Dr. Lerman Performs Advanced Microvascular Breast Reconstruction Surgery

Black and white portrait of woman from neck to waist in a black bra Dr. Oren Lerman has extensive training and experience in a variety of breast reconstruction techniques that allow him to deliver beautiful results with minimal risks. He has advanced fellowship training in microvascular surgery, a technique that is in high demand, but relatively few surgeons are qualified to perform. He has performed hundreds of DIEP and other perforator flap breast reconstructions. Dr. Lerman is an attending physician in the Department of Plastic Surgery and the director of breast reconstruction at Lenox Hill Hospital.

Although most patients are candidates for natural tissue breast reconstruction they may not have been told so. If you are scheduled to undergo a mastectomy, find out if you are a candidate for one of the numerous perforator flap surgeries, including DIEP flaps, offered by Dr. Lerman. To learn more about the benefits of one of these advanced reconstructive breast surgery techniques, contact his Manhattan, NYC, practice today and schedule your consultation. We also provide answers to frequently asked questions for patients to read before their visit. 

Flap Reconstruction

Autologous breast reconstruction, or flap reconstruction, involves transferring a flap of living tissue – which usually includes skin, and fat – from another area of the body to recreate the breast mound. There are two primary methods of flap reconstruction. A pedicled flap reconstruction involves harvesting donor tissue and tunneling it under the skin to the breast mound, while keeping the original blood vessels attached. This operation known as a pedicled TRAM flap was originally described back in 1979. Dr. Lerman prefers the more advanced and current method called a free flap. A free flap involves completely separating the tissue from the original blood supply, and reattaching the flap to new blood vessels near the breast mound. 

This process is called microvascular tissue transfer and it involves the use of a surgical microscope. Because this advanced technique requires special training in microsurgery, free flap breast reconstruction is not as widely available as pedicled flap reconstruction. Not all free flap reconstruction is the same. Although microvascular free flap breast reconstruction has become the preferred approach because it maximizes the blood flow to the tissue, the most advanced type of free flap breast reconstruction, called a DIEP flap, also preserves the muscle from the abdominal wall. A free TRAM flap does not preserve the whole muscle and minimize the risk of postoperative weakness, bulge or hernia. Free DIEP flap breast reconstruction results in the most natural appearing, natural feeling, and long lasting reconstructed breast mound. 

Types of Microvascular Reconstruction

There are a number of microvascular flap reconstruction techniques, and they differ according to the area of the body from which the tissue flap is harvested. They also differ according to whether or not muscle is transferred with the tissue. One of the most common flaps used by Dr. Lerman for breast reconstruction is a DIEP flap reconstruction, in which fat and skin tissue is harvested from the abdomen to recreate the breast. Compared to the TRAM flap technique, which harvests abdominal muscle along with the skin and fat, the DIEP flap does not remove the abdominal musculature and therefore has a significantly lower incidence of abdominal muscle weakness, hernia or bulge. Patients who undergo DIEP flap breast reconstruction get the added benefit of improved abdominal contour, not unlike the improvements seen with a tummy tuck.

For those patients who do not have adequate excess abdominal tissue and are poor candidates for a DIEP flap, Dr. Lerman can perform autologous breast reconstruction utilizing other microvascular flaps including:

  • SGAP flap, in which a flap is created using tissue from the buttocks.
  • PAP flap, which uses tissue harvested from the posterior thigh.
  • TUG flap, which reconstructs the breast using tissue from inner thigh.
  • TAP flap, which uses tissue transferred from the back.
  • or Stacked Flaps, which combines two flaps such as the DIEP and the PAP to create one breast.

Implant-based Reconstruction

Although autologous tissue reconstruction is one of the most advanced techniques used for breast reconstruction it is only one of the options Dr. Lerman provides to his patients. Reconstruction with breast implants is the most common type of breast reconstruction performed in the United States every year and it is often the best choice for certain patients. Implant reconstruction is typically performed in two stages. The first stage can occur at the time of the mastectomy, and involves placing a tissue expander under the skin and muscle of the chest wall. By gradually expanding the device over time, the skin and muscle are slowly stretched to create a pocket to hold the breast implant. A saline or silicone implant is placed about three to four months later during a second surgery.

