The standard radical mastectomy deformity	Subcutaneous or submuscular expansion of the right breast is performed in combination with repositioning of the left breast to compensate for deficit of the breast skin envelope that was created during the skin resection mastectomy	The circular recipient site for the delayed Peg Flap
For a delayed autologous Peg flap, a circular excision of the recipient site on the breast is performed	The diameter of the recipient site is 1 cm smaller than the diameter of the contralateral and Bowtie nipple-areolar complexes	The recipient site circle of breast skin is removed full thickness down to the breast expander
The circular recipient site is manually expanded prior to Peg flap transfer	Intraoperative expansion of the circular recipient site.	Expansion will improve the projection of the nipple-areolar complex.
The Rectus Peg flap is elevated from the abdomen. The Bowtie nipple-areolar complex is typically created at the donor site	The Rectus Peg flap is rotated in a clockwise direction for the right breast and in a counter clockwise direction for the left breast. Poorly perfused portions of the flap are resected prior to transfer	Additional subcutaneous fat is harvested for a Latissimus Dorsi peg flap
Insertion of the latissimus dorsi Peg flap into the expanded breast skin envelope	The Peg Flap is inserted into the circular recipient site. The double tier scarring and pigmentary demarcation of a standard elliptical flap is avoided	Delayed right breast reconstruction with a Rectus Peg flap
Completion of a delayed breast reconstruction with a Rectus Peg flap	Completion of a delayed breast reconstruction with a latissimus dorsi Peg flap	Projection of the Bowtie nipple-areolar complex with a delayed reconstruction is achieved through the elastic recoil of the breast skin at the circular recipient site
Additional projection of the nipple-areolar complex can be obtained with the design of the Bowtie flap	A divergent shaped Bowtie Flap that is curved	Completed Bowtie nipple-areolar reconstruction
The double tier scarring of each breast with a TRAM flap	Double tier scarring of each breast from a TRAM flap after a subsequent nipple-areolar reconstruction	The pigmentary demarcation of a standard latissimus dorsi flap of the right breast
Two months after a delayed right breast reconstruction with a Peg flap (before pigmentation of the nipple-areolar complex)	Two months after a delayed right breast reconstruction with a Peg flap (before pigmentation of the nipple-areolar complex)	Six months after a delayed breast reconstruction with a Peg flap (before pigmentation). Additional projection obtained from the Bowtie nipple areolar reconstruction

Immediate Autologous Reconstruction with the Latissimus Dorsi Peg Flap

Immediate Autologous Reconstruction with the Rectus Peg Flap