US20150250476A1 - Systems and methods for tissue suspension and compression - Google Patents

Abstract

Suture passer systems for tissue suspension and tissue compression are described. The system can include a shaft and a needle, wherein the needle is freely rotatable with respect to the shaft. The suture may include an overmolded segment. Methods of placing one or more implants, sutures, fastener, bone anchors and other devices are also described. The methods include moving tissue, including the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch. The methods include hyoid bone suspension.

Description

INCORPORATION BY REFERENCE TO ANY PRIORITY APPLICATIONS
• Any and all applications for which a foreign or domestic priority claim is identified in the Application Data Sheet as filed with the present application are hereby incorporated by reference under 37 CFR 1.57. This application claims the priority benefit under 35 U.S.C. §119(e) as a nonprovisional application of U.S. Provisional Application No. 61/948,473, filed on Mar. 5, 2014, which is hereby incorporated by reference in its entirety Also incorporated by reference in their entireties is U.S. Pat. No. 8,460,322 issued on Jun. 11, 2013, and U.S. Pat. Pub. No. 2014/0074518 A1 published on Mar. 13, 2014.
BACKGROUND
• 1. Field
• In some aspects, the invention relates generally to suture passer systems and methods for tissue suspension and tissue compression. Disclosed herein are systems and methods for tissue suspension using one or more sutures, implants, fasteners and/or bone anchors for treating obstructive sleep apnea.
• 2. Description of the Related Art
• In many surgical procedures, there is a need to pass a suture deep into tissue. Sometimes, a surgeon needs to pass a suture deep into tissue to suspend the tissue by fixing the suture to bone. In particular, one such surgical procedure is suspension of tissues for treating conditions such as obstructive sleep apnea (OSA).
• Respiratory disorders during sleep are recognized as a common disorder with significant clinical consequences. During the various stages of sleep, the human body exhibits different patterns of brain and muscle activity. In particular, the REM sleep stage is associated with reduced or irregular ventilatory responses to chemical and mechanical stimuli and a significant degree of muscle inhibition. This muscle inhibition may lead to relaxation of certain muscle groups, including but not limited to muscles that maintain the patency of the upper airways, and create a risk of airway obstruction during sleep. Because muscle relaxation narrows the lumen of the airway, greater inspiratory effort may be required to overcome airway resistance. This increased inspiratory effort paradoxically increases the degree of airway resistance and obstruction through a Bernoulli effect on the flaccid pharyngeal walls during REM sleep.
• Obstructive Sleep Apnea (OSA) is a sleep disorder that affects up to 2 to 4% of the population in the United States. OSA is characterized by an intermittent cessation of airflow in the presence of continued inspiratory effort. When these obstructive episodes occur, an affected person will transiently arouse, regain muscle tone and reopen the airway. Because these arousal episodes typically occur 10 to 60 times per night, sleep fragmentation occurs which produces excessive daytime sleepiness. Some patients with OSA experience over 100 transient arousal episodes per hour.
• In addition to sleep disruption, OSA may also lead to cardiovascular and pulmonary disease. Apnea episodes of 60 seconds or more have been shown to decrease the partial pressure of oxygen in the lung alveoli by as much as 35 to 50 mm Hg. Some studies suggest that increased catecholamine release in the body due to the low oxygen saturation causes increases in systemic arterial blood pressure, which in turn causes left ventricular hypertrophy and eventually left heart failure. OSA is also associated with pulmonary hypertension, which can result in right heart failure.
• Radiographic studies have shown that the site of obstruction in OSA is isolated generally to the supralaryngeal airway, but the particular site of obstruction varies with each person and multiple sites may be involved. A small percentage of patients with OSA have obstructions in the nasopharynx caused by deviated septums or enlarged turbinates. These obstructions may be treated with septoplasty or turbinate reduction procedures, respectively. More commonly, the oropharynx and the hypopharynx are implicated as sites of obstruction in OSA. Some studies have reported that the occlusion begins with the tongue falling back in an anterior-posterior direction (A-P) to contact with the soft palate and posterior pharyngeal wall, followed by further occlusion of the lower pharyngeal airway in the hypopharynx. This etiology is consistent with the physical findings associated with OSA, including a large base of tongue, a large soft palate, shallow palatal arch and a narrow mandibular arch. Other studies, however, have suggested that increased compliance of the lateral walls of the pharynx contributes to airway collapse. In the hypopharynx, radiographic studies have reported that hypopharyngeal collapse is frequently caused by lateral narrowing of the pharyngeal airway, rather than narrowing in the A-P direction.
• OSA is generally diagnosed by performing overnight polysomnography in a sleep laboratory. Polysomnography typically includes electroencephalography to measure the stages of sleep, an electro-oculogram to measure rapid eye movements, monitoring of respiratory effort through intercostal electromyography or piezoelectric belts, electrocardiograms to monitor for arrhythmias, measurement of nasal and/or oral airflow and pulse oximetry to measure oxygen saturation of the blood.
• Following the diagnosis of OSA, some patients are prescribed weight loss programs as part of their treatment plan, because of the association between obesity and OSA. Weight loss may reduce the frequency of apnea in some patients, but weight loss and other behavioral changes are difficult to achieve and maintain. Therefore, other modalities have also been used in the treatment of OSA, including pharmaceuticals, non-invasive devices and surgery.
• Among the pharmaceutical treatments, respiratory stimulants and drugs that reduce REM sleep have been tried in OSA. Progesterone, theophylline and acetozolamide have been used as respiratory stimulants, but each drug is associated with significant side effects and their efficacy in OSA is not well studied. Protriptyline, a tricyclic antidepressant that reduces the amount of REM sleep, has been shown to decrease the frequency of apnea episodes in severe OSA, but is associated with anti-cholinergic side effects such as impotence, dry mouth, urinary retention and constipation.
• Other modalities are directed at maintaining airway patency during sleep. Oral appliances aimed at changing the position of the soft palate, jaw or tongue are available, but patient discomfort and low compliance have limited their use. Continuous Positive Airway Pressure (CPAP) devices are often used as first-line treatments for OSA. These devices use a sealed mask which produce airflow at pressures of 5 to 15 cm of water and act to maintain positive air pressure within the pharyngeal airway and thereby maintain airway patency. Although CPAP is effective in treating OSA, patient compliance with these devices is low for several reasons. Sleeping with a sealed nasal mask is uncomfortable for patients. Smaller sealed nasal masks may be more comfortable to patients but are ineffective in patients who sleep with their mouths open, as the air pressure will enter the nasopharynx and then exit the oropharynx. CPAP also causes dry nasal passages and congestion.
• Surgical treatments for OSA avoid issues with patient compliance and are useful for patients who fail conservative treatment. One surgery used for OSA is uvulopalatopharyngoplasty (UPPP). UPPP attempts to improve airway patency in the oropharynx by eliminating the structures that contact the tongue during sleep. This surgery involves removal of the uvula and a portion of the soft palate, along with the tonsils and portions of the tonsillar pillars. Although snoring is reduced in a majority of patients who undergo UPPP, the percentage of patients who experience reduced frequency of apnea episodes or improved oxygen saturation is substantially lower. Postoperatively, many patients that have undergone UPPP continue to exhibit oropharyngeal obstruction or concomitant hypopharyngeal obstruction. Nonresponders often have physical findings of a large base of tongue, an omega-shaped epiglottis and redundant aryepiglottic folds. UPPP is not a treatment directed at these structures. UPPP also exposes patients to the risks of general anesthesia and postoperative swelling of the airway that will require a tracheostomy. Excessive tissue removal may also cause velo-pharyngeal insufficiency where food and liquids enter into the nasopharynx during swallowing.
• Laser-assisted uvulopalatopharyngoplasty (LAUP) is a similar procedure to UPPP that uses a CO₂laser to remove the uvula and portions of the soft palate, but the tonsils and the lateral pharyngeal walls are not removed.
• For patients who fail UPPP or LAUP, other surgical treatments are available but these surgeries entail significantly higher risks of morbidity and mortality. In genioglossal advancement with hyoid myotomy (GAHM), an antero-inferior portion of the mandible, which includes the attachment point of the tongue musculature, is repositioned forward and in theory will pull the tongue forward and increase airway diameter. The muscles attached to the inferior hyoid bone are severed to allow the hyoid bone to move superiorly and anteriorly. Repositioning of the hyoid bone expands the retrolingual airspace by advancing the epiglottis and tongue base anteriorly. The hyoid bone is held in its new position by attaching to the mandible using fascia. Variants of this procedure attach the hyoid bone inferiorly to the thyroid cartilage.
• A laser midline glossectomy (LMG) has also been tried in some patients who have failed UPPP and who exhibit hypopharyngeal collapse on radiographic studies. In this surgery, a laser is used to resect the midline portion of the base of the tongue. This involves significant morbidity and has shown only limited effectiveness.
• In some patients with craniofacial abnormalities that include a receding mandible, mandibular or maxillomandibular advancement surgeries may be indicated for treatment of OSA. These patients are predisposed to OSA because the posterior mandible position produces posterior tongue displacement that causes airway obstruction. In a mandibular advancement procedure, the mandible is cut bilaterally posterior to the last molar and advanced forward approximately 10 to 14 mm. Bone grafts are used to bridge the bone gap and the newly positioned mandible is wire fixated to the maxilla until healing occurs. Mandibular advancement may be combined with a Le Fort I maxillary osteotomy procedure to correct associated dental or facial abnormalities. These procedures have a high morbidity and are indicated only in refractory cases of OSA.
