> ## Content Index > Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt > Use this file to discover other available public pages before exploring further. # Foad Nahai on How I Operate, 5 Flap Concepts, & Ideas That Changed Our Specialty - URL: https://www.theplasticsfella.com/july-12th/ - Published: 2026-07-10T19:03:10.000Z - Updated: 2026-07-12T10:21:45.000Z - Description: Also: Latissimus Dorsi in action, gracilis myocutaneous flap harvest, evidence on reverse-flow flaps. - Author: PlasticsFella - Tags: thePlasticsPaper #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/july-12th/#a-letter-from-pfella) The ideas that change how we work 2. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/july-12th/#how-i-operate) Episode 2 releasing tomorrow! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-12th/#image-of-the-week) Latissimus Dorsi: Type V in action 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-12th/#technique-tip) Gracilis myocutaneous free flap harvest 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-12th/#what-does-the-evidence-say) Reverse-flow flaps: Why the vein matters most 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-12th/#articles-of-the-week) Perforator flaps & the lower trapezius musculocutaneous flap. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Ideas That Change How We Work* 👋 Most papers have a shelf life. They get read, cited a few times, maybe shape a bit of practice, and then drift into the background with time. A few do something else entirely. They stop being just papers and become part of the way a specialty thinks. That’s what happened with Mathes and Nahai. At some point, it just became the language people use when they talk about muscle flaps. Type I. Type II. Type V. Dominant pedicle. Secondary segmental supply. Once an idea starts doing that, it’s no longer just living on the page. What’s interesting is that this usually doesn’t happen because the underlying subject is simple. Muscle vascular anatomy isn’t simple. Flap behaviour isn’t simple. What lasts is when someone manages to take something complicated and present it in a way that's simple enough for most to grasp. A lot of clever ideas get dismissed because a majority can't carry them. They’re too messy, too buried in detail, too badly explained, or too difficult to teach. The ideas that survive are the ones that break down the complexity, instead of making it even more complex. The Mathes and Nahai publication gave surgeons a framework they could actually use. You could teach it, test it against real anatomy, and apply it in theatre. You could explain why the latissimus behaves one way and the gracilis another. You could predict what changes when the pedicle changes. The contribution wasn't simply discovering something, it was figuring out the way to break it down in a way for everyone to understand When it comes to lasting concepts in surgery, it’s not only about whether the idea was right, although that obviously is the key thing. An idea needs to be communicated clearly enough, taught well enough, and built simply enough that those who come after you could pick it up and actually use it. Otherwise, good ideas might stay trapped with the people who first discovered them. We’re releasing my conversation with **Professor Foad Nahai** tomorrow, and it’s really about where one of those rare ideas came from. Not just the anatomy, but the thinking, the presentation, and why it managed to last. If you haven’t already subscribed, [keep an eye out for it tomorrow](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com)! P’Fella ❤️ ## How I Operate **Episode 2 Releasing Tomorrow!* Our next episode of ****How I Operate** comes out this Monday, featuring ****Professor Foad Nahai**, co-creator of the ****Mathes & Nahai classification**. More than 40 years after its publication, the classification remains one of the core frameworks in plastic surgery training. In this conversation, Professor Nahai reflects on the ****anatomy lab work**, ****clinical problems**, and ****collaboration with Dr Stephen Mathes** that led to a system still used to understand muscle flap vascular anatomy today. Stay tuned for Monday’s release! 