Objective Women with locally advanced breast cancer face many conflicting issues affecting their choice of immediate versus delayed versus no breast reconstruction (BR). This single‐centre pilot study assessed high‐risk women's reasons and priorities in choosing the timing and type of BR in a setting where all clinically feasible options were discussed with all women. Methods Fifty‐one women from a metropolitan breast oncology practice, who were likely to require post‐mastectomy radiotherapy (PMRT), were recruited after making their decision about BR. Participants completed a questionnaire (69% preoperatively), adapted from Reaby (1998), evaluating the factors affecting their decision. Responses were subsequently classified into eight issue‐based domains (feeling normal, feeling good, being practical, influence of others, expectations, fear, timing and unnecessary). Demographic and clinical data were also collected. Results There were 32 immediate BR (IBR = 63%), seven delayed BR (DBR = 13%) and 12 no BR (NBR = 23%). Analysis using the chi square test showed women over 60 were more likely to choose NBR (p = 0.005), while women living with a partner were more likely to choose IBR (p = 0.032). The most relevant domains for both IBR and DBR were ‘feeling good’ and ‘feeling normal’; and for NBR were ‘unnecessary’ and ‘being practical’. Although all women understood pre‐operatively the potential aesthetic limitations of PMRT, 63% still chose IBR. Conclusions These data will enable clinicians, researchers and women with breast cancer to gain a clearer understanding of the factors that impact on the choice and timing of BR in women requiring PMRT, a major breast cancer survivorship decision. Copyright © 2016 John Wiley & Sons, Ltd.