• Experimental procedures described in the clinical literature for OSA include the volumetric radiofrequency tissue ablation and hyoidplasty, where the hyoid bone is cut into several segments and attached to a brace that widens the angle of the U-shaped hyoid bone. The latter procedure has been used in dogs to increase the pharyngeal airway lumen at the level of the hyoid bone. The canine hyoid bone, however, is unlike a human hyoid bone because the canine hyoid bone comprises nine separate and jointed bones, while the human hyoid bone comprises five bones that are typically fused together.
• Another surgical procedure performed to treat OSA is suture based tongue suspension. However, current techniques for suture based tongue suspension require the passage of suture through the tongue and into the oral space. This technique carries with it significant risks of infection as well as difficulty in accessing the optimal placement for the suspension suture.
• Notwithstanding the foregoing, there remains a need for improved methods and devices for treating various conditions, including but not limited to obstructive sleep apnea. There is also a need for improved devices and methods for delivering suture into tissue. Specifically with respect to current methods for tissue suspension and compression, there is a need to reduce infection risk due to suture exposure to the oral cavity, to improve the surgeon's range and ability to precisely locate and orient the suture, and to improve the ability of surgeons to properly tension the suture by eliminating the need to perform knot-tying while simultaneously controlling the final tension of the suture.
SUMMARY
• The present disclosure provides suture passer system and methods for tissue suspension or compression.
• In some embodiments, a suture passer is provided. The suture passer can comprise a proximal handle. The suture passer can comprise an elongate shaft having a proximal end, a distal end, and a longitudinal axis. The suture passer can comprise a suture passing element coupled to the distal end of the shaft. In some embodiments, the suture passing element is movable with respect to the shaft, and configured to swivel with respect to the shaft in an arc of at least about 90 degrees. In some embodiments, the suture passing element comprises a feature to engage the suture. In some embodiments, the suture passing element comprises a tube.
• In some embodiments, a suture passer is provided. The suture passer can comprise an elongate shaft. The suture passer can comprise a suture passing element coupled to the elongate shaft. In some embodiments, the suture passing element is configured to swivel with respect to the elongate shaft. The suture passer can comprise a second stage element carried within the suture passing element. In some embodiments, the second stage element can be configured to extend from and retract into the suture passing element. In some embodiments, the second stage element can be configured to exit an opening at or near a distal end of the suture passing element and form a path through tissue. The suture passer can comprise a suture carried by the second stage element. In some embodiments, the second stage element comprises a grasping element operably connected to the suture. In some embodiments, the grasping element comprises a snare. In some embodiments, the grasping element comprises movable jaws.
• In some embodiments, a suspension line is provided. The suspension line can comprise a suture. The suspension line can comprise an overmolded segment. The suspension line can comprise a feature between the suture and the overmolded segment which serves as a bearing.
• In some embodiments, a method is provided. The method can include the step of providing an implant having a first end and a second end. The method can include the step of securing the first end of the implant to the palatopharyngeal arch. The method can include the step of tensioning the implant. The method can include the step of securing the second end of the implant to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch.
• In some embodiments, the implant comprises barbs. In some embodiments, the implant comprises suture loops. The method can include the step of securing the implant to a bone anchor. The method can include the step of adjusting the tension of the implant post-operatively.
• In some embodiments, a method is provided. The method can include the step of moving a portion of a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch. The method can include the step of securing a fastener to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch.
• In some embodiments, a method is provided. The method can include the step of forming a loop around the hyoid bone. The method can include the step of securing the loop to a bone anchor, wherein the bone anchor is located on the mandible. In some embodiments, the loop is a girth hitch. In some embodiments, the loop is formed by an implant comprising a longitudinally extending tail and an implant head. In some embodiments, the implant comprises a ratchet for tensioning the loop.
• In some embodiments, a method is provided. The method can include the step of forming a hole in the hyoid bone. The method can include the step of passing an implant through the hole in a collapsed configuration. The method can include the step of expanding the implant to an expanded configuration, wherein the implant is unable to pass through the hole in the expanded configuration. In some embodiments, the implant comprises expandable barbs.
• In some embodiments, a suspension line for tensioning tissue is provided. The suspension line can comprise a suture having a first thickness dimension. The suspension line can comprise an elastomer surrounding a portion of the suture having a second thickness dimension greater than the first thickness dimension. The suspension line can comprise at least one bearing element configured to allow the suture to move with respect to the elastomer while maintaining the flexibility of the suture.
• In some embodiments, the at least one bearing element is at least partially covered by the elastomer. In some embodiments, the at least one bearing element comprises a knot. In some embodiments, the at least one bearing element comprises a bead. In some embodiments, the at least one bearing element comprises a coil. In some embodiments, the coil comprises polypropylene. In some embodiments, the elastomer comprises silicone. In some embodiments, the elastomer is at least partially radiopaque. In some embodiments, the elastomer is compounded with a radiopacifier.
• In some embodiments, a suture passer is provided. The suture passer can comprise a first section with a first distal tip and a first proximal handle. The suture passer can comprise a second section with a second distal tip and a second proximal handle. The suture passer can comprise a slot on the sidewall of the first section. The suture passer can comprise a first interior lumen extending through a portion of the first section and in communication with the slot. The suture passer can comprise a plunger configured to enter the slot and the first interior lumen and move a suture toward the second section.
• In some embodiments, the plunger comprises a feature to engage the suture. The suture passer can comprise a second interior lumen extending through a portion of the second section. In some embodiments, the plunger is configured to enter the second interior lumen. In some embodiments, the second section comprises a snare. In some embodiments, the first section is configured to pivot relative to the second section. In some embodiments, the plunger comprises a head, wherein the head has at least one dimension larger than a corresponding dimension of the plunger. In some embodiments, the first distal tip is curved. In some embodiments, the second distal tip is curved. In some embodiments, the first interior lumen is open at the first distal tip. In some embodiments, the second interior lumen is open at the second distal tip.
• In some embodiments, a method of using a suture passer is provided. The method can include the step of providing a suture passer comprising a first section with a first distal tip, a second section with a first distal tip, and a first interior lumen extending through a portion of the first section. The method can include the step of advancing the suture passer around a hyoid bone. The method can include the step of passing a plunger into the first interior lumen.
• The method can include the step of engaging the plunger with a suture. The method can include the step of engaging the suture with a snare. The method can include the step of engaging the suture with a feature of the second section. The method can include the step of disengaging the suture as the plunger is retracted through the first interior lumen. The method can include the step of protruding the plunger from the first interior lumen toward the second distal tip. In some embodiments, the suture passer comprises a second interior lumen extending through a portion of the second section, further comprising passing the plunger into the second interior lumen. The method can include the step of engaging the suture with a snare coupled to the second section. The method can include the step of engaging the suture with a feature coupled to the second section. The method can include the step of engaging a suture with the second section. The method can include the step of advancing the plunger toward the suture. The method can include the step of engaging the suture with the plunger. The method can include the step of moving the suture through the first interior lumen as the plunger is retracted. The method can include the step of moving the suture through the first interior lumen as the first section is pivoted.
• In some embodiments, a method is provided. The method can include the step of providing a suture having a first strand, a second strand, and an arc between the first strand and the second strand. The method can include the step of placing the arc on one side of the hyoid bone. The method can include the step of placing the first strand and the second strand on the other side of the hyoid bone. The method can include the step of forming a girth hitch around the hyoid bone. The method can include the step of securing the first strand and the second strand to a bone anchor. In some embodiments, the bone anchor is located on the mandible. In some embodiment, the system further includes a second suture comprising a third strand, a fourth strand, and a second arc between the third strand and the fourth strand. The method can include the step of coupling the third strand to the first strand. The method can include the step of pulling the third strand to form the girth hitch. The method can include the step of placing the second arc under the first arc. The method can include the step of pulling the suture such that the second arc is on one side of the hyoid bone and both the third and fourth strands are on other side of the hyoid bone. In some embodiments, the system further comprises an elastomer surrounding a portion of the suture. In some embodiments, the system further comprises an at least one bearing element on the suture. In some embodiments, the at least one bearing element is at least partially covered by the elastomer.
• In some embodiments, an apparatus is provided having a shaft for passing a suture and a needle coupled to the shaft. The needle is freely rotatable with respect to the shaft. The needle can include a feature to engage the suture. The needle can include a tube. The apparatus can have a second stage element configured to extend from the needle.
• In some embodiments, an apparatus is provided having a suture, an overmolded segment, and a feature between the suture and the overmolded segment which serves as a bearing.
• In some embodiments, a method is provided which comprises the steps of providing an implant having a first end and a second end, securing the first end of the implant to the palatopharyngeal arch, tensioning the implant, and securing the second end of the implant to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch. The implant can include barbs. The implant can include suture loops. The method can include the step of securing the implant with a bone anchor. The method can include the step of adjusting the tension of the suture loops post-operatively.
• In some embodiments, a method is provided which comprises the steps of moving a portion of a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch; and securing a fastener to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch.
• In some embodiments, a method is provided which comprises the steps forming a loop around the hyoid bone, and securing the loop to a bone anchor, wherein the bone anchor is located on the mandible. The loop can be a girth hitch. The loop can be formed by an implant comprising a longitudinally extending tail and an implant head. The implant can include a ratchet.
• In some embodiments, a method is provided which comprises the steps of forming a hole the hyoid bone; passing an implant through the hole in a collapsed configuration; and expanding the implant to an expanded configuration, wherein the implant is unable to pass through the hole. The implant can include expandable barbs.
• Also disclosed herein is a suture passer comprising one or more of: a proximal handle; an elongate shaft having a proximal end, a distal end, a tubular body, and a longitudinal axis; a needle coupled to the distal end of the shaft, the needle having an arcuate deployed configuration, wherein the needle is movable with respect to the shaft, and configured to swivel with respect to the shaft in an arc of at least about 90 degrees; and a control on the proximal handle configured to swivel the needle with respect to the shaft. The needle can comprise a feature to engage the suture, and comprise a tube in some embodiments.
