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Radial forearm free flap (RAFF) is the workhorse flap for oral cavity reconstruction. In the context of oncological reconstruction with radial forearm flap, the patient-reported outcomes of donor site morbidity amongst Indian patients have not been reported previously. Cultural and racial differences prevent extrapolation of morbidity data from Western literature. We aimed to evaluate subjectively the subjective long-term functional and aesthetic outcomes of the RAFF donor site. Patients who underwent RAFF reconstruction for intra-oral defects between 2014 and 2016 were included. Two questionnaires (Cosmesis and Sensibility and Forearm Disability) were administered. Fifty-two patients who completed a 2-year follow-up were identified. Thirty-five patients (67%) had complaints regarding the donor site. With regard to cosmesis and sensibility, hand numbness was seen in 21 (40.4%) patients. With regard to forearm disability, a problem in lifting heavy weights was seen in 22 (42.3%) patients. Only three patients in the entire cohort had complaints regarding the cosmesis of the forearm scar. Overall disability score was low (7.83). With regard to donor site morbidity, numbness and difficulty in lifting weights was the most common complaint. There is good acceptance of the donor site and scar with minimum morbidity. These findings are useful for the preoperative counselling of the patients. This is the first Indian study evaluating the long-term subjective outcomes of the radial forearm donor site. We believe the RAFF is still the most preferred flap for oral reconstruction.

The purpose of the present study was to translate and culturally validate the University of Washington Quality of Life Questionnaire, Version 4.1 (UW-QOL v4.1) in Malayalam, a language commonly used in the state of Kerala in India. The tool underwent translation and adaptation. The translated instrument then underwent a pretest survey in 30 patients. The intention was to identify any problems with the questionnaire when applied to the participants and make any minor changes if required. This was followed by validation in 100 patients. The reliability was tested for internal consistency with Cronbach's alpha. Concurrent validity was tested by correlating it with the concurrently administered FACT-HN questionnaire scores. Construct validity was tested using 'Known-group validity.' Pretest survey did not identify any major problems. There was a moderate to strong correlation between the PF, SEF subscales and the composite scores on UW-QOL scores and the Head and Neck Cancer subscale and the FACT-H&N Total score. QOL scores were more in early staged patients and those who underwent no reconstructive procedure. This proved the construct validity. This study validates the Malayalam version of the UW-QOL instrument. It is reliable, valid and culturally adapted.

The case of reverse sural artery neurocutaneous flap done for lower leg defects under combined sciatic and femoral nerve block is presented. Doing the flap using this method of anesthesia makes the positioning changes necessary during surgery easy. All flaps survived. Nine out of the ten blocks acted satisfactorily. The technique of giving the combined block is described in brief. The mean time of onset of action was 16.62 min, and the mean duration of action was 6.26 h using 1% Lidocaine with 1 in 200,000 adrenaline.

To evaluate the Limberg or rhomboid flap done during the past 2 years with regard to applicability, reliability and complications.All Limberg flaps done were reviewed by inspecting case records and directly following up patients. The indications, suitability, post-operative course and complications were noted.Eleven Limberg flaps were done during this period. Seven patients underwent the procedure for cutaneous malignancies. Rest for various benign lesions. All the flaps survived. One patient developed a hematoma under the flap. A significant cosmetic defect was noted in two patients.The Limberg flap is a safe and reliable flap for the coverage of various cutaneous defects if properly planned.

We thank Henderson et al. for the insightful comments. Although, they have echoed most of our opinions, we think two facts may merit further comments. One, the fact that local scalp flaps may not be reliable in neonates is underscored by Dr. Henderson’s team’s experience. We tend to fully agree with them that in patients with a large scalp defect parental allografts should be considered as a first-line measure rather than as a salvage procedure pending definitive autografting. Two, in our case, the maternal autograft stayed on, and the entire wound healed without the need for auto grafting, even though the epidermis peeled off after a month. The auto graft was done for a limited area of breakdown much later (after a year!!). We believe that specifically maternal autograft is preferable due to the perinatal transmission of maternal T cells to the neonate. It confers in many cases, a type of immunological tolerance [1] and hence improves the probability of the duration and extent of survival of the graft. Of course, more experience is needed on this issue. In our patient, the wait to see the fate of the calvarial bone is adding to our anxiety as we are unclear if dura was intact as the infant presented to us with eschar and granulation. We await further follow-ups.