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The temporomandibular joint (TMJ) is a critical articulation between the mandible and cranium. The unique anatomy allows for a multifaceted motion unlike any other joint in the human body. The bi-convex curvature of the bony prominences facilitates a compound hinging and sliding movement, which are driven by the muscles of mastication and constrained by various ligamentous connections surrounding the joint. Proper alignment and function of these structures are essential to ensure a relationship between the mandibular and maxillary dental arches and fluid motion of the mandible during mastication. While the versatile form and function of the TMJ allow for coordinated jaw movements, pathologic conditions can lead to dysfunction and pain. Therefore, understanding the anatomy and associated pathophysiology of the TMJ is critical for a plastic surgeon who manages craniomaxillofacial trauma and disorders. The present manuscript is the first of a 3-part series with an overview of the TMJ anatomy. Subsequent sections will address the pathology and the treatment of various TMJ disorders.

The temporomandibular joint (TMJ) is a ginglymoarthrodial joint that allows translational or sliding movement in the superior compartment and rotational or hinging movements in the inferior compartment. The articulation of both mandibular condyles with the glenoid fossa of the temporal bone is separated by a cartilaginous articular disk that allows the joint to undergo the functional movements involved in speech and mastication. Any anatomic disequilibrium of the TMJ can produce mechanical dysfunction and orofacial pain. The complexity of the TMJ necessitates a thorough understanding of the anatomy and physiology to diagnose and treat its pathology properly. The authors present the second of a three-part educational series on the TMJ, focusing on the pathophysiology and assessment of joint disorders.

As of January 26, 2022, the United States Medical Licensing Examination(USMLE) Step 1 score reporting will be changed from a numeric scoring system to pass/fail. Although the new scoring policy is expected to benefit medical students, there is concern that it will also amplify preexisting disadvantages and worsen disparities for students applying in the already-competitive plastic surgery match. Whether the reporting change will tangibly benefit applicants to plastic surgery has yet to be elucidated.A cross-sectional survey was distributed to medical students and graduates via social media platforms. Data were analyzed using Student t test and Chi-squared statistic, with an alpha level set at 0.05.Data collection and analysis was performed at Johns Hopkins University School of Medicine.This study included a sample of 120 American Medical Trainees (AMTs) and International Medical Trainees (IMTs) who are interested in plastic surgery.The plurality of respondents were against the new Step 1 score reporting (AMT: 40.7%; IMT: 44.3%), but differences existed between AMTs when compared to IMTs, especially regarding opinions about the reporting change on stress levels and competitiveness of highly competitive specialties. Regardless of training status, respondents felt that the pass/fail scoring system would increase their likelihood to engage with more research, dual apply, prioritize studying for Step 2 CK, and consider a dedicated research year.While a pass/fail reporting system for Step 1 may alleviate some stress for medical trainees, other issues arise that may perpetuate disparities and bias against students with little resources in the field of plastic surgery. Residency programs should offer anticipatory guidance regarding prioritization of aspects of application to ease this psychosocial and financial pressure, as well as help students reorganize their constrained time.

The temporomandibular joint (TMJ) has a complex and unique anatomy. When disarranged, it may produce a constellation of symptoms and dysfunction, leading to morbidity. The causes of TMJ dysfunction are numerous but often present with similar clinical signs and symptoms. In this series, we included a review of normal anatomy and a review of the pathophysiology with assessment of the most common TMJ dysfunctions, including myofascial pain, internal derangements of the articular disk, osteoarthrosis, among others. The authors present the last of a 3-part educational series on the TMJ, addressing treatment strategies for these disorders.

Surgical repair of supraspinatus tendons (SSTs) has a high failure rate at the insertion site. A significant hurdle to therapeutic development is that effective intrinsic healing mechanisms are unknown. The MRL/MpJ (MRL) mouse exhibits tissue-specific enhanced healing; however, these tissues exhibit disparate properties from the complex SST. The extent of SST healing in the complex environment of the rotator cuff is unknown. We hypothesized that MRL mice would exhibit enhanced restoration of the structurally complex insertion site, resulting in functional improvements.B6 and MRL mice underwent SST detachment and immediate surgical repair. Mice were analyzed for gait assessment after either 2 or 6 weeks and were then killed humanely for immunohistologic analysis.MRL SSTs demonstrated enhanced recovery of zonal architecture and bone structure compared with B6 SSTs. MRL SSTs exhibited decreased levels of type III collagen at 2 weeks and increased levels of type I procollagen at 6 weeks compared with B6 SSTs. MRL mice experienced initial gait deficits at 2 weeks that had recovered by 6 weeks.The temporal balance of collagen in MRL mice suggests recovery toward naive composition. Initial gait deficits in MRL mice may provide a protective loading environment that is ultimately beneficial. The mechanisms of enhanced healing observed previously in MRL mice may be conserved in the complex SST, providing a platform to interrogate specific aspects of improved healing.

