Sir: We are very delighted to hear Dr. Agostini and his colleagues appreciate the usefulness of our new method of preparing a pectoralis major myocutaneous flap and propose two additional advantages our new method offers. Not only the pectoralis major myocutaneous flap but also the deltopectoral flap still play important roles in head and neck reconstruction, as they commented. First, we would like to comment about the deltopectoral flap that is used after our new method was performed. Vascularization of the deltopectoral flap is provided mainly by the second and third intercostal perforating branches of the internal thoracic artery. The third intercostal perforating branch, however, is killed in our new method. We think that vascularization of the deltopectoral flap that derived from only the second intercostal perforating branch is unstable, although the second perforator is the dominant branch. In the case of raising the deltopectoral flap after performing our new method, we think that the wide pedicle including the first and second intercostal perforating branches and the delay incisions make the vascularization more stable. As they pointed out, it is possible to raise the deltopectoral flap for single-stage transfer with vascularization using the second and third intercostal perforating branches from the thoracoacromial artery in the pectoralis major muscle. We have already performed reconstruction with a one-stage deltopectoral flap for some cases and will soon report the results. Second, we would like to state our opinion about the possibility of raising a double skin paddle flap. We think that it is sufficiently possible to prepare a pectoralis major myocutaneous flap as a double skin paddle, provided that the double skin paddles are prepared using both the conventional method and our new method. As they commented, it is very useful to prepare the double skin paddles for patients who are not candidates for microsurgery and require multiple or composite reconstruction. Finally, we deeply appreciate their comments on our new method. They have shown additional possibilities for the pectoralis major myocutaneous flap. We believe the pectoralis major myocutaneous flap will make a greater contribution to patients suffering from head and neck lesions. Hideaki Rikimaru, M.D., Ph.D. Kensuke Kiyokawa, M.D., Ph.D. Kurume University School of Medicine Fukuoka, Japan DISCLOSURE Neither of the authors has a financial interest to declare in relation to the content of this reply or the article being discussed.