01Principles and purposeThe professional or clinical skill and the decisions it supports.
Reconstruction is a series of choices about treatment and life after mastectomy. A person may want a breast mound immediately, wish to avoid an implanted device, prioritise abdominal function or decide that further surgery has little value for them. These aims can conflict: an option that avoids one concern can create a different donor wound, recovery burden or need for revision. Shared decision-making brings the clinician’s assessment of feasible treatment together with the importance that the patient assigns to those consequences. It requires a reasoned comparison and a supported choice, including the possibility of no reconstruction.
The discussion begins before mastectomy when possible and continues as information changes. NICE recommends discussing immediate and delayed options, including those unavailable locally, and offering immediate reconstruction unless comorbidity rules out reconstructive surgery. The possibility of radiotherapy must be included in that discussion. Its effects differ between techniques, and the long-term result may be uncertain. Explain what is currently known, what awaits pathology or another assessment, and how that information could change the patient’s preferred sequence. A recommendation can help, provided its reasons are clear and the patient remains free to choose a reasonable alternative.
GMC consent guidance treats the dialogue as a professional responsibility extending beyond a form. Discuss risks that a person in this patient’s position would consider significant and risks that matter to this particular individual. A relatively uncommon functional problem may be especially important to someone whose occupation or caring role depends on that function. Conversely, a patient may accept substantial procedural burden for a benefit the clinician would not personally prioritise. Written information and photographs support the conversation; they do not demonstrate that its meaning has been understood.
Key points
- Ask what matters before recommending a reconstruction: appearance, sensation, recovery, donor-site function, device concerns and further procedures can carry different importance for each person.
- Discuss immediate and delayed reconstruction, reasonable implant and tissue options, an external prosthesis and no reconstruction. NICE says to offer reconstruction choices whether or not they are available locally; arrange an appropriate referral for an unavailable reasonable option.
- Explain the material benefits, harms and uncertainty in a form the patient understands, then check their understanding and voluntary preference. Possible radiotherapy changes counselling and planning; it is not an automatic reason to exclude immediate reconstruction.
- Revisit consent when the cancer plan, operative assessment, health or patient’s preferences change. Record the current choice, agreed contingency, responsible team and next review rather than relying on an earlier signature.
- Ask the patient how they want information and supporters involved. A relative’s concern about distress does not justify concealing information the patient needs for the decision.
- Check practical assumptions about travel, repeat visits and help during recovery before confirming the plan. A clinically suitable option may require coordinated support to be workable for this patient.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Ask what the person hopes reconstruction will make possible and what they most want to avoid. Explore everyday activities, caring responsibilities, work, intimate relationships and feelings about scars or devices with permission. Translate each priority into a question about the proposed procedure: whether another donor site is involved, what help may be needed during recovery, or whether repeat visits are acceptable. Avoid assuming that age, body shape or a wish for a good appearance establishes the same preference for everyone.
A patient may nod because the terms are unfamiliar, the information feels overwhelming or they do not want to disappoint the clinician. Ask them to describe the main differences in their own words and explain that this checks the explanation. If they confuse a temporary expander with the finished reconstruction or believe a flap restores normal sensation, address that particular misunderstanding. Difficulty with medical vocabulary alone is not evidence that the person cannot decide; use plain language and appropriate communication support.
New radiotherapy information, a complication risk identified at assessment or a change in home support can alter the balance. Ask whether the earlier priorities remain the same and distinguish a changed preference from a misunderstanding. Reopening the decision need not mean abandoning timely cancer treatment. The teams should identify the realistic time available, what can be decided now and what can be reconsidered after mastectomy, while avoiding pressure from an operating-list booking or an earlier signed form.
Ask whom the patient wants present, what information may be shared and how they want that person involved. A supporter can help remember explanations or ask questions, but their preferences do not replace the patient’s own decision. If a relative asks the team to conceal a material risk because it will be upsetting, explore the concern and speak with the patient about their information preferences. Ordinary distress is not a justification for withholding information needed to make the choice.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Establish the current clinical choices - Why
- Review the cancer operation, anticipated adjuvant treatment, operative fitness and reconstructive assessment so the consultation compares options that are clinically reasonable for this patient. Identify whether a specialist opinion is needed before excluding a technique.