• In some embodiments, disclosed herein is a suture passer comprising one or more of: a proximal handle having a first actuator control and a second actuator control; a first elongate shaft extending distally from the handle; a first needle carried within the first elongate shaft, the first needle configured to extend from and retract into the first elongate shaft, the first needle having a straight configuration when located within the first elongate shaft, the first needle configured to exit an opening at or near a distal end of the first elongate shaft and form a curved or lateral path through tissue upon actuation of the first actuator control; and a second needle carried within the first needle, the second needle configured to extend from and retract into the first needle, the second needle having a straight configuration when located within the first elongate shaft, the first needle configured to exit an opening at or near a distal end of the first needle and form a curved or lateral path through tissue upon actuation of the second actuator control, the second needle having an extended geometry that is different from that of the first needle; and a suture carried by the second needle. The second needle can comprise a grasping element operably connected to the second needle, such as, for example, a snare or movable jaws.
• Also disclosed herein is a suspension line comprising a suture; an overmolded segment; and a feature between the suture and the overmolded segment which serves as a bearing.
• In another embodiment, disclosed is a method comprising providing an implant having a first end and a second end; securing the first end of the implant to the palatopharyngeal arch; tensioning the implant; and securing the second end of the implant to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch. The implant can comprises barbs and/or suture loops. The implant can also be secured with a bone anchor. The tension of the suture loops can be adjusted during the procedure, or post-operatively, such as 1 hour, 6 hours, 1 day, 1 week, 1 month, or more post-operatively.
• Also disclosed is a method comprising moving a portion of a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch; and securing a fastener to a tissue selected from the group consisting of: the superior pharyngeal constrictor muscle, palatopharyngeal arch, and palatoglossal arch.
• Also disclosed is a method comprising: forming a loop around the hyoid bone; and securing the loop to a bone anchor, wherein the bone anchor is located on the mandible. The loop can be a girth hitch. The loop can be formed by an implant comprising a longitudinally extending tail and an implant head. The implant can also comprise a ratchet for tensioning the loop.
• In some embodiments, disclosed is a method comprising: forming a hole in the hyoid bone; passing an implant through the hole in a collapsed configuration; and expanding the implant to an expanded configuration, wherein the implant is unable to pass through the hole. The implant can comprise expandable barbs.
• Further disclosed herein is a suspension line for tensioning tissue, comprising: a suture having a first thickness dimension; a elastomer surrounding a portion of the suture and defining a central segment of the suspension line having a second thickness dimension greater than the first thickness dimension; and at least one bearing element on the central segment of the suspension line, the bearing element configured to provide a rigid bearing to allow the suture to move with respect to the elastomer (e.g., silicone) while maintaining the flexibility of the suture. The at least one bearing element can be at least partially covered by the elastomer. The bearing element can include, for example, a knot, a bead, and/or a coil. The coil can comprise polypropylene, for example. The elastomer can be at least partially radiopaque, and/or compounded with a radiopacifier, such as barium sulfate for example.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIGS. 1A-1C illustrate an embodiment of a suture passer with a suture passing element.
• FIGS. 2A-2C illustrate a method of using the suture passer ofFIG. 1A.
• FIGS. 3A-3D illustrate an embodiment of a suture passer with a suture passing element.
• FIGS. 4A-4D illustrate embodiments of a suture passing element.
• FIG. 5 illustrates the inability of a suture passer to reach a target location.
• FIGS. 6A-6C illustrate an embodiment of a suture passer with a second stage element.
• FIGS. 7A-7B illustrate an embodiment of a suture passer with a second stage element.
• FIGS. 8A-8B illustrate an embodiment of a suture passer with a second stage element.
• FIGS. 9A-9B illustrate an embodiment of a suture passer system with a second stage element.
• FIGS. 10A-10B illustrates an embodiment of a suture passer with a second stage element.
• FIGS. 11A-11E illustrate embodiments of a suture.
• FIGS. 12A-12B illustrate a method of making a suture.
• FIGS. 13A-D illustrates a method of delivering a plurality of suture loops into tissue.
• FIG. 14 illustrates a method of narrowing the lateral pharyngeal wall, according to one embodiment of the invention.
• FIGS. 15A-15B illustrate the anatomy with and without an implant.
• FIGS. 16A-16D illustrate an embodiment of a method of inserting an implant.
• FIGS. 17A-17B illustrate an embodiment of an implant with a tissue ingrowth portion.
• FIGS. 18A-18B illustrate an embodiment of a method of inserting an implant.
• FIGS. 19A-19E illustrate an embodiment of a method of inserting a suture.
• FIG. 20 illustrates an embodiment of a method of inserting a suture.
• FIGS. 21A-21B illustrate an embodiment of a method of using a bone anchor.
• FIGS. 22A-22B illustrate an embodiment of an apparatus and method of securing a tissue.
• FIGS. 23A-23C illustrate embodiments of a fastener.
• FIGS. 24A-24D illustrate an embodiment of a method of hyoid bone suspension.
• FIGS. 25A-25B illustrate an embodiment of a suture passer.
• FIGS. 26A-26B illustrate an embodiment of a method of hyoid bone suspension.
• FIGS. 27A-27D illustrate an embodiment of a method of hyoid bone suspension.
• FIG. 28 illustrates an embodiment of a method of hyoid bone suspension.
• FIGS. 29A-29C illustrate an embodiment of an implant and a method of hyoid bone suspension.
• FIG. 30 illustrates an embodiment of an implant.
• FIG. 31 illustrates a method of hyoid bone suspension using an implant.
• FIGS. 32A-32B illustrate an embodiment of an implant.
• FIGS. 33A-33B illustrate an embodiment of an implant.
• FIGS. 34A-34F illustrate an embodiment of a suture passer.
DETAILED DESCRIPTION
• In some embodiment, disclosed is a suture passer system and method for passing a suture (e.g., a suspension line, a tether, a tether loop, a suture, a suture loop, suture tape, an implant, etc.) through tissue to suspend or compress the tissue. The term “suture” as used herein, unless otherwise specified or limited, is intended to have its ordinary meaning and is also intended to include all structures, including any of the aforementioned or later-described examples, that can be passed through tissue using the devices described herein.
• As illustrated inFIG. 1A, thesuture passer100 can include a first elongate tubular body orshaft102. Theshaft102 can releasably couple to asuture passing element104. Thesuture passing element104 can be a flexible needle. Thesuture passing element104 can pass one, two, or more sutures therethrough. Portions of the one or more sutures can reside outside of thefirst shaft102. The distal end of thesuture passing element104 can be sharpened to facilitate tissue penetration. In other embodiments, the distal end of thesuture passing element104 can be blunt to prevent distal penetration through the mucosa, thus preventing a through-and-through puncture. Theshaft102 can have a length of between about 4 cm to about 30 cm in some embodiments.
• Thesuture passer100 can include a second elongate tubular body or shaft (not shown). The second shaft can couple to a suture receiving element (not shown). The suture receiving element can be a snare, for example. The second shaft and thesuture passer100 can be substantially similar to suture passer system described in commonly owned U.S. Pat. No. 8,460,322, the entire disclosure of which is incorporated by reference. Thesuture passer100 can include any feature described in commonly owned U.S. Pat. No. 8,460,322.
• Theshaft102 can extend distally from aproximal handle108. As illustrated inFIG. 1A, the proximal end of theshaft102 can be coupled to thehandle108. In some embodiments, theshaft102 rotates when thehandle108 rotates. Theshaft102 can rotate about thelongitudinal axis114 of theproximal handle108. In some embodiments, theshaft102 can rotate independently from thehandle108. Theshaft102 can rotate about thelongitudinal axis112 of theshaft102.
• As illustrated inFIG. 1A, thesuture passing element104 can be coupled to the distal end of theshaft102. Thesuture passing element104 can rotate relative to the distal end of theshaft102. Theshaft102 can include one, two, or more slots orapertures105 on the sidewall of the distal end of theshaft102. Thesuture passing element104 can be located within theslot105. In some embodiments, thesuture passing element104 is formed as an independent component from theshaft102. Thesuture passing element104 can rotate relative to the slot105 (e.g., 0°, 10°, 20°, 30°, 40°, 50°, 60°, 70°, 80°, 90°, 100°, 110°, 120°, 130°, 150°, 160°, 170°, 180°, 190°, 200°, 210°, 220°, 230°, 240°, 250°, 260°, 270°, 280°, 290°, 300°, 310°, 320°, 330°, 340°, 350°, 360°, at least 90°, at least 180°, at least 270°, etc., or a range including any two of the foregoing values, such as between about 0° and about 180° for example).
• Thesuture passing element104 can function as a hook. Thesuture passing element104 can be moved in position relative to theshaft102. Theshaft102 can be rotated relative to thesuture passing element104 after thesuture passing element104 hooks, or passes an elongate element around a bone. Thesuture passing element104 can rotate when theshaft102 is held stationary. Theshaft102 can rotate when thesuture passing element104 is held stationary. Thesuture passing element104 and theshaft102 can rotate at the same time, in the same directions and/or orientations or a different directions and/or orientations. Thesuture passing element104 can rotate relative to thelongitudinal axis112 of theshaft102. Thesuture passing element104 can rotate relative to thelongitudinal axis114 of theproximal handle108. Thesuture passing element104 can rotate about anaxis116, whereinaxis116 is perpendicular to thelongitudinal axis112 of theshaft102. Thesuture passing element104 can rotate about one, two, or more axes. In some embodiments, thesuture passing element104 while rotating in an arc, offset from the longitudinal axis of theshaft102, during at least one point during rotation the path of the arc intersects thelongitudinal axis112 of theshaft102. The degree of rotation of thesuture passing element104 can be, in some embodiments, at least about 45°, 90°, 135°, 180°, 225° or more, or between about 90° and 180°, 135-225°, or different ranges including two of the foregoing values thereof for example.
