How I Operate

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In this episode of How I Operate, Ryan Sugrue is joined by Pedro Cavadas, a reconstructive microsurgeon known for tackling complex limb salvage and replantation cases where conventional reconstructive options can begin to run out.
Beginning with the medial sural artery perforator (MSAP) flap, Cavadas gives a characteristically direct account of where the flap is useful, where it is not, and why anatomy and surgical efficiency matter more than novelty. The conversation then moves into the practical details of microsurgery: intramuscular dissection, perforator selection, venous anastomosis, vessel geometry and the sequence of repair in digital replantation. Along the way, he challenges established dogma, explains the small technical habits he believes improve patency, and shares why de-airing an arterial anastomosis may be critical to avoiding unexplained flap failure.
Key Takeaways
When the MSAP flap is a useful regional free flap and why Cavadas does not consider it a universal workhorse.
How high-setting, non-stick bipolar dissection can make intramuscular perforator dissection faster and more controlled.
Why Cavadas usually wants a single perforator and believes one perfect venous anastomosis can be better than two suboptimal ones.
The microsurgical habits he uses to protect the endothelium, optimise vessel geometry, and improve anastomotic reliability.
How changing the sequence of repair can make digital replantation faster, cleaner, and more reproducible under tourniquet.
Why air bubbles in an arterial anastomosis may contribute to apparent “no-reflow” and unexplained flap failure.

Chapters

00:00 – Reconstructing the “Impossible”
01:50 – The Rise of Perforator Flaps and the MSAP Flap
04:15 – What the MSAP Flap Is Really Good For
08:40 – Choosing the Right Flap for Complex Limb Reconstruction
10:20 – Raising the MSAP Flap and Intramuscular Dissection
16:30 – Flap Design, Doppler and Perforator Selection
18:20 – Why One Vein Can Be Better Than Two
21:10 – Anastomosis Tricks and Avoiding Endothelial Injury
28:20 – Replantation Strategy, Bone Shortening and Repair Sequence
39:40 – Air Embolism, “No-Reflow” and Flap Failure
Thank you for listening to How I Operate. Brought to you by ThePlasticsFella.

If you enjoyed this episode, please follow the show, leave a rating and review, and share it with colleagues. New episodes are released bi-weekly, featuring the surgeons, innovators, and ideas that continue to shape modern plastic surgery.

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In this episode of How I Operate, Ryan Sugrue is joined by Dr Elizabeth Hall-Findlay, whose work has helped reshape the way plastic surgeons think about breast reduction.
Dr Hall-Findlay traces the evolution of her approach from the traditional inverted T inferior pedicle technique to vertical reduction and the true superomedial pedicle. She explores the importance of separating skin design, blood supply and parenchymal reshaping, explaining why the skin shouldn't be relied upon as a "brassiere". From nipple position and pedicle selection to markings, tissue resection and managing complications, she shares the lessons and surgical principles developed throughout her career.
Key Takeaways:
 How Dr Hall-Findlay transitioned from the inverted T technique to vertical breast reduction. 
 Why understanding the superficial blood supply is fundamental to pedicle design and nipple viability. 
 The principles behind the true superomedial pedicle and its advantages for blood supply, sensation and breast shape. 
 Why surgeons should "remove the excess where it is" rather than relying solely on predetermined patterns. 
 How parenchymal reshaping, rather than skin tension, can create more predictable long-term results. 
 The importance of the upper breast border, breast meridian and individual anatomy when determining nipple position. 
 When a horizontal scar may still be required and why the vertical incision shouldn't be cinched. 
 How honest reflection, photography and long-term follow-up can help surgeons continually refine their technique. 
Chapters:
00:15 – The Evolution of Breast Reduction
03:24 – Moving Away from the Inverted T
06:29 – Transitioning to Vertical Reduction
09:49 – Understanding the True Superomedial Pedicle
14:33 – Sensation, Shape and Parenchymal Reshaping
24:52 – Remove the Excess Where It Is
31:03 – Gravity, Weight and the Inframammary Fold
36:47 – Marking the Breast and Choosing Nipple Position
47:00 – Inside the Hall-Findlay Technique
53:56 – The Pucker, the T and Surgical Judgement
58:59 – Managing Complications and Nipple Necrosis
62:26 – A Career Built on Surgical Evolution
Thank you for listening to How I Operate.
If you enjoyed this episode, please follow the show, leave a rating and review, and share it with colleagues. New episodes are released monthly, featuring the surgeons, innovators and ideas that continue to shape modern plastic surgery.

