Reconstructive Surgery After Cancer: How UK Patients Are Referred

For many people, the most frightening moment in a cancer diagnosis is the one before anyone mentions surgery. Then comes a second worry, which is what the face or body will look like afterward. In the UK, the route from a worrying lesion to reconstruction follows a defined pathway, and knowing it helps patients feel less lost.

Who plans reconstruction

Reconstruction after cancer surgery is the work of plastic surgeons, often alongside dermatologists, head and neck surgeons and oncologists. In skin cancer, the person who removes the tumour and the person who rebuilds the area may be the same or may work as a pair.

The practice of Jonathan Dunne, consultant plastic surgeon, describes expertise in skin cancer surgery, eyelid, nose and ear reconstruction, Mohs surgery reconstruction, head and neck surgery and sentinel lymph node biopsy. It also says he is lead clinician for the Imperial Skin Cancer Service and founded the Imperial Facial Reconstruction Centre, a multi-specialty collaboration.

Facial reconstruction is demanding because the face carries function and identity. An eyelid must close, a nostril must stay open and an ear must hold its shape, and each of these must be rebuilt without losing the person's appearance. That is why many centres run joint clinics where the cancer surgeon and reconstructive surgeon plan together.

How suspicion becomes a referral

Most patients first see a GP. Macmillan Cancer Support's rapid referral guidelines for skin cancer, which summarise the NICE suspected cancer guideline, explain how GPs decide urgency. For a lesion that raises the suspicion of squamous cell carcinoma, they advise considering urgent referral for an appointment within two weeks.

For a lesion that raises the suspicion of basal cell carcinoma, the guidance suggests considering routine referral, and only considering an urgent appointment if there is concern that a delay may have an unfavourable impact because of the location or size of the lesion. Suspected melanoma follows a separate suspected cancer pathway, with its own criteria.

In practice, the GP examines the lesion, sometimes with a dermatoscope, and refers to a dermatology or plastic surgery skin cancer service. Patients who are worried and have not been seen should ask for an appointment instead of waiting.

Do not wait for a lesion to become obviously alarming. Features that should prompt a GP visit include a spot that changes size, shape or colour, a sore that does not heal within a few weeks, a crusted or scaly patch that bleeds, and a mole that itches or becomes inflamed. Early removal usually means a smaller operation and a simpler repair, which is a strong reason to act quickly.

Diagnosis and the team meeting

A specialist usually confirms the diagnosis with a biopsy, in which a small piece of the lesion is removed and examined under a microscope. The result shows the type of cancer, how deeply it has grown and whether it has features that raise the risk of spread.

For higher-risk cases, a multidisciplinary team discusses the findings. It may include surgeons, pathologists, oncologists and radiologists, and it recommends treatment based on the cancer, its position and the patient's health. For melanoma of a certain thickness, a sentinel lymph node biopsy may be discussed to check for spread.

Patients should be told the plan, including who will remove the cancer, who will reconstruct the area and how the sequence will work. Ask whether reconstruction will happen at the same operation or at a later one. Staging a repair can give a better result in some areas, but it means living with a temporary dressing or graft, so ask what to expect.

What reconstruction involves

Options depend on the size and site of the defect. The simplest is direct closure, in which the edges are brought together. A skin graft takes skin from another site to cover a wound. A local flap moves nearby skin and its blood supply into the gap, and is often used for the nose, cheek and eyelid because the colour and texture match.

Larger defects may need a regional or free flap, in which tissue is taken with its blood vessels from elsewhere and reconnected under a microscope. After Mohs surgery, which removes the tumour in thin layers checked under a microscope until clear, the surgeon knows the exact defect and can plan the repair, sometimes on the same day.

Results take time. Scars soften over months, and a second small operation to refine contour is sometimes needed. A good surgeon explains the trade-offs between a single big operation and staged repair. Ask.

NHS and private routes

Most skin cancer care in the UK is provided through the NHS, and a patient on the suspected cancer pathway does not need to pay for anything. Some patients choose a private consultation for speed, for choice of surgeon or for a second opinion, and then either continue privately or return to the NHS.

If you are considering private care, check if your insurer covers cancer treatment and reconstruction, and ask for the cost of each stage in writing. Ask who will coordinate with your GP and with the NHS team, so that records and follow-up scans do not fall between two systems.

Whatever the route, regular follow-up matters. People who have had one skin cancer are at higher risk of another, so skin checks and sun protection become a lifelong habit. Use shade, clothing and sunscreen, avoid sunbeds and check your skin monthly, with a family member helping for areas you cannot see.