• Thesuture passing element104 can include alongitudinal axis118. In some orientations, thelongitudinal axis118 of thesuture passing element104 is aligned with thelongitudinal axis112 of theshaft102, as shown inFIGS. 1A and 2A. In some orientations, thelongitudinal axis118 of thesuture passing element104 is not aligned with thelongitudinal axis112 of theshaft102, as shown inFIGS. 1B,1C, and2C as well as the schematic ofFIG. 1C clarifying certain features. Thesuture passing element104 can be rotated relative to theslot105 as shown inFIG. 1C.
• In some embodiments, a mechanism (not shown) can control the rotation of thesuture passing element104 relative to theshaft102. The mechanism110 can be housed within theshaft102. Thesuture passing element104 can be coupled to theshaft102. Thesuture passing element104 can be retained in theslot105. Theslot105 can include abushing120 or other device known in the art to permit free rotation. The distal end of theshaft102 can be split to house thebushing120. Acomponent130 such as a fastener can couple the split distal end of theshaft102 to prevent the disengagement and/or loosening of thebushing120. In some embodiments, thebushing120 provides friction to hold thesuture passing element104 relative to theshaft102. The torque exerted by rotating theshaft102 can rotate theshaft102 relative to thesuture passing element104.
• As illustrated inFIGS. 2A-2C, a method of using thesuture passer100 is shown with respect to the hyoid bone. The method illustrates a generally superior to inferior approach. Thelongitudinal axis118 of thesuture passing element104 can be generally aligned with thelongitudinal axis112 of theshaft102. Thesuture passing element104 can extend from the distal end of theshaft102. Theshaft102 can be manipulated relative to the hyoid bone until thesuture passing element104 surrounds, such as least partially circumscribes a portion of the hyoid bone.FIG. 2B illustrates the front view of the approach. As shown inFIGS. 2A-2B, thelongitudinal axis118 of thesuture passing element104 is aligned with thelongitudinal axis112 of theshaft102. Thesuture passing element104 can hook or otherwise pass an elongate element such as a suture around the hyoid bone. Theshaft102 can be rotated relative to thesuture passing element104 and/or thesuture passing element104 can be rotated relative to the shaft.FIG. 2C illustrates thesuture passing element104 in a position after a completed pass in some embodiments. Theshaft102 is rotated relative to the suture passing element104 a different position relative to the hyoid bone. Thelongitudinal axis118 of thesuture passing element104 is not aligned with thelongitudinal axis112 of theshaft102.
• As illustrated inFIGS. 3A-3D, thesuture passing element104 can rotate relative to theshaft102. This can be completed by an internal mechanism to actively rotate thesuture passing element104, overcoming frictional forces between theshaft102 and thesuture passing element104. Thesuture passing element104 can be coupled to theshaft102 via thebushing120. Thesuture passing element104 can rotate in an arc about, or at least about 15 degrees, 30 degrees, 60 degrees, 90 degrees, 105 degrees, 120 degrees, 135 degrees, 150 degrees, 165 degrees, 180 degrees, 195 degrees, 210 degrees, 225 degrees or more relative to theaxis116. Theaxis116 can be transverse to thelongitudinal axis112 of theshaft102.
• Thesuture106 can be carried by thesuture passing element104 and thereby passed around the hyoid bone. As illustrated inFIG. 4A, thesuture106 can form a suture loop including afirst strand106A, asecond strand106B and an arc (e.g., loop portion)106C connected to and residing between thefirst strand106A and thesecond strand106B. Thearc106C can form a portion of a circle. Thesuture106 can be pre-attached to thesuture passing element104 prior to thesuture passing element104 being passed around the hyoid bone. In other embodiments, thesuture106 can be attached to thesuture passing element104 after thesuture passing element104 is passed around the hyoid bone. Thesuture106 can be passed around the hyoid bone as thesuture passer100 is retracted. Thesuture106 can remain in place, around the hyoid bone, after thesuture passer100 is retracted.
• As illustrated inFIGS. 4A-4D, thesuture passing element104 can have a variety of configurations. As shown inFIGS. 4A-4C, a portion of thesuture passing element104 can include one or more suture engagement mechanisms. As shown inFIG. 4A, the suture engagement mechanism can be aslot124. Thesuture106 can be inserted into theslot124. For instance, thefirst strand106A, thesecond strand106, and/or thearc106C can be inserted into the slot. The insertion of thearc106C into theslot124 and around the hyoid bone may facilitate the tying of a knot, as described herein. As shown, theslot124 can be a lateral slot extending through thesuture passing element104. Thesuture106 can be inserted so that thearc106C is on one side of thesuture passing element104 and thefirst strand106A and thesecond strand106B of thesuture106 are on the other side of thesuture passing element104.
• As shown inFIG. 4B, the suture engagement mechanism can be a plurality ofholes126,126′ (e.g., two or more holes). While two holes are shown, other configurations are contemplated (e.g., three, four, five, six, etc.). Thefirst strand106A of thesuture106 can be inserted into afirst hole126, and thesecond strand106B of thesuture106 can be inserted into asecond hole126′. As shown, theholes126,126′ can be laterally-facing (or alternatively distal-facing) holes with respect to the distal end of thesuture passing element104. Theholes126,126′ can extend through thesuture passing element104. Thesuture106 can be inserted so that thearc106C is on one side of thesuture passing element104 and thefirst strand106A and thesecond strand106B of thesuture106 are on the other side of thesuture passing element104.
• As shown inFIG. 4C, the suture engagement mechanism can be anotch128. Thesuture106 can be inserted into thenotch128. As shown, thenotch128 can be a lateral notch extending along a surface of thesuture passing element104. Thearc106C of thesuture106 can be inserted into thenotch128. Thefirst strand106A is on one side of thesuture passing element104 and thesecond strand106B is on the other side of thesuture passing element104. Theslot124, theholes126, and thenotch128 can be formed in a distal end of thesuture passing element104. Thesuture106 can be coupled to thesuture passing element104 before or after passing thesuture passing element104 is passed around a bone or tissue. In some methods, the suture engagement mechanism can guide thesuture106 around the bone or tissue.
• As shown inFIG. 4D, the suture engagement mechanism can be alumen130. In some embodiments, thelumen130 extends through a portion of the entire length of thesuture passing element104. Thelumen130 can include a distally-facing exit aperture, as opposed to the laterally-facing suture engagement mechanisms described with respect toFIGS. 4A-4C. Thelumen130 can extend the entire length of thesuture passing element104. Thelumen130 can extend along the length of the curvedlongitudinal axis118 of thesuture passing element104. In other words, thesuture passing element104 can be in the form of a tubular structure.
• In some embodiments, thesuture passing element104 includes asecond stage element132 as shown inFIG. 6A. Thesecond stage element132 can be movable within thecentral lumen130 as illustrated inFIG. 4D. Thesecond stage element132 can be coaxial with thesuture passing element104. Thesuture passing element104 allows for the passage of thesecond stage element132 through thesuture passing element104. As shown inFIG. 5, thesuture passing element104 may be unable to reach atarget location302. Thesuture passing element104, in some embodiments, does not penetrate thesoft tissue300. In some cases, this limitation is caused by the interference of theshaft102 with thesoft tissue300. In some cases, this limitation is caused by the geometry of thesuture passer100 and/or the geometry of the patient's anatomy.
• This limitation has been observed, for example, in some cases when attempting to pass thesuture passing element104 close to the backside (e.g., posterior surface) of a body structure such as abone200, such as the hyoid bone for example. Thebone200 can be located deep within an incision. Thebone200 can be surrounded bysoft tissue300. Asuture passing element104 that is agile enough to start the pass while maintaining proximity to thebone200 may not be sufficiently long enough to penetrate the soft tissue on the opposing side of thebone200 to reach thetarget location302. In other words, the need for agility of thesuture passing element104 may limit the length of thesuture passing element104. In other words, the design constraints of thesuture passer100 may prevent thesuture passing element104 from reaching thetarget location302.
• Thesecond stage element132 can be deployed to reach thetarget location302, as shown inFIG. 6A. Thesecond stage element132 can be deployed through thelumen130 of thesuture passing element104. Thesuture passer100 with thesecond stage element132 can penetrate thesoft tissue300 after passing around thebone200. Thesuture passer100 with thesecond stage element132 can form a complete pass (e.g., a loop) around thebone200.
• As shown inFIGS. 6A-6B, thesecond stage element132 can extend distally beyond, and from a distal end of thesuture passing element104. Thesecond stage element132 can be a linear extension of the distal end of thesuture passing element104. As shown inFIGS. 6A-6C, atool134 can be used to pass thesecond stage element132 through thesuture passing element104. Thetool134 can insert thesecond stage element132 into thelumen130 of thesuture passing element104. In some embodiments, thesecond stage element132 can be inserted into thesuture passing element104 at the proximal end of thesuture passing element104. In some embodiments, thesecond stage element132 can be inserted into thesuture passing element104 at the location where thesuture passing element104 couples with theshaft102.
• Thesecond stage element132 can include aneedle136, as shown inFIG. 6B. Theneedle136 facilitates the additional tissue penetration to reach thetarget location302. Thesecond stage element132 can include a suture engagement mechanism to engagesuture106. The suture engagement mechanisms can include those shown inFIGS. 4A-4D. For instance, the distal end of thesecond stage element132 can include a slot, one or more holes, a notch, or a lumen or other feature.
