Persistent pain is a common but undesirable outcome of breast cancer surgery. With the increasing popularity of breast reconstruction after mastectomy for breast cancer, researchers have recently directed attention to the prevalence of intractable pain due to reconstructive surgery. However, available studies that examine factors associated with the development of postreconstruction pain are limited to clinical investigations that have been descriptive, retrospective, or cross-sectional in their study design. There is obvious clinical value identifying presurgical factors that are associated with increased risk for the onset of chronic pain after breast reconstruction surgery. This prospective study examined the effect of presurgical psychological distress and somatic preoccupation in predicting persistent pain after postmastectomy reconstructive surgery. Two hundred and ninety-five women seeking reconstruction at the time of mastectomy or delayed from prior mastectomy served as the subject pool. Surgical intervention included either expander/implant or autologous tissue reconstruction. Before surgery, subjects completed psychological inventories to assess levels of affective distress, somatization, depressive and anxiety symptoms, and somatic anxiety/preoccupation. At 1- and 2-year follow-up, subjects rated the degree to which they experienced problems with breast pain, abdominal pain, and back pain. Multiple linear regression analyses indicated that affective distress, depressive and anxiety symptoms, and somatization held significant association with abdominal and back pain at both 1- and 2-year follow-up. For breast pain, all the psychological measures predicted more severe pain at 1 year, but none retained significant association at year 2. Somatic anxiety had more variable relation to pain complaints. These data highlight pain morbidity as a potential negative outcome of breast reconstruction and the significant influence of affective distress and somatic preoccupation in the development of postreconstruction chronic pain. These data support continued investigation into the role of presurgical psychological screening and intervention for women seeking reconstructive surgery.