**6. Flap contouring**

The goal of breast reconstruction is to emulate natural esthetics. Achieving this not only requires technical finesse in microsurgery, but esthetic prowess. This often requires multiple stages of surgery, however as reconstructive surgeons become more proficient in the operating room, less time is spent on microsurgery and more time can be dedicated to contouring the breast mound at the first stage. This is evident in outcomes seen with PAP flaps. The elliptical orientation of the flaps lends itself to being molded immediately, regardless of the need for skin paddle. The fat is more supple and yields to contouring. This is often achieved on the back table prior to inset. If the patient is fortunate to have a nipple sparing mastectomy, the entire flap is de-epithelialized and folded to produce an esthetically pleasing breast mound. Otherwise, a skin paddle is left to monitor the flap. The three-dimensional construct is maintained with absorbable internal sutures and does not require the addition of supplemental materials such as meshes or slings (**Figure 6**).

**Figure 6.** *Intra-operative contouring of a single PAP flap into an esthetic breast mound.*
