insurance, and lower educational attainment in patient's area of residence., Conclusions: PMR rates among AI/AN women with stage 0 to III breast cancer have increased, yet they remain significantly lower than rates among NHW women. Further research should elicit AI/AN perspectives on PMR, and guide early breast cancer detection and treatment., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)