Synopsis
Conduct a reconstruction discussion that connects medically reasonable options to the patient’s priorities, checks understanding and ends with an enacted decision and a plan for revisiting uncertainty.
- 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.
Reasoning priorities
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.
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.
Worked reasoning
A 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.
- The 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.
- They 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.
- Using 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.
- The 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.