- Interpretation and limitations
- Separate a medical limitation from a service limitation. The absence of a local flap service does not establish that a flap is unsuitable; conversely, an option available elsewhere is not automatically appropriate without assessment. Explain any clinical reason for recommending against a technique and the alternatives that remain.
- 02
Elicit goals and recovery resources - Why
- Ask the patient to identify and rank the outcomes and burdens that matter, including help at home, travel to appointments and the consequences of a longer recovery or donor wound. Use their own description in the record.
- Interpretation and limitations
- A list of preferences becomes useful when it changes the comparison. For example, avoiding a donor-site recovery may favour an implant for one person, while avoiding a device may make tissue reconstruction preferable for another. Check practical assumptions with the relevant team rather than promising a universal return-to-work interval.
- 03
Check the basis of risk information - Why
- Identify the source, population and time period for any numerical estimate used. Distinguish a broad published estimate from a local service outcome or an individual clinical judgement, and explain uncertainty where the evidence cannot predict this patient’s result.
- Interpretation and limitations
- When numbers are helpful, use a consistent denominator and time frame so options can be compared. A percentage without its outcome definition can mislead: needing a minor adjustment differs from losing a reconstruction. Do not invent precision or suggest that a satisfactory early result removes the possibility of later complications.
- 04
Verify understanding and information preferences - Why
- Ask what level and format of detail the patient wants, arrange an interpreter or accessible material when needed, and invite teach-back of the main options, important risks and next action. Check whether they wish to involve a supporter.
- Interpretation and limitations
- A preference for a plain-language discussion rather than detailed numerical tables can be respected while still explaining the nature and likely consequences of treatment, material harms and reasonable alternatives. Correct the identified misunderstanding and check again. If important uncertainty remains, arrange further support or review within the clinically available time.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseA recovery priority leads to a completed choiceA 44-year-old needing mastectomy is assessed as suitable for implant or abdominal tissue reconstruction. She is the main carer for her disabled child, has limited help at home and wants a breast mound while avoiding an abdominal donor wound.+
- 1The surgeon explains the cancer operation, immediate and delayed reconstruction, implant and flap options, a prosthesis and no reconstruction. The patient identifies the abdominal recovery and the burden of arranging care as more important than avoiding an implant. The team checks that her preference is based on the actual options rather than a belief that flap surgery is mandatory.
- 2They compare the expected course of the reasonable techniques, including scars, altered sensation, wound problems and further procedures. The clinician explains that an implant may later need revision and that radiotherapy, if indicated, could affect its result. The patient accepts these uncertainties and chooses the proposed implant pathway, subject to the operative tissue assessment.
- 3Using teach-back, she accurately explains that an implant avoids an abdominal donor site but does not guarantee a single operation or a breast with normal sensation. She initially expects unrestricted lifting immediately after surgery; the team corrects this and arranges a recovery discussion and additional help with her caring duties.
- 4The reconstructive review is completed, the chosen operation and agreed alternative if tissue cover is unsuitable are recorded, and the surgical team updates the booking. At the subsequent preoperative consultation she confirms the same choice, describes the contingency correctly and reports that the agreed home support is in place. The documented outcome is an informed, practical plan ready for surgery.
02Clinical caseNew treatment information changes the sequenceA patient who initially chose immediate implant reconstruction learns that chest-wall radiotherapy is likely. She now places greater importance on avoiding a device and asks about delayed tissue reconstruction, which her hospital does not provide.+
- 1The clinician explains what has changed in the cancer plan and how radiotherapy may affect reconstructive outcomes. Immediate reconstruction remains part of the discussion where clinically suitable; the new information is not treated as an automatic prohibition. The patient compares proceeding with the earlier plan against a delayed tissue approach and no reconstruction.
- 2She prefers mastectomy without immediate reconstruction while she obtains an autologous opinion. The team sends a referral to a reconstructive service, agrees the interim closure and prosthesis discussion, and updates the consent and operating plan so the previous implant booking is no longer the assumed choice.
