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Background:  Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction., Methods:  We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018., Results:  We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p  = 0.45), any breast-related complications (18 and 21%, respectively, p  = 0.75), or any major breast-related complications (13 and10%, respectively, p  = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group ( p  = 0.18)., Conclusion:  Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  The interview process for surgical trainees aims to select those individuals who will perform best during training and have the greatest potential as future surgeons. The objective of this study was to evaluate the relationship between criteria assessed at interview, technical skills, and performance, for the first time, to optimize the selection process for a Microsurgery fellowship., Methods:  Twenty microsurgery fellows in three consecutive annual cohorts at a single academic center were prospectively evaluated. At interview, subjects were scored for multiple standardized domains. At the start and at end of the fellowship, microsurgical technical skill was assessed both in the laboratory and operating room (OR) using a validated assessment tool. At the end of the fellowship, there was a final evaluation of performance., Results:  At the start, microsurgical skill significantly correlated with almost all domains evaluated at interview, most closely with prior plastic surgery training experience. At the end of the fellowship, skill level improved in all trainees, with the greatest improvement made by the lowest ranked and skilled trainees. The highest ranked trainees, however, made the greatest improvement in speed., Conclusions:  The results of this study, for the first time, validate the current interview process to correctly select the highest performing and most skilled candidates and support the effectiveness of a 1-year microsurgical fellowship in improving microsurgical skill in all trainees, irrespective of their initial ability. The importance of valuing the relative quality of prior training and experience at selection is also highlighted., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Competing Interests: Financial Disclosure: None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article.

Microvascular free tissue transfer is associated with a 1 to 5% failure rate, most commonly as a result of thrombosis in the region of the vascular anastomosis or the distal flap microcirculation. Although many laboratory and clinical studies have been performed, there is no consensus on the efficacy and optimal dosage of various pharmacological agents available for the prevention and treatment of thrombosis in microvascular surgery. Some agents have potentially serious side effects; and all agents carry the risks of undesirable bleeding and hematoma formation. We review the current experimental and clinical evidence regarding the agents commonly used to prevent and treat thrombosis in microvascular surgery and make practical recommendations for the management of vascular compromise in free flaps.