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In this episode of How I Operate, Ryan Sugrue is joined by Professor Claudio Angrigiani, the creator of the Posterior Interosseous Artery (PIA) flap and one of the pioneers of perforator flap surgery.
Looking back over four decades of innovation, Professor Angrigiani shares the story behind the development of the PIA flap, from cadaveric anatomy studies in Argentina to its adoption as a reliable reconstructive option for hand and wrist defects around the world. Along the way, he explores the importance of anatomy, surgical simplicity, and why understanding vascular territories remains fundamental to flap design today.
Key Takeaways:
How the PIA flap was developed as an alternative to traditional reconstructive options for the hand.
The role of anatomical research and cadaveric studies in creating dependable surgical techniques.
Why the middle perforators are key to the reliability of the PIA flap.
Common technical mistakes that can lead to complications or flap failure.
The importance of simplifying flap surgery through a deep understanding of anatomy.
Professor Angrigiani's approach to innovation, research, and developing new surgical techniques.
Chapters:
00:00 – Introducing the PIA Flap
04:10 – Hand Reconstruction in the 1980s
09:25 – The Origins of the PIA Flap
16:40 – Early Anatomical Research and Cadaver Studies
24:15 – Understanding Perforators and Vascular Territories
33:50 – The Physiology Behind the PIA Flap
43:20 – Flap Design, Landmarks, and Planning
54:35 – Raising the PIA Flap Step by Step
01:06:10 – Common Mistakes and Avoiding Complications
01:15:45 – Innovation, Anatomy and Surgical Thinking

Thank you for listening to How I Operate. Brought to you by ThePlasticsFella.

If you enjoyed this episode, please follow the show, leave a rating and review, and share it with colleagues. New episodes are released bi-weekly, featuring the surgeons, innovators, and ideas that continue to shape modern plastic surgery.

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In the second episode of How I Operate, Ryan Sugrue (ThePlasticsFella) sits down with Professor Foad Nahai, co-creator of the Mathes & Nahai classification, one of the most influential frameworks in reconstructive surgery.

More than four decades after its publication, the classification remains a cornerstone of plastic surgery training and clinical practice. Professor Nahai reflects on the anatomy lab discoveries, clinical challenges, and collaborative work with Dr. Stephen Mathes that led to the development of a system that transformed how surgeons understand muscle flaps. Together, they explore the origins of the classification, its lasting relevance, and the principles that continue to shape reconstructive surgery today.

Key Takeaways:
How the Mathes & Nahai classification was developed from anatomical research.
Why understanding vascular anatomy changed the reliability of muscle flaps.
The role of anatomy in advancing reconstructive and microsurgical techniques.
Lessons learned from creating a framework that has remained relevant for over 40 years.
Why simplicity, clinical relevance, and practicality are key to lasting surgical innovation.
Chapters:

00:00 – Introducing the Mathes & Nahai Classification
04:09 – Muscle Flaps Before the Classification
09:04 – Reconstruction, Microsurgery, and a Changing Specialty
13:13 – Why Anatomy Still Matters
17:06 – Discovering the Pattern in the Anatomy Lab
22:40 – Publishing the Research and Early Reception
24:40 – Building a Framework That Lasted
31:16 – Seeing the Classification Adopted Worldwide
34:18 – Clinical Impact Beyond the Classification
38:48 – Advice for the Next Generation of Surgeons
Thank you for listening to How I Operate. Brought to you by ThePlasticsFella.

If you enjoyed this episode, please follow the show, leave a rating, and share it with colleagues. New episodes are released bi-weekly, exploring the ideas, techniques, and innovations that continue to shape modern plastic surgery.

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In the first episode of How I Operate, Ryan Sugrue is joined by Professor JP Hong, one of the leading innovators in modern reconstructive microsurgery and a pioneer of the SCIP flap.

From its origins as a modification of the traditional groin flap to its evolution into one of the most versatile perforator flaps in reconstructive surgery, Professor Hong shares the anatomical discoveries, technical refinements, and clinical insights that transformed the SCIP flap into a global workhorse. Along the way, he discusses the importance of continuous innovation, the role of ultrasound in modern flap surgery, and the principles that guide his approach to surgical problem-solving.

Key Takeaways:
How the SCIP flap evolved from the traditional groin flap.
The anatomical principles that improved flap reliability and reduced complications.
Why understanding perforator anatomy remains fundamental to successful reconstruction.
The growing role of ultrasound in flap planning and surgical decision-making.
How incremental improvements can transform a good operation into a great one.
Professor Hong's philosophy on innovation, teaching, and building a lasting surgical legacy.
Chapters:

00:00 – Introducing the SCIP Flap
03:20 – The Evolution of the Groin Flap
09:15 – Early Modifications and the Work of Dr Kashima
16:30 – Understanding Perforator Anatomy
24:45 – Improving Reliability Through Anatomical Research
34:20 – The Role of Veins and Flap Design
45:10 – When to Use (and Not Use) the SCIP Flap
55:35 – Ultrasound as a Microsurgical Tool
01:06:30 – SCIP Flap Design and Surgical Technique
01:25:40 – Innovation, Legacy, and Lessons for Future Surgeons
Thank you for listening to How I Operate. Brought to you by ThePlasticsFella.

If you enjoyed this episode, please follow the show, leave a rating and review, and share it with colleagues. New episodes are released bi-weekly, featuring the surgeons, innovators, and ideas that continue to shape modern plastic surgery.