- 3At the receiving consultation, donor assessment confirms a feasible tissue option. She explains its donor-site and recovery implications and elects to revisit timing after cancer treatment and recovery. The oncology and reconstructive teams receive the same documented plan, and a named service accepts responsibility for her follow-up. The referral and revised decision have occurred rather than merely being suggested.
03Clinical caseLess numerical detail with meaningful understandingA patient asks for explanations in everyday language rather than detailed risk tables and wants her sister present. Before the appointment, the sister privately asks the surgeon not to mention reconstruction failure because it may frighten her.+
- 1The surgeon confirms the patient’s own information preference and permission for her sister’s involvement. The patient wants to know the important possible outcomes but does not want a list of small percentages. The surgeon explains that a reconstruction can fail and that further surgery or a different result may follow, using plain language and offering numbers if she wants them later.
- 2They discuss reasonable alternatives and the risks that matter to her, including how another operation would affect her work. The sister helps her ask questions but does not choose on her behalf. The team does not omit the possibility of failure on the basis of the sister’s request or equate the patient’s preference against tables with refusal of essential information.
- 3The patient accurately describes the intended procedure, the possibility of failure and the alternative she would accept. She chooses to proceed and receives a short written account in her preferred format. At a planned follow-up call she confirms her understanding and asks one further recovery question, which the team answers and records. The communication approach has been checked against an observed response.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- After the discussion, record the patient’s goals, the reasonable options compared, relevant risks and uncertainties, the chosen route and any agreed contingency. Include what further assessment or referral is needed and who will contact the patient. A form without this decision context can leave the next clinician following an obsolete or misunderstood plan.
- Before surgery, check whether the patient still wants the planned procedure and whether new clinical information or practical circumstances affect that choice. Review a misunderstanding directly and document its resolution. Confirm that the operating team can see the current consent and the boundaries of any agreed alternative.
- At a later decision point, such as final pathology or completion of adjuvant treatment, explain information that changes the reconstructive options or expectations. Give the patient an opportunity to reconsider without assuming that a delayed choice is a commitment to later surgery.
- Following treatment, ask whether the result and recovery match what the patient understood and wanted, including function, comfort and body image. Explore dissatisfaction or regret without implying that another operation is always the answer. Feedback about an unexpected burden should inform both the patient’s follow-up and future counselling.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Recommendation and choice can coexist
A clinician can recommend a route and explain why it fits the person’s health and priorities. Presenting that reasoning openly helps the patient assess it. Pressure arises when alternatives or uncertainty are concealed, or when accepting the recommendation is treated as proof of cooperation.
No reconstruction deserves a concrete plan
Choosing no breast reconstruction still requires discussion of the planned closure, expected appearance, prosthetic options if wanted and follow-up. Do not describe the person as having refused cancer treatment because they declined reconstruction or later decided against a completion procedure.
Uncertainty must be located
Explain whether uncertainty concerns future pathology, tissue suitability, the need for radiotherapy or the eventual appearance of a chosen reconstruction. Identifying what will resolve a question, and what may remain uncertain, is more useful than a general statement that all surgery has risks.
The service pathway is part of the decision
Travel, repeat attendance and support arrangements can make an otherwise reasonable option difficult to pursue. Discuss these honestly and help coordinate referral or local follow-up. They are practical consequences to consider with the patient, not substitutes for a clinical assessment of suitability.
07Common pitfallsFrequent interpretation and management errors.
- 01
Treating a signature, a nod or agreement with the surgeon as a substitute for checking whether the patient understands the material differences between the available choices.
- 02
Using a generic complication list without asking which consequences matter to this person, or quoting precise percentages without a relevant population, outcome definition or time horizon.
- 03
Allowing local service availability, an operating-list booking or a relative’s preference to decide the reconstructive route without an informed choice by the patient.
- 04
Continuing with an earlier reconstruction plan after new treatment information or a changed preference without checking consent, updating the record and informing the responsible teams.