The present study sought to evaluate whether the mFI-5 and modified Charlson Comorbidity Index (mCCI) are stronger predictors of 30-day postoperative complications after open reduction of facial fractures compared with historic risk proxies.A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted to investigate patients who underwent open reduction facial fracture surgery between 2013 and 2018. Risk factors including age, smoking status, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) class were extracted for each patient. The mFI-5 score and mCCI score were calculated based on this data. Univariate logistic regressions were performed (P0.05).A total of 2667 cases were included. Of these, 2131 (80%) were male. The strongest predictors for overall 30-day complications and complication severity were ASA class ≥3 (Odds Ratio [OR]=3.34), comorbidities ≥2 (OR=2.78), mCCl score ≥2 (OR=2.19), and mFI-5 ≥1 (OR=1.96). Smoking status and BMI were not strong predictors of total complications or complication severity. Age was found to be a statically significant, but low-impact, predictor of complications, and severity (OR=1.02, P0.001). The only significant predictors of surgical site infections (SSI) were smoking status (OR=1.56) and ASA class ≥3 (OR=2.40). mFI-5 ≥1 was a significant predictor of hospital readmission. BMI was not associated with any increased risk.The mCCI and mFI-5 are statistically significant predictors of total complications and complication severity in open reduction of facial fracture repair, and thus provide a tool to inform decision making and improve care. Smoking status may increase risk for SSIs following facial fracture repair.

The majority of successful academic physicians cite mentorship as a critical element of their achievements. The goal of this study was to survey established leaders in plastic surgery to identify the importance that mentorship played in their career development, and to identify common themes that enabled them to "pay it forward" in helping to develop the next generation of leaders in plastic surgery.The authors performed a qualitative survey of 14 established leaders in plastic surgery (mentors) in the United States with a strong reputation for mentorship. The authors asked each to identify a key mentor (senior mentor) and mentee, grouping them in triads of a senior mentor, mentor, and mentee. The authors then submitted a similar survey to the mentee.Thirteen mentor-mentee pairs for which both members had responded were included. After reviewing responses to these questions, the authors elicited a number of recurring themes. All respondents emphasized the importance of mentorship to their success in academic plastic surgery. Additional themes included encouraging mentees to find their passion, leading by example, discussing complex cases with residents/students, and using research time as an opportunity.Strong patterns of mentorship are highlighted among the careers of leaders in academic plastic surgery. The authors advocate for formation of mentorship relationships within training programs and more national mentorship programs such as those emerging through the American Society of Plastic Surgeons and the Plastic Surgery Research Council for interested medical students, residents, and junior faculty.

Unilateral coronal craniosynostosis (UCS) is a congenital disorder resulting from the premature suture fusion, leading to complex primary and compensatory morphologic changes in the shape of not only the calvarium and but also into the skull base. This deformity typically requires surgery to correct the shape of the skull and prevent neurologic sequelae, including increased intracranial pressure, sensory deficits, and cognitive impairment.The present multicenter study sought to reverse-engineer the bone dysmorphogenesis seen in non-syndromic UCS using a geometric morphometric approach. Computed tomography scans for 26 non-syndromic UCS patients were converted to three-dimensional mesh models. Two hundred thirty-six unique anatomical landmarks and semi-landmarked curves were then plotted on each model, creating wireframe representations of the Patients' skulls.Generalized Procrustes superimposition, Principal Component Analysis, and heatmaps identified significant superior displacement of the ipsilateral orbit ("harlequin" eye deformity), anterior displacement of the ear ipsilateral to the fused coronal suture, acute deviation of midline skull base structures ipsilateral to the fused coronal suture and flattening of the parietal bone and associated failure to expand superiorly.The described technique illustrates the impact of premature coronal suture fusion on the development of the entire skull and proposes how bone dysmorphology contributes to the Patients' neurologic sequelae. By bridging novel basic science methodologies with clinical research, the present study quantitatively describes craniofacial development and bone dysmorphogenesis.