• As shown inFIGS. 7A-7B, thesecond stage element132 can include asnare137. Thesnare137 can extend through thelumen130 of thesuture passing element104 as described herein.FIG. 7A shows thesnare137 retracted andFIG. 7B shows thesnare137 advanced from the distal end of thesuture passing element104. Thesnare137 creates a larger target for the user to place thesuture106. In other words, thesnare137 may be, in some embodiments, easier to thread with thesuture106 than the suture engagement mechanisms such as the slot, the holes, and the notch, shown inFIGS. 4A-4D.
• As shown inFIGS. 8A-8B, thesecond stage element132 can include features ofFIGS. 6A-6B and7A-7B. Thesecond stage element132 can include both aneedle140 and asnare142. Theneedle140 facilitates the additional tissue penetration to reach thetarget location302. Thesnare142 creates a larger target for the user to place thesuture106 in thesuture passer100. Thesnare142 can be operably attached to theneedle140 as illustrated, such as via laterally-facing apertures in theneedle140.FIG. 8A shows thesecond stage element132 in a retracted configuration andFIG. 8B shows thesecond stage element132 in an extended configuration and advanced from the distal end of thesuture passing element104.
• As shown inFIGS. 9A-9B, thesecond stage element132 can be agrasper144 having a plurality of movable jaws. Thegrasper144 can be configured to hold one ormore sutures106 when thegrasper144 is retracted.FIG. 9A shows thegrasper144 retracted.FIG. 9B shows thegrasper144 advanced from the distal end of thesuture passing element104. In some embodiments, thegrasper144 can open when deployed from the distal end of thesuture passing element104, releasing thesutures106. Thesutures106 can be coupled to thegrasper144 and/or thesuture passer100 prior to thesuture passer100 advancing around thebone200. In some embodiments, thegrasper144 can close around thesutures106 and transport thesutures106 around thebone200. Thegrasper144 can be retracted into thesuture passing element104.
• In some embodiments, thesuture passing element104 can have a complex configuration having a plurality of distal curved regions having differing radii of curvature, such as a first region having a first radii of curvature, and a second region having a second radii of curvature that is greater or less than the first radii of curvature. The first region and the second region can have convex curves, concave curves, or one convex and the other concave in some embodiments.FIGS. 10A-10B show a coiledsuture passing element148, resembling a pig's tail. The coiledsuture passing element148 can have any combination of the characteristics described herein with reference to suture passingelement104. The coiledsuture passing element148 can be tubular. The coiledsuture passing element148 can include asecond stage element132. Thesecond stage element132, such as a needle, facilitates the additional tissue penetration to reach thetarget location302. Thesecond stage element132, such as a snare, can create a larger target for the user to place thesuture106. Thesecond stage element132, such as grasper, can hold or releasesutures106 during the pass.
• In some embodiments, the outer or inner diameter of the shaft of thesuture passer100 can be between about ⅜ inch and about 1 inch. The diameter can be selected based upon the method to be performed. The outer or inner diameter of thesuture passing element104 and the coiledsuture passing element148 can be, for example, between about 1/16 inch and about ⅛ inch for methods for passing a suture around the hyoid bone.
• The diameter rod or tube used to make thesuture passing element104 can depend on a number of factors. In some embodiments, it may be desirable to have thesuture passing element104 that is stiff. For instance, thesuture passing element104 may need to be stiff enough to penetrate tissue, such as tough connective tissues around the hyoid bone. Thesuture passing element104 may need to be large enough to accommodate features described herein, such as suture engagement mechanisms. Thesuture passing element104 may need to be large enough to accommodate additional components, such as thesecond stage element132. It may be desirable to design thesuture passer100 as small as possible, for instance, with as small diameter as possible. A small diameter may minimize the amount of injury to the tissue. The diameter ofsecond stage element132 can be, for example between about 1/16 inch and about ⅛ inch for methods for passing a suture around the hyoid bone.
• In some embodiments, thesuture passing element104 is subjected to torque. For instance, thesuture passing element104 may be subjected to torque loads when pushed through connective tissue. It can be advantageous, in some embodiments, to minimize deformations that occur when thesuture passing element104 is subjected to torque, load and/or force. Thesuture passing element104 may be sufficiently stiff to navigate through connective tissue. Thesuture passing element104 can be formed, in some embodiments, from a material (e.g., stainless steel) that has adequate characteristics to resist deformation during the intended use. Thesecond stage element132 can be formed, in some embodiments, from a material that is super-elastic (e.g., nitinol).
• FIGS. 11A-11E illustrate various embodiments ofsutures106. The sutures described herein can include a variable-thickness suspension line for suspending tissue, including asuture106 having a first thickness dimension. The suture described herein can include an elastomer surrounding a portion of the suture forming anovermolded segment150 and defining a central segment of the suspension line having a second thickness dimension greater than the first thickness dimension. The elastomer can be overmolded onto thesuture106. The elastomer can be, for example silicone. Thesuture106 can be braided. The elastomer can be overmolded over a plurality of discontinuous segments of thesuture106. The central segment of the suspension line can include one or more knots and/or one or more beads for improving adhesion between the suture and the elastomer. The suspension line could have a rounded, and/or a rectangular cross-section. As such, the sutures can either be elastic or inelastic. In some embodiments, elastic sutures can be stretched to at least about 110%, 120%, 130%, 140%, 150%, 175%, 200%, 250%, 300%, or more of their unstretched length.
• Thesuture106 can include at least one transition zone extending from the central segment of the suspension line to a lateral end of the suspension line, the transition zones having a thickness dimension that tapers from the second thickness dimension to the first thickness dimension. Thesuture106 can have any features described in commonly owned U.S. patent application Ser. No. 14/020,617, the disclosure of which is incorporated by reference herein.
• Thesuture106 can be a #2 suture, or any other size depending on the desired clinical result (e.g., #1 to #6). Thesuture106 can be formed from a suitable material (e.g., braided polyester, braided polyethylene). Thesuture106 can include a longitudinal suture optionally coupled with additional features. Thesuture106 can include two free ends. Thesuture106 can include one, two, or more sections of increased thickness, that can beovermolded segments150, or otherwise attached over thesuture106 to increase thickness of the suture. Theovermolded segment150 can be formed from, for example, silicone or other elastomer. Theovermolded segment150 can be silicone compounded with a radiopacifier, such as barium sulfate, and as such be radiopaque under an imaging modality, such as fluoroscopy or CT. In other embodiments, the suture, e.g., theovermolded segment150, or a portion thereof is visible under other imaging modalities, such as ultrasound for example. As thesuture106 stretches under load, theovermolded segment150 will move and stretch with thesuture106, and can advantageously provide a bearing against wear in some cases.
• FIG. 11A shows asuture106 with a series of spaced-apartknots152, or areas of increased width and/or surface area. Theknots152 can be overhand knots in some embodiments. Thelongitudinal suture106 can be knotted to form an integral structure. The series ofknots152 increase adhesion between thesuture106 and theovermolded segment150.
• FIG. 11B shows asuture106 with asuture braid154. Thesuture braid154 can be formed with the longitudinalfirst suture106 and asecond suture106′ having the same size (e.g., #2) or a different (e.g., larger or smaller) size (e.g., #5) with respect to the size of the longitudinalfirst suture106. Thesecond suture106′ is braided with the longitudinalfirst suture106 and forms a suture sock as shown. The ends of thesecond suture106′ can be fixed to the longitudinalfirst suture106 to prevent fraying. In some embodiments, heat is used to fix thesecond suture106′ to the longitudinalfirst suture106. Thesuture braid154 provides some bulk to theovermolded segment150. Thesuture braid154 can serve as a bearing.
• FIG. 11C shows asuture106 with a series ofbeads156. Thebeads156 can be rigid or flexible beads. Thebeads156 can be formed from a suitable material (e.g., glass). Thebeads156 can all have the same diameter, as shown inFIG. 11C. Thebeads156 can be retained on thelongitudinal suture106 byknots152 positioned at the end of thebeads156. Theknots156 can be overhand knots. Theknots152 can be adjacent to the first andlast beads156 or spaced apart from the first andlast beads156. Thebeads156 can serve as a rigid bearing, and in some embodiments advantageously allow thesuture106 to slide, stretch, or otherwise move within theovermolded segment150. Thebeads156 allow thesuture106 to remain flexible due to the discrete nature of thebeads156.
• FIG. 11D shows asuture106 with a series ofbeads158. Thebeads158 can have varying diameters as illustrated inFIG. 11D. Thebeads158 can be formed from a suitable material (e.g., glass). Thesuture156 can have similar characteristics assuture158. Thebeads158 can have different diameters. The diameter of thebeads158 can be selected to accommodate the shape of theovermolded segment150. Thesuture106 can have two differing diameters ofbeads158. Thesmaller diameter beads158 can be located near the suture ends, and thelarger diameter beads158 can be located between thesmaller diameter beads158, or in a different arrangement.
• FIG. 11E showssuture106 with acoil160. Thecoil160 can be formed from a suitable material (e.g., a polymer (e.g., polypropylene), suture, (e.g., #2 or other size monofilament suture), or a metal (e.g., stainless steel)). Thecoil160 can be wrapped around thelongitudinal suture106. Thecoil160 can be threaded around thelongitudinal suture106. Thecoil160 can be retained on thelongitudinal suture106 byknots152 positioned at the end of thecoil160. Theknots152 can be overhand knots. Theknots152 can be adjacent to the ends of thecoil160 or spaced apart from the ends of thecoil160. Thecoil160 can serve as a bearing. Thecoil160 can allow thesuture106 to slide, stretch, or otherwise move within theovermolded segment150. Thecoil160 allows thesuture106 to remain flexible. Thecoil160 ofsuture106 may be more flexible than thebeads156,158 of sutures shown inFIG. 11C-11D.
