Immediate reconstruction (IR) of the breast following mastectomy is not available to all appropriate patients. Previous studies have examined general surgeons attitudes toward reconstruction but have not assessed how these translate into surgical practice. We investigated the current rates of referral for, and availability of, IR across the West Midlands region.A postal questionnaire was sent to all breast surgery units in the region. Out of 20 units 19 responded. Units where IR was performed in-house were likely to have more breast surgeons (2.3 vs. 1.5, p=0.0106), and a higher annual workload (222 new cases vs. 174). Only two of 19 surgeons said they did not discuss IR with appropriate patients. Selection criteria in the other units included age, lack of co-morbidity, favourable pathology, smoking habit, and in one unit, only small-breasted women were offered IR. IR is performed in 13 of 19 units. Reconstructive procedures range from implants to deep inferior epigastric artery perforator (DIEP) flaps; the surgery is performed by breast and plastic surgeons together in seven units, breast surgeons alone in five and plastic surgeons alone in one. Six units do not carry out reconstruction. These units referred between two and 10 patients (average five) for IR in 2001. Units where some types of IR were available referred between three and 35 patients for surgery not performed in-house, and there was no relationship between complexity of surgery available in-house and referral rates. Reasons for low referral rates included: surgeons' attitudes; geographical isolation; long waiting times for plastic surgical opinion and for surgery; and loss of control of patients' management. Although surgeons' attitudes in the West Midlands are generally positive toward IR, availability and referral rates vary widely. Reconstructive surgeons should encourage referrals by increasing contact with general surgeons to overcome logistical problems and by ensuring appropriate systems for referral exist.