0:00 /0:59 1× How I Operate - Episode 2 [Subscribe & Stay Tuned](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## Image of the Week **Latissimus Dorsi: Type V in Action* 🖼️ ****Image of the Week** This week's image is from the original Mathes and Nahai publication, illustrating the principle that ****blood supply** determines what a flap can do. The ****latissimus dorsi** is a ****Type V** muscle with one dominant pedicle (thoracodorsal) and additional segmental perforators. The diagrams highlight the key idea: ****change the pedicle, and you change the arc of rotation**. This is what makes the reverse latissimus possible. The operative image reinforces that preserving segmental vessels creates options when the main pedicle isn’t usable. This is the core of the classification: ****predicting how far a flap can safely reach, and under what conditions**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/Screenshot-2026-01-23-at-17.15.51.png) Latissimus Dorsi Flap - Source: Mathes and Nahai, 1981 ## Technique Tip **Gracilis Myocutaneous Free Flap Harvest* 🚑 ****Technique Tip of the Week** The ****gracilis** is a classic ****Mathes & Nahai Type II** muscle flap, supplied by a single dominant vascular pedicle with additional minor pedicles. Its reliable anatomy, long pedicle, and minimal donor-site morbidity make it a versatile option for free tissue transfer in head and neck, perineal, and extremity reconstruction. This operative video demonstrates the key steps of ****gracilis flap harvest**, including muscle identification, pedicle dissection, preservation of the skin paddle, and flap elevation. ## What Does the Evidence Say? **Reverse-Flow Flaps: Why the Vein Matters Most* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Reverse-flow flaps are a useful reminder that flap reliability is not always dictated by the “dominant” pedicle alone. We usually think in terms of named vascular territories and major pedicles, but reverse-flow flaps show that ****distal communications and secondary inflow can be clinically usable**, provided venous outflow is respected. Classic anatomic and clinical work on reverse-flow island flaps showed that retrograde arterial perfusion is possible, but that the real challenge is ****how venous blood escapes against venous valves**. Cadaveric studies of the deep venous system suggested that simple macrovenous bypass channels are often insufficient on their own, helping explain why venous congestion has always been the issue in reverse-flow designs. Reverse-flow flaps opened up reconstructive options without microsurgical transfer or sacrifice of a major axial vessel. Studies have shown that the reverse-flow posterior tibial artery island flap can be a reliable option for foot defects, supporting the idea that reverse perfusion can be dependable in carefully selected cases. The ****distally based superficial sural flap** then became a major workhorse for the distal third of the leg, ankle, and heel, precisely because it exploits this same reverse-flow principle through peroneal perforators and the sural vascular axis. While reverse-flow flaps do not “break” vascular rules, they depend on understanding them more deeply, especially the balance between ****retrograde inflow and precarious venous return**. ([Torii](https://journals.lww.com/plasreconsurg/abstract/00006534-198704000-00015~reverse-flow-island-flap-clinical-report-and-venous-drainage?ref=theplasticsfella.com), 1987); ([del Pinal](https://www.jprasurg.com/article/0007-1226%2893%2990195-H/fulltext?ref=theplasticsfella.com), 1993); ([Liu](https://pubmed.ncbi.nlm.nih.gov/2367580/?ref=theplasticsfella.com), 1990); ([Hasegawa](https://europepmc.org/article/MED/8134458?ref=theplasticsfella.com), 1994); ([Almeida](https://europepmc.org/article/MED/11818840?ref=theplasticsfella.com), 2002) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Perforator Flaps: Classification and Applications**](https://www.ovid.com/jnls/annalsplasticsurgery/abstract/00000637-200301000-00016~perforator-flaps-evolution-classification-and-applications?ref=theplasticsfella.com) Perforator flaps achieve reliable reconstruction while minimising donor site morbidity by preserving muscle, but require precise anatomical understanding and careful perforator selection to maximise their versatility and outcomes. ✅ [****Direct vs Indirect Perforators: A Simpler Way to Think About Flaps**](https://journals.lww.com/plasreconsurg/abstract/10.1097/01.prs.0000040462.38363.c7~direct-and-indirect-perforator-flaps-the-history-and-the?ref=theplasticsfella.com) All perforator flaps can be reduced to a simple principle of vascular anatomy, with reliability determined by whether the perforator reaches the skin directly or indirectly, guiding flap design and predicting outcomes. ✅ [****Lower Trapezius Flap: Long Pedicle with Reliable Supply**](https://journals.lww.com/plasreconsurg/abstract/10.1097/01.prs.0000117188.03152.10~the-lower-trapezius-musculocutaneous-flap-from-pedicled-to?redirectionsource=fulltextview&ref=theplasticsfella.com) The lower trapezius musculocutaneous flap offers a long, consistent pedicle via the dorsal scapular artery with low donor morbidity, but requires precise anatomical understanding to safely extend its arc of rotation or use it as a free flap. ## Feedback ### I hope you enjoyed it 😄 ---