• FIG. 12A shows an embodiment of thesuture106 before overmolding.FIG. 12B shows thesuture106 after overmolding, withovermolded segment150. The length, suture size, and/or overall diameter of thecoil160 can be adjusted depending on the desired clinical result. Thecoil160 ofsuture106 may be advantageously relatively simple to manufacture. The length, suture size, and/or overall diameter of theovermolded segment150 can be adjusted depending on the desired clinical result. Theovermolded segment150 ofsuture106 may be advantageously relatively simple to manufacture.
• In some embodiments, thesuture106 and/orsuture106′ could be USP #2, or about 0.020″ or less in diameter. In some embodiments, the sections of increased thickness, e.g., theovermolded sections150, could be between about 0.080″ to 0.120″, or 0.020″ to 0.030″×0.080″ to 0.120″. In some embodiments, the lengths of theovermolded sections150 could be between about 2 cm and about 3 cm. Thesuture106 with theovermolded section150 could also include a tapered thickness or diameter section, such as parts of theovermolded sections150. The length of the taper could be, for example, less than 1 cm, or less than 0.5 cm. In some embodiments, thefirst suture106 could be USP #3, or about 0.024″ or less in diameter. In some embodiments, theovermolded sections150 could be between about 0.030″ to 0.200″, or 0.020″ to 0.030″×0.030″ to 0.200″, or have a diameter that it at least about 20%, 30%, 40%, 50%, 60%, 75%, 100%, 125%, 150%, 200%, or more larger than that of theunderlying suture106 without overmolding. In some embodiments, the lengths of theovermolded sections150 could be between about 1 cm and about 5 cm. The length of the taper on either side of theovermolded section150 or largest diameter/thickest section could be up to about 20%, 30%, 40%, or 50% of the length of theovermolded section150 or entire large diameter/thickest section. In some embodiments,additional suture106 and other features that can be used or modified for use with embodiments disclosed herein can be found, for example, in U.S. patent application Ser. No. 14/020,617 to Feezor et al., which is hereby incorporated by reference in its entirety.
• The surface of any of the disclosed sutures may be mechanically, chemically, or otherwise modified to improve adhesion with, for example, muscle cells and other tissues of the genioglossus. Mechanical modifications create improved adhesion by modifying the surface texture of the implant and may be achieved as part of the manufacturing process and may involve the removal of material from, or the addition of material to the surface of the implant. Chemical adhesion may be achieved through the incorporation of chemical (including biological) compounds into the surface or the bulk material or materials that makes up the implant in order to improve the affinity between cellular components and the implant. Compounds may include, but are not limited to proteins, peptides, antibodies, growth factors, or other molecules which create an affinity for cellular or tissue components.
• FIGS. 13A-13D illustrate a method of narrowing the lateral pharyngeal wall. Some surgical procedures indirectly tension the lateral pharyngeal wall. The technique involves a plurality, e.g., two, three, or more suture passes around the superior pharyngeal constrictor muscle. The sutures are sewn into the palatoglossal muscle and tied off as shown. The aforementioned technique can require exposure of muscle with several incisions in the mucosa layer, and the technical ability to consistently anchor the suture in the superior pharyngeal constrictor muscle. The technique can also require the ability to consistently anchor the suture in the palatoglossal muscle. In some cases, there may be increased pain and recovery time for patients due to the mucosal incisions.
• In some embodiments, as illustrated inFIG. 14, abarbed implant162 can be utilized. Thebarbed implant162 can include afirst end164 and asecond end166. Thefirst end164 can include one or more barbs. Thesecond end166 can include one or more barbs. The barbs on thefirst end164 can point in a first direction away from thesecond end166. The barbs on thesecond end166 can point in a second direction away from thefirst end164. In other embodiments, the barbs can point in the same direction. Thebarbed implant162 can have a longitudinally extending portion between thefirst end164 and thesecond end166. In some embodiments, the longitudinally extending portion does not include barbs as shown inFIG. 14. In other embodiments, the longitudinally extending portion includes barbs. Thebarbed implants162 can be elastic or inelastic. The longitudinally extending portion can be elastic or inelastic. The barbs can generally move in one direction (e.g., to be inserted into tissue). The barbs resist movement in an opposite direction (e.g., to prevent back out of the barbed implant162).
• The system can include one or a plurality (e.g., about or at least about 2, 3, 4, 5, 6, or more) ofbarbed implants162. The barbs can function as proximal and/or distal anchors. Thebarbed implant162 can be implanted intotissue300. Thebarbed implant162 can be horizontally oriented within the body of the patient. The method of use can include animplant inserter tool168. Theimplant inserter tool168 can include a proximal handle, an elongate shaft, and a distal tip. Thebarbed implant162 can be implanted by advancing animplant inserter tool168 in a generally horizontal orientation. Theimplant inserter tool168 can release thebarbed implant162 into thetissue300. In some embodiments, thebarbed implants162 could be implanted within about 10 degrees of the horizontal axis. However, in other embodiments, thebarbed implants162 could be within less than about 15 degrees, 30 degrees, 45 degrees, 60 degrees, 75 degrees of the horizontal axis. This provides more localized control of tissue suspension, depending on the desired clinical result.
• In some methods of use, a combination of generally horizontally-orientedbarbed implants162 can be used as shown inFIG. 14. In some methods of use, a combination of generally horizontally orientedbarbed implants162 and generally vertically-orientedbarbed implants162 can be used. In some methods of use, a combination of generally vertically-orientedbarbed implants162 can be used. In some embodiments, the distance betweenbarbed implants162 could be irregular or regular. The distance between the midlines of thebarbed implants162 could be, for example, between about 0.1 cm and about 3 cm. Thebarbed implants162 can have the same or different orientations within thetissue300. In some instances where additional suture strength is required at a single location within tissue, the multiplebarbed implants162 may share a midline axis, but be oriented differently (from −90 to +90 degrees) from each other.
• FIG. 14 illustrates threebarbed implants162 deployed in thetissue300. As shown, thebarbed implants162 are used to tack the superior pharyngeal constrictor muscle to the palatoglossal muscle. Thebarbed implants162 may extend from the palatoglossal arch to the palatopharyngeal arch. Thebarbed implants162 may each include a longitudinal extending section, thefirst end164 and thesecond end166, as described herein. The barbs of thefirst end164 may be oriented the same as, or differently from the barbs on thesecond end166. The barbs on thefirst end164 may be opposite the orientation of the barbs on thesecond end166. The barbs may be configured to engagetissue300 when tensioned from different directions.
• FIGS. 15A-15B illustrates a cross-sectional view of the palatoglossal arch and the palatopharyngeal arch.FIG. 15A shows thebarbed implant162 deployed. Thebarbed implant162 compresses the palatopharyngeal arch toward the palatoglossal arch.FIG. 15B illustrates a cross-sectional view of the anatomy without thebarbed implant162. Thebarbed implant162 can be deployed at an angle relative to the horizontal. The angle may be approximately 45 degree. The angle can be determined by the relative anatomy of the patient.
• FIGS. 16A-D illustrate a method of inserting thebarbed implant162.FIG. 16A shows theimplant inserter tool168 having the proximal handle, the elongate shaft, and the distal tip. Theimplant inserter tool168 can be inserted into and extends between the palatoglossal arch and the palatopharyngeal arch. Theimplant inserter tool168 can be advanced until the distal tip is proximate a target location.FIG. 16B shows thebarbed implant162 being deployed from the distal tip of theimplant inserter tool168. This can be accomplished, for example, by actuating a control on the proximal handle to actuate a pushrod distally, for example to expel thebarbed implant162. Thefirst end164 of thebarbed implant162 engagestissue300 of the palatopharyngeal arch. In some embodiments, the barbs may further embed in thetissue300 as a force is applied to thebarbed implant162. The barbs of thebarbed implant162 dig into or otherwise embed in thesoft tissue300. Thetool168 is retracted from the palatopharyngeal arch.
• FIG. 16C shows thetool168 being retracted to the palatoglossal arch. By applying a force (e.g., tension) on thebarbed implant162, the barbs may further embed in thetissue300. The palatopharyngeal arch may be brought toward the palatoglossal arch. The palatopharyngeal arch may be compressed against the palatoglossal arch. In some embodiments, the palatopharyngeal arch may touch the palatoglossal arch. The palatopharyngeal arch may be pulled laterally and/or anteriorly.
• FIG. 16D shows theimplant inserter tool168 being retracted from the palatoglossal arch. Thesecond end166 of thebarbed implant162 engagestissue300 of the palatoglossal arch. Thebarbed implant162 may be deployed such that thefirst end164 engages the palatopharyngeal arch and thesecond end166 engages the palatoglossal arch. As force is applied to thebarbed implant162, the barbs may further embed into thesoft tissue300, thereby inhibiting further movement of thebarbed implant162. The method steps shown inFIGS. 16A-16D can be repeated to deploy one or morebarbed implants162 on one or more sides of the airway.
• In some cases, the method can include several advantages depending on the desired clinical result. The technique can leave the mucosa layer intact. Thebarbed implants162 can be anchored to a larger tissue area than the sutures, in some embodiments. The technique is a simple, repeatable process providing dependable results. The technique may produce a large clinical benefit for minimally invasive intervention.
