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TUG and PAP Flap Breast Reconstruction

If you are considering autologous breast reconstruction but do not qualify for DIEP flap surgery, you may qualify for a TUG or PAP flap.

TUG or PAP flap surgery harvests tissue from one or both inner thighs instead of the abdomen.

Dr. Oren Lerman provides these procedures at his Manhattan, NY, practice...

TUG and PAP Flap vs. DIEP Flap

Autologous Harvest Site Fatty Tissue Used Muscle Tissue Used
DIEP Flap Abdomen
TUG Flap Inner Thigh(s)
PAP Flap Inner Thigh(s)

Source: Breastcancer.org


The most common type of autologous tissue reconstruction is the DIEP flap procedure, which harvests tissue from the abdomen. DIEP is named after the deep inferior epigastric perforator (DIEP) artery that runs through the abdomen. During the DIEP procedure, the surgeon moves fat, skin, and blood vessels from the abdomen up to the chest in order to form a new breast mound following a mastectomy.

TUG Flap and PAP Flap

While DIEP is a popular breast reconstruction technique, patients who are slender or who have undergone abdominal surgery before typically do not have enough fat tissue to harvest. In such cases, transverse upper gracilis (TUG) and profunda artery perforator (PAP) flap surgeries may be recommended. Both surgeries use harvested tissue from one or both inner thighs. The major difference between the TUG and PAP flap procedures is the type of tissue harvested. While the PAP flap harvests only fatty tissue, TUG flap harvests both fatty and muscle tissue. 

TUG and TAP flap surgery
TUG and TAP flap surgery harvest tissue from one or both inner thighs to reconstruct the breast mound.

Stacked Flaps Technique

Dr. Lerman can also perform a special type of breast reconstruction known as stacked flaps. During the procedure, he will combine two types of flaps to form one breast. By stacking multiple flaps, Dr. Lerman can create a larger breast without using an implant. This technique can benefit very thin patients who cannot achieve the breast size they want with a single flap.

How to Decide Which Surgery Is Right for You

Many women face a difficult choice when deciding which autologous breast reconstruction technique is right for them. Several factors must be considered when choosing between breast reconstruction techniques, including: 

  • Whether you prefer to use your own tissue or implants
  • Whether you prefer the quicker surgical and recovery time of breast reconstruction with implants or the long-term benefits of breast reconstruction using a flap
  • The amount of abdominal, thigh, and buttock tissue available to build a flap

During a consultation at his Manhattan, NY, office, Dr. Lerman can get to know you, learn about your personal preferences, and build a personalized surgical plan to help you reach your goals. Not all surgeons perform every type of technique, but Dr. Lerman offers a wide range of natural tissue flap breast reconstruction techniques to meet your unique needs. 

Contact Us Today & Learn More about This Advanced Breast Reconstruction Technique

If you are considering breast reconstruction using an advanced flap technique, contact our New York practice to explore your options and learn about the benefits of each technique. 

Dr. Lerman is the director of breast reconstruction at the Institute for Comprehensive Breast Care at Lenox Hill Hospital. His advanced training and experience in microvascular surgery and flap procedures give him the tools to provide natural-looking breast reconstruction results and a safe recovery. If you require a mastectomy and would like to learn more about your breast reconstruction options, contact our practice online today or call us to schedule a consultation:

(212) 434-6980

Dr. Oren Lerman and Patient

"He Has My Highest Recommendation."




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Dr Lerman is best of the best!  From his bedside manner and ability to really listen to his patients to his highly skilled surgical hand I am so grateful and fortunate to have found him.  He has my highest recommendation.  As well, everyone on his staff  helpful and lovely to deal with.  5 stars!

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Beth Stern


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I came to see Dr Lerman having begun the implant process post mastectomy but very unhappy with the tissue expander. I had constant discomfort and a misshapen breast. Within hours of Flap surgery my pain was gone. I am so thankful!

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What to Expect during the Procedure

Transverse upper gracilis (TUG) and profunda artery perforator (PAP) flap surgeries can be performed immediately after a mastectomy, or they can be delayed. They are both performed under general anesthesia.


To extract the tissue, Dr. Lerman creates a vertical incision along the inside of the thigh, crossed with a horizontal incision that runs just below the groin and the crease of the buttock.

Extraction & Tissue Transfer

The tissue is completely extracted from the thigh and transferred to the breast. Once placed, Dr. Lerman will individually attach the blood vessels in the flap to those in the surrounding tissue so that it is properly nourished. 


At this point, the incisions in the thighs and the breasts can be closed, and the patient is moved to the recovery room.


Once you have been released from the hospital, it will take six to eight weeks to heal. While you will have scars on the thigh, crease of the buttock, and breast from the incisions, they will fade over time, and will be placed in a way that allows them to be easily concealed.

Are There Any Risks Involved?

Like deep inferior epigastric perforator (DIEP) flap surgery or any surgical procedure, TUG and PAP flaps involve some risks, such as infection, lumps in the harvested tissue, and tissue breakdown.

Choosing a credentialed surgeon with many years of experience in breast reconstruction surgery can minimize these risks. Dr. Lerman is board-certified and has fellowship training in microvascular reconstructive surgery. He uses his training and skills to mentor other surgeons in safely performing breast reconstruction with natural-looking results. Because of his reputation and the caliber of his work, patients visit Dr. Lerman from throughout New York and beyond.

dr. lerman consults with his patient

"I Feel Lucky and Blessed to Call Him My Doctor."


Kimberly del Gaizo


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Dr. Oren Lerman's expertise and skill are of the absolute highest caliber. He masterfully navigated my demanding journey with breast reconstruction following my cancer diagnosis and double mastectomy. As my body persisted in presenting formidable challenges, Dr. Lerman never wavered in his thoughtful and methodical decisions and treatments.  His empathy and humanity gave me reassurance and hope throughout the  five surgeries he performed on me. Dr. Lerman is the ideal doctor. I feel lucky and blessed to call him my doctor.

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Yelena Bernstein


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Dr. Lerman is an amazing doctor and a very kind and carrying individual. His attention to details and ability to explain complicated surgeries make his patients and their families very comfortable. It is important to trust your doctor and Dr. Lerman is trustworthy! Thank you Dr. Lerman for your expertise and amazing care that you provide!

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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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