Introduction: Within the surgical management algorithm for frontal sinus fracture (FSF), the choice of material for nasofrontal duct (NFD) obliteration is controversial, and a multitude of materials have been described in the literature. The present study aims to perform a systematic review to determine postoperative outcomes associated with various NFD obliteration materials. Methods: Two independent reviewers identified studies to be included based on inclusion and exclusion criteria. Odds ratios and Fisher’s Exact Tests were then used to compare outcomes between cohorts based on the material used for NFD obliteration. Complications under review included donor site complications, reoperations, frontal sinus infections, cerebrospinal fluid leaks, cosmetic defects, persistent pain and/or headaches, and mucocele formation. Results: Twenty-nine studies met inclusion criteria. The use of a vascularized flap was associated with a reduced risk of reoperation and postoperative frontal sinus infection compared with non-flap materials (OR = 0.23 (CI: 0.05, 1.04), P = .05. The use of avascular bone graft was associated with an increased risk of reoperation (OR = 8.89 (CI: 2.24, 29.94), P

INTRODUCTION Appropriate treatment of scalp arteriovenous malformations (SAVMs) remains largely unclear given the rarity of reported cases. This single-institution case series presents consecutive patients with extracranial SAVMs and long-term follow up.The primary aim of this study was to review treatment decisions, evaluate clinical outcomes, and compare our experience to available literature in order to better understand SAVMs and improve future outcomes. MATERIALS AND METHODS A retrospective review of consecutive patients with extracranial SAVMs between January 2015 and December 2019 was performed. Treatment factors of interest included embolization method, embolic agents, and decision to proceed with surgical resection. Relevant clinical outcomes included recurrence rates, cure rates, and complications. RESULTS Seven patients were included in the present series. Satisfactory outcomes were ultimately achieved for all 7 patients using embolization with or without combined surgical resection. Embolizations performed in combination with resection were curative in 4 of 4 cases (100%). Embolizations performed without resection were curative in 0 of 4 cases (0%), satisfactory in 2 of 4 cases (50%), and unsatisfactory in 2 of 4 cases (50%). DISCUSSION All SAVM patients in this series were treated satisfactorily using embolization with or without operative resection. This study strongly suggests that embolization combined with surgical resection during the same admission yields the best treatment outcomes for SAVMs, specifically demonstrating lower rates of recurrence and embolization-related complications. Decisions on whether or not to proceed with resection should be made by the interventional radiologist, the plastic surgeon, and the patient together.

Background: Hand and wrist injuries can cause painful, everyday obstacles for patients. Carefully indexing preoperative patient health conditions may better inform surgical care, leading to improved postoperative outcomes. The purpose of the present study is to evaluate if the Modified-Five Item Frailty Index (mFI-5) can accurately predict postoperative complications for hand and wrist surgical repair. Methods: A retrospective review of the American College of Surgeons’ National Surgical Quality Improvement Program database was conducted to investigate patients who underwent hand and wrist surgical repair from January 2013 to December 2019. Patient demographics, comorbidities, surgical logistics, and 30-day readmission due to postoperative complications were extracted. Surgical risk proxies including the mFI-5, age, body mass index (BMI), smoking status within 1 year, the Modified Charlson Comorbidity Index (mCCI), comorbidities, and American Society of Anaesthesiologists Physical Status Classification (ASA class) were calculated. Results: A total of 11 369 patients were included. Thirty-day readmission for total postoperative complications (n = 258) was significantly associated with all surgical risk proxies. However, age, mFI-5 > 2, mCCI > 2, comorbidities > 1, and ASA class 2/3 had the highest statistical significance ( P = 2, and ASA class 2/3 ( P = 1 (n = 224) had the highest statistical significance with age, mCCI > 2, comorbidity of 1, and an ASA class 3 ( P = Conclusions: The mFI-5 may have value in predicting 30-day readmission due to postoperative complications after surgical repair of hand and wrist injuries.

Cleft and craniofacial conditions often present with a variety of functional and esthetic sequelae optimally treated by a multidisciplinary approach. Diagnosis of such conditions pre- or postnatally may evoke parental uncertainty and anxiety, and an important primary consideration is the selection of a cleft and craniofacial team. Identifying an optimal team may be particularly important for developing long-term relationships with clinicians who will ideally work intimately with the family from diagnosis to adulthood. While families, parents, and providers should consider several factors, a dearth of evidence-based suggestions preclude critical appraisal of cleft and craniofacial teams. In this article, the authors summarize medical, surgical, and social considerations for selecting a cleft and craniofacial team to optimize patient outcomes and the family/caregiver experience.