• FIGS. 17A-17B illustrate embodiments of thebarbed implant162 withtissue ingrowth material170. Thetissue ingrowth material170 may be located near thefirst end164. Thetissue ingrowth material170 may be located near thesecond end166. Thetissue ingrowth material170 may be located near thefirst end164 and near thesecond end166. Thetissue ingrowth material170 may be located beyond thefirst end164. Thetissue ingrowth material170 may be located beyond thesecond end166. Thetissue ingrowth material170 may be located beyond thefirst end164 and beyond thesecond end166. Thetissue ingrowth material170 may provide long-term stability of thebarbed implant162. Thetissue ingrowth material170 may prevent migration of the barbs out of the tissue. Thetissue ingrowth material170 can be biocompatible, to prevent rejection of thebarbed implant162 by the body of the patient. Thetissue ingrowth material170 and may include one or more drugs or other therapeutic agents.
• FIGS. 18A-18B illustrate a method of inserting thebarbed implant162.FIG. 18A shows theimplant inserter tool168 inserted into the palatopharyngeal arch. Theimplant inserter tool168 is advanced until the distal tip is located at a target location.FIG. 18A shows thebarbed implant162 being deployed from the distal tip of theimplant inserter tool168. Thebarbed implant162 engagestissue300 of the palatopharyngeal arch. In some embodiments, the barbs may further embed in the tissue as a force is applied to thebarbed implant162. The barbs of thebarbed implant162 dig into or otherwise embed in the soft tissue. Theimplant inserter tool168 is retracted from the palatopharyngeal arch.FIG. 18B shows theimplant inserter tool168 retracted. Thebarbed implant162 spans from the palatopharyngeal arch to the base of the palatoglossal arch. Thebarbed implant162 compresses the palatoglossal arch. By applying a force (e.g., tension) on thebarbed implant162, the barbs may further embed in the tissue. The palatopharyngeal arch may be brought toward the palatoglossal arch. The palatopharyngeal arch may be pulled laterally. This technique avoids tacking the palatopharyngeal arch directly to the palatoglossal arch.
• FIGS. 19A-19E illustrate a method of inserting asuture106 for a tissue lift procedure. Thesuture106 can include theovermolded segment150 as described herein.FIG. 19A shows the method step of making an incision in the skin of the head of a patient.FIG. 19B shows the method step of making a small surgical dissection pocket.FIGS. 19C-19E show various non-limiting possible suture passes. Path A provides neck lift, Path B provides mid-level cheek lift, and Path C provides eye line lift, as shown inFIG. 19C. Path D, as shown inFIG. 19D, shows the path wherein the suture passes inferiorly to the mandible. The suture is advanced until reaching the midline of the neck. The method may include the step of placing suspension sutures such assuture106 with theovermolded segment150 under the jaw line. Path E, as shown inFIG. 19E illustrates the path ofsuture106 forming loops in the neck. The method may include the step of suspending a suture, trimming extra skin, and/or closing the incision. The sutures may be placed using the SMAS, or the sub-muscular aponeurotic system. The system and methods, such as the use of various suture passers, can be as disclosed herein and can be, or modified from systems and methods described in U.S. Pat. No. 8,460,322, the entire disclosure of which is incorporated by reference.
• FIG. 20 illustrate a method of inserting asuture106. Thesuture106 can include theovermolded segment150 as described herein. The methods can be performed by a suture passer described herein and in commonly owned U.S. Pat. No. 8,460,322, the entire disclosure of which is incorporated by reference. The suture passer can be modified, (e.g., reduced in size). The suture passer can be used to placesuture106. Thesuture106 can form loops within the tissue instead of single short sections of suture. The suture passer can place suture106 into the superior pharyngeal constrictor muscle. Thesuture106 can be placed as shown. Thesuture106 can be placed near the palatopharyngeal arch, the palatoglossal arch and/or any location between the palatopharyngeal arch and the palatoglossal arch. Thesuture106 can be anchored. Thesuture106 can be anchored into palate tissue and/or the hard palate. Thesuture106 can be tensioned to stabilize the lateral pharyngeal wall. The method can in some embodiments narrow the lateral pharyngeal wall and/or provide the lateral pharyngoplasty.
• FIGS. 21A-21B illustrate a method of using one or more bone anchors172 in an adjustable tensioning system. The bone anchors172 can be knotless bone anchors in some embodiments. Thesuture106 can be inserted into the bone anchors172. In some embodiments, thesuture106 includes afirst strand106A, asecond strand106B and an arc connecting thefirst strand106A and thesecond strand106B. Thefirst strand106A has a free end and thesecond strand106B has a free end. The free ends of thesuture106 can be inserted into a lumen of thebone anchor172. Thebone anchor172 can be tightened to secure thefirst strand106A and thesecond strand106B. Thebone anchor172 can be loosened to release thefirst strand106A and thesecond strand106B and allow for adjustable tensioning without necessarily requiring untying of the suture loop.
• The bone anchors172 can be used to secure thesuture106 within the face or neck, or another desired anatomical location. Thesuture106 can form a loop such that thesuture arc106C is disposed within the tissue. Thesutures106 may be placed to provide a face and/or neck lift.
• Thebone anchor172 can provide post-operative adjustability to thesuture106. For instance, thesuture106 can be adjusted after thearcs106C are placed, during the procedure and/or at any time in the future. Thesuture106 could be adjusted days, months, or years after thesuture106 is placed within the body. Thebone anchor172 permits adjusting thesuture106 by increasing or decreasing tension in a minimally invasive manner. In some embodiments, thebone anchor172 can selectively release thefirst strand106A. In some embodiments, thebone anchor172 can selectively release thesecond strand106B. In some embodiments, thebone anchor172 can selectively release thefirst strand106A and thesecond strand106B. The surgeon can apply tension to thefirst strand106A and/or thesecond strand106B. Once adjusted, thebone anchor172 can be tightened to retain thefirst strand106A and thesecond strand106B. Thebone anchor172 permits adjusting the face and/or neck lift in a minimally invasive manner. The free ends of thesuture106 may be pulled, slid, tensioned and/or manipulated to adjust thesuture106. This movement would then adjust the tissue, bone, and/or skin coupled to the suture106 (e.g., adjust the face and neck lift).
• Thebone anchor172 can have lock and unlock capabilities. Thebone anchor172 can include an opening (e.g., a hexagonal opening) for the insertion of a tool (not shown). The tool can lock and unlock thebone anchor172, allowing for thesuture106 to be adjusted. Thebone anchor172 may be implanted on a surface of the skin and/or within the body. Thebone anchor172 can be placed above the ear (e.g., in the temporal bone), as shown inFIG. 21A. Thebone anchor172 can be placed under the skin near the ear, as shown inFIG. 21B. Thebone anchor172 placed under the skin can be adjusted by making a small incision near thebone anchor172. The incision may be near the implantation location for thebone anchor172. The tool can be inserted into the incision to adjust thebone anchor172.
• FIGS. 22A-22B illustrate atool176 and method for moving the superior pharyngeal constrictor or another desired muscle. Thetool176 can move the superior pharyngeal constrictor muscle in any direction (e.g., laterally and/or anteriorly). Thetool176 can stabilize the superior pharyngeal constrictor muscle in the desired location (e.g., laterally and/or anteriorly). Thetool176 can insert a fastener178 (e.g., a tack, staple, cap, suture loop, or suture). Thefastener178 can be biodegradable or bioabsorbable in some cases. Thetool176 can include a blunt tip for moving the tissue. Thetool176 can couple to thefastener178 for stabilizing the tissue.FIG. 22A shows thetool176 moving the superior pharyngeal constrictor muscle laterally. Thetool176 can move the superior pharyngeal constrictor muscle via the blunt tip. The superior pharyngeal constrictor muscle may be moved toward the side of the airway. Thetool176 can be positioned to discharge (e.g., launch, fire) thefastener178 to stabilize the tissue. The method can be repeated for the contralateral side of the airway to move the superior pharyngeal constrictor muscle laterally.
• FIGS. 23A-23C illustrate some embodiments of thefastener178, with the placement of thefastener178 shown in relation to the superior pharyngeal constrictor muscle.FIG. 23A shows thefastener178 as a staple, with ends biased toward each other.FIG. 23B shows thefastener178 as a tack, having a proximal tissue contacting structure and a distal tissue contracting structure, both operably connected to a tension element.FIG. 23C shows thefastener178 as thesuture106. Thesuture106 can form a loop by bringing thefirst end106A to thesecond end106B. Thesuture106 can be stabilized with anchors as described herein. Thesuture106 can be placed with a device like a suture passer as described herein. Thefastener178 can be abarbed suture162, as shown inFIG. 14 for example. Thefastener178 can be bioabsorbable in some embodiments. Thefastener178 can extend from the superior pharyngeal constrictor muscle to a location near the palatopharyngeal arch, the palatoglossal arch and/or any location between the palatopharyngeal arch and the palatoglossal arch. Thefastener178 can extend from the fascia behind the superior pharyngeal constrictor muscle.
• FIGS. 24A-24D illustrate a method of hyoid suspension. The hyoid bone is located in the anterior midline of the neck and is anchored by muscles. The hyoid aids in tongue movement and swallowing. Hyoid suspension involves pulling the hyoid forward in order to increase the size of the airway.FIG. 24A illustrates the method step of forming an incision in the neck of a patient. The incision can be, for example, between 2 cm and 4 cm. The incision may extend from, for example, the hyoid bone to the mandible. The surgeon can dissect the tissue and muscle to reach the hyoid bone.