Direct-to-implant Reconstruction

Some implant reconstruction patients may be able to skip the tissue expander process in what is called direct-to-implant reconstruction. This innovative technique is performed immediately at the time of mastectomy, allowing the patient to avoid a second surgery. During this procedure, Dr. Lerman will place the permanent silicone or saline implant and reinforce the reconstruction with AlloDerm® Tissue Matrix, essentially creating an internal bra. This safe, state-of-the-art technology promotes tissue regeneration by supporting cell repopulation and rapid revascularization (delivery of blood to the capillaries). It also provides an increased support for the implant to optimize shape, symmetry and contour of the breast mounds. During your consultations, Dr. Lerman will work with you and your other providers to determine if this approach is right for you.

Immediate versus Delayed Reconstruction

Immediate reconstruction begins on the same day as the mastectomy whether it is a breast implant or autologous DIEP flap reconstruction. Some patients never had reconstruction at the time of the mastectomy or chose to wait to have reconstruction later. These delayed reconstruction cases can occur months or even years after the mastectomy. Aesthetic outcomes are generally more favorable following immediate reconstruction. On the other hand, delayed reconstruction is sometimes necessary in order to complete all cancer treatments such as radiation before moving on with the reconstruction. Unfortunately the number of women in the United States that undergo reconstruction at the time of mastectomy is less than 40%. It is not uncommon for a woman to be told to wait until after radiation treatment following mastectomy and perform a delayed reconstruction. Dr. Lerman, however, utilizes the latest techniques that obviate the need for delayed reconstruction. 

Most patients who did not undergo immediate reconstruction at the time of the mastectomy are still good candidates for "Delayed Reconstruction" and can usually have all of their options available to them including both autologous tissue reconstruction as well as implant reconstruction. 

Preventative Mastectomy and Reconstruction

Women at a high risk of developing breast cancer, whether due to family history or testing positive for the BRCA gene, may choose to have a preventative mastectomy and reconstruction. This is an important and very personal decision requiring close consideration of health, goals, and lifestyle, as well as insurance coverage for the procedure. Fortunately, the decision is generally not an urgent one. Patients usually have ample time to consult their surgeons and other medical professionals. After becoming educated, patients often feel confident in deciding if a preventative mastectomy is in their best interest.

Nipple-sparing Mastectomy & Reconstruction

Many women who choose to receive a preventative mastectomy as well as some woman with breast cancer are eligible for a nipple-sparing procedure. This technique preserves the nipple and skin, removing only the underlying breast tissue to provide very natural-looking results. In fact, when combined with advanced reconstructive techniques, the results can look as authentic as a breast augmentation procedure. Nipple-sparing reconstruction techniques can even improve the appearance of the breasts in some cases.

Schedule Your Breast Reconstruction Consultation

Dr. Lerman wants all his patients to have all the information they need to make the right decision for themselves when choosing a breast reconstruction technique. He takes pride in knowing that he can offer his patients the most advanced surgical techniques that help deliver the most satisfying results. He will work closely with you and your other healthcare providers to determine a treatment plan that maintains your safety, gives you the best aesthetic outcome and allows you to heal both inside and out. Contact his practice today to schedule your consultation.

Dr. Oren Lerman

Oren Z. Lerman, MD

Dr. Oren Lerman performs a variety of cosmetic and reconstructive procedures with a specialty in reconstructive breast surgery. In fact, he is the director of breast reconstruction at Lenox Hill Hospital's Institute for Comprehensive Breast Care as well as the Microvascular and Cosmetic Breast Fellowship. In addition to the hospital, Dr. Lerman is affiliated with:

  • The New York Regional Society of Plastic Surgeons (Past President)
  • The American Board of Plastic Surgery (Diplomate)
  • The American College of Surgeons (Fellow)
  • The American Society of Plastic Surgeons
  • The American Society of Reconstructive Microsurgery

You can schedule a consultation with Dr. Lerman by filling out our online form or calling (212) 434-6980.

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"The one thing that is most important when we're doing cosmetic surgery and aesthetic surgery of the face or the body is to make sure that the patient is happy afterwards..." Dr. Oren Lerman

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