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Background and Objectives : Surgical management of local recurrence of soft tissue sarcomas (STS) is still challenging. In this article, we report on multiple flap reconstructions for multiple local recurrences of STS. Their feasibility will be validated by examining clinical cases. Materials and Methods : Patients who underwent multiple flap reconstructions for multiple local recurrences of STS between April 1997 and October 2021 were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics, and postoperative complications were examined. Results : Twenty operations of eight patients were identified. The location of the defects was the back in two, the buttock in two, the groin in two, and the lower extremities in two. The average total number of wide resections was 4.0 and the average total number of flap reconstructions was 2.5. The average follow-up period was 109.4 months. The average size of the defect was 102.4 cm 2 and the average flap size was 15.7 × 10.8 cm. The histological diagnoses were malignant fibrous histocytoma (MFH) in eight operations, osteosarcoma in two operations, myxoid liposarcoma in two operations, undifferentiated pleomorphic sarcoma (UPS) in six operations, and myxofibrosarcoma (MFS) in one operation. Of twelve subsequent operations, the resection of the previously transferred flap was performed in six operations (50%). The occurrence of take back, flap complications, and donor-site complications in the primary operation group was 25%, 25%, and 12.5%, respectively. The occurrence of take back, flap complications, and donor-site complications in the second and subsequent operation group was 0%, 0%, and 16.7%, respectively. Conclusions : Multiple operations including wide resections followed by flap reconstructions for multiple local recurrences are feasible. Reconstructive surgeons should choose the options of the flaps considering the future local recurrence for tumors with a high risk of recurrence.

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x -axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x -axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Background and Objectives : Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods : Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results : By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions : An SCIP flap can be reliably harvested using the Deep Fat Saving technique.

Background and Objectives : Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods : Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results : The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions : Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

Various dietary phytochemicals seem to display antioxidant activity through the NF-E2-related factor 2 (Nrf2) pathway. However, few studies have demonstrated its antioxidant effect and Nrf2 dependency at the animal level. We constructed a zebrafish-based assay system to analyze the in vivo antioxidant activity of phytochemicals and examined the activity of 10 phytochemicals derived from spices, using this system as a pilot study. Hydrogen peroxide and arsenite were used as oxidative stressors, and Nrf2 dependency was genetically analyzed using an Nrf2-mutant zebrafish line. The activities of curcumin, diallyl trisulfide and quercetin were involved in the reduction of hydrogen peroxide toxicity, while those of cinnamaldehyde, isoeugenol and 6-(methylsulfinyl)hexyl isothiocyanate were involved in the reduction of arsenite toxicity. The antioxidant activities of these phytochemicals were all Nrf2 dependent, with the exception of cinnamaldehyde, which showed strong antioxidant effects even in Nrf2-mutant zebrafish. In summary, we succeeded in constructing an assay system to evaluate the in vivo antioxidant activity of various phytochemicals using zebrafish larvae. Using this system, we found that each spice-derived phytochemical has its own specific property and mechanism of antioxidant action., Competing Interests: The authors declare no conflict of interest.

The Keap1-Nrf2 system is an evolutionarily conserved defense mechanism against oxidative and xenobiotic stress. Its regulatory mechanisms, e.g., stress-sensing mechanism, proteasome-based regulation of Nrf2 activity and selection of target genes, have been elucidated mainly in mammals. In addition, emerging model animals, such as zebrafish, fruit fly and Caenorhabditis elegans , have been shown to have similar anti-stress systems to mammals, suggesting that analogous defense systems are widely conserved throughout the animal kingdom. Experimental evidence in lower animals provides important information beyond mere laboratory-confined utility, such as regarding how these systems transformed during evolution, which may help characterize the mammalian system in greater detail. Recent advances in genome projects of both model and non-model animals have provided a great deal of useful information toward this end. We herein review the research on Keap1-Nrf2 and its analogous systems in both mammals and lower model animals. In addition, by comparing the amino acid sequences of Nrf2 and Keap1 proteins from various species, we can deduce the evolutionary history of the anti-stress system. This combinatorial approach using both experimental and genetic data will suggest perspectives of approach for researchers studying the stress response.