Loose skin

In your opinion, where is the need for psychologists and psychiatrists most critical?

Last week was back-to-back five bilobed bipaddled PMMC flaps for full-thickness buccal mucosa defects. It made me reflect— In India, where many patients present late with advanced head and neck cancers, and where microvascular expertise or resources may be limited, this flap becomes more than a salvage,It becomes a purposeful craft, especially when where risk, and resources are in short supply. Success in reconstruction lies less in patient factors, and more in the surgeon’s design and execution. Every wound dehiscence, infection, or flap failure often reflects a planning flaw rather than patient factors. The Bilobed PMMC Flap Is More Than a Procedure.It’s a mastery of balance between form and function & between art and science As surgical oncologists, we must reconstruct with the same precision we resect. Both are part of the same journey,and in that journey, mindful reconstruction is where true surgical wisdom lies. Here are my 2 cents for how to plan for Bilobed PMMC Flap ✅ Flap Design • Center on the Nipple-Areola Complex (NAC) • Inner paddle → inferolateral, for mucosal lining • Outer paddle → medial, for skin cover • Lateral “C” design allows a large harvest with primary closure ✅ Paddle Orientation • Taper both ends to prevent dog-ears • Leave 1 cm between paddles for de-epithelialization & tension-free folding ✅ Safe Flap Limits • Do not extend >2 cm beyond the pectoralis major borders to preserve viability ✅ Pedicle Handling • Avoid spiraling of the pedicle • If NAC is included, anticipate nipple positioning in inner paddle or mark inner paddle ✅ Commissure Reconstruction • Prioritize primary closure • Use flap bulk to maintain commissure symmetry and prevent deviation ✅ Nerve Division • Always divide the lateral pectoral nerve to prevent post-op compression Suggestions are welcome for insightful discussion regarding same .