• FIG. 24B illustrates the method step of using a suture passer for hyoid suspension. The method may utilize a suture passer substantially similar to the systems and methods described herein or in commonly owned U.S. Pat. No. 8,460,322, the entire disclosure of which is incorporated by reference. The suture passer can be used to pass asuture loop106 around the body of the hyoid bone. Thesuture106 can include theovermolded segment150. Thesuture106 has the first strand extending longitudinally106A, the second strand extending longitudinally106B, and thearc106C connecting thefirst strand106A and thesecond strand106B. Thearc106B is passed around the hyoid bone. Thesuture loop106 can be elastic or inelastic. Thesuture106 can be substantially similar to the sutures described herein, including the sutures shown inFIGS. 11A-12B. Thearc106C can be on one side of the hyoid bone. The first106A andsecond strand106B can be on the other side of the hyoid bone. In some methods, thefirst strand106A and thesecond strand106B are then passed around the hyoid bone. Thefirst strand106A and thesecond strand106B are passed under thearc106B. Thesuture106 can form a girth hitch. Other knot configurations are contemplated. For instance, thesuture106 could be wrapped around the hyoid bone forming a klemhiest or prusik knot.
• Thefirst suture106 can be replaced with a second,larger suture108. Thelarger suture108 can include be a larger diameter suture, suspension loop, suture tape, etc. Thelarger suture108 can be similar tosuture106. Thelarger suture108 can prevent erosion through the bone. The second,larger suture108 can be elastic. Thelarger suture108 can include theovermolded segment150 as described herein. Thesuture108 has a first strand extending longitudinally108A, a second strand extending longitudinally108B, and anarc108C connecting thefirst strand108A and thesecond strand108B.
• In some methods of use, thefirst strand106A is passed around the hyoid bone. Thearc106C can be in contact with the hyoid bone. Thesecond strand106B can be on the other side of the hyoid bone. Thesuture106 can be used to place thesuture108, akin to a guide suture. In some methods, thearc108C can be placed around thefirst strand106A. Thearc108C can be operably coupled to thefirst strand106A. Thesuture106 can be pulled. In some embodiments, thesecond strand106B of thesuture106 is pulled. Thearc108C can be on one side of the hyoid bone. The first108A andsecond strand108B can be on the other side of the hyoid bone. In some methods, thefirst strand108A and thesecond strand108B are then passed around the hyoid bone. Thefirst strand108A and thesecond strand108B are passed under thearc108B. Thesuture108 can form a girth hitch. Other knot configurations are contemplated. For instance, thesuture108 could be wrapped around the hyoid bone forming a klemhiest or prusik knot.
• In some methods of use, thearc106C is passed around the hyoid bone as shown inFIG. 24C. Thearc106C is on one side of the bone and thefirst strand106A and thesecond strand106B can be on the other side of the hyoid bone. In some methods, thearc108C can be placed under thearc106C. Thesuture loop106 can be pulled. In some embodiments, thefirst strand106A and thesecond strand106B of thesuture106 are pulled. Thearc108C can be on one side of the hyoid bone. The first108A andsecond strand108B can be on the other side of the hyoid bone. In some methods, thefirst strand108A and thesecond strand108B are then passed around the hyoid bone. Thefirst strand108A and thesecond strand108B are passed under thearc108B. Thesuture108 can form a girth hitch. Other knot configurations are contemplated.FIG. 24C shows the method of pulling thelarger suture108, which can be operably connected to thesmaller guide suture106 in some embodiments.
• FIG. 24D illustrates the method step of securing thesuture106 and/orlarger suture108 to the mandible. The method may utilize abone anchor178, which can include any or all of the features ofbone anchor178 described herein. Thebone anchor178 can be a knotless bone anchor. Thebone anchor178 can be a locking bone screw. The loop of thesuture106 and/orlarger suture108 provides a knotless attachment to the hyoid bone.
• The tension, position, and/or suspension of the hyoid bone can be adjusted by adjusting the loop of thesuture106 and/orlarger suture108. For instance, pulling on thefirst strand106A and/or thesecond strand106B can change the position of hyoid bone. For instance, changing the location of thesuture106 relative to the hyoid bone can change position of the hyoid bone.
• Thebone anchor178 can allow for post-operative adjustment of thesuture106 and/orlarger suture108. Thebone anchor178 can release thefirst strand108A and or thesecond strand108B. The surgeon can adjust the tension provided by thefirst strand108A and thesecond strand108B. Thelarger suture108 can be adjusted after the knot is placed, and/or at any time in the future. Thelarger suture108 could be adjusted days, months, years after thelarger suture108 is placed within the body. Thelarger suture108 can be adjusted acutely or chronically. The method of passing thesuture106,108 around the hyoid bone may be simpler, easier, and more minimally invasive than using a curved needle. AlthoughFIG. 24D shows onelarger suture108, more than onelarger suture108 can be utilized (e.g., two girth hitch knots, three girth hitch knots, etc.). The thickness, strength, and/or other material properties may be selected to minimize the number oflarger sutures108. A singlelarger suture108 of a sufficiently thick and/or strong material may be able to stabilize the hyoid bone with respect to the mandible.
• FIG. 25A-25B illustrate a suture passer, in particular the distal end of the suture passer. Thesuture passer182 can be modified from the suture passer described in commonly owned U.S. Pat. No. 8,460,322, the entire disclosure of which is incorporated by reference. Thesuture passer182 can be modified to include one or more sharpened suture passing needles184. The sharper needles184 may be configured for passing through tissues having a greater inherent resistance to puncture, such as ligaments (e.g., hyoepiglottic ligaments, hypothyroid ligaments). The design and/or material of theneedle184 may be selected to enhance stiffness.
• Thesuture passer182 can be modified to include one or moresharp tips186. Thesharp tips186 on the ends of thesuture passer182 may be useful in passing through ligaments as noted above. Thesuture passer182 can include adepth stop188 which may limit the forward movement of thesuture passer182. Thedepth stop188 may serve as a safety measure, to prevent thesuture passer182 from puncturing the airway. Alternatively, the tips could be blunt and atraumatic in some embodiments.
• FIG. 25B illustrates the placement of thesuture passer182 within the body of the patient. Thesharp tips186 may surround the hyoid bone. Theneedle184 may penetrate the hyoepiglottic ligament. Theneedle184 may extend from onesharp tip186 to the othersharp tip186 in order to pass the suture. Surrounding structures such as the hypothyroid ligament, thyroid cartilage, and epiglottis are also shown for reference.
• FIG. 26A-26B illustrate a method of hyoid bone suspension.FIG. 26A illustrates the method step of forming a girth hitch around the hyoid bone.FIG. 26A utilizes two sutures106 (e.g., #2 suture, suture tape (e.g., 2 mm suture tape)). One, two, or more girth hitch knots may be utilized as shown inFIG. 26A. Thefirst strand106A and thesecond strand106B pass under thearc106C. Thefirst strand106A and thesecond strand106B of thesuture106 are secured to abone anchor178. Thebone anchor178 can be located on the mandible. Thebone anchor178 can be tightened to securely hold thefirst strand106A and thesecond strand106B. Thebone anchor178 can be loosened to release thefirst strand106A and thesecond strand106B. The surgeon can alter the tension applied to the hyoid bone. Thebone anchor178 can be tightened after the adjustment.FIG. 26A shows a configuration with two side-by-side girth hitch knots, and two bone anchors178.FIG. 26B shows a configuration with one girth hitch knot illustrated using suture tape, and three bone anchors178. Additional girth hitchknots utilizing sutures106 may be utilized inFIG. 26B with respect to the remaining bone anchors178. The ratio of girth hitches or other knots to bone anchors178 may be greater than 1:1 (2 girth hitches to 1 bone anchors) or equal to 1:1 (2 girth hitches to 2 bone anchors) in some embodiments. The ratio ofsutures106 to bone anchors178 may be greater than 1:1 (2 girth hitches to 1 bone anchors) or equal to 1:1 (2 girth hitches to 2 bone anchors) in some embodiments.
• FIG. 27A-27D illustrates a method of forming a girth hitch, in some embodiments. Thesuture106 includes thefirst strand106A, thesecond strand106B, and thearc106C.FIG. 27A shows the method step of conducting a pass with a suture passer. Thesuture106 may be folded, held or otherwise coupled to the suture passer.FIG. 27B shows the method step of retracting the suture passer and/or the needle of the suture passer. Thearc106C remains within the body.FIG. 27C illustrates passing thefirst strand106A and thesecond strand106B of thesuture106 through thearc106C of thesuture106 to form a girth hitch.FIG. 27D illustrates the method step of tensioning thefirst strand106A and thesecond strand106B of thesuture106 to form a girth hitch. Thefirst strand106A and thesecond strand106B of thesuture106 can be coupled to abone anchor178 as described herein. Thebone anchor178 can be attached to the mandible. Thesuture106 may be either pre-attached to thebone anchor178 prior to the procedure, or following formation of the girth hitch. Thesuture106 can be a smaller diameter guide suture. In some methods, thesuture106 can be coupled with alarger diameter suture108, which can follow the path of theguide suture106 to create a girth hitch. In some methods, thearc108C of thelarger diameter suture108 can be passed under thearc106C of thesuture106C to create a girth hitch.
• The method illustrated inFIG. 27A-27D illustrates the creation of a girth hitch around the hyoid bone at the midline (e.g., near the midline, substantially near the midline). The girth hitch may be connected to abone anchor178. Thebone anchor178 may be attached to the mandible at the midline (e.g., near the midline, substantially near the midline).
• Alternatively two girth hitch knots may be deployed. The girth hitch knots may be coupled to the hyoid bone. The two girth hitch knots can be around the hyoid bone. The two girth hitch knots can be placed on either side (e.g., right side, left side) of the midline of the hyoid bone, as shown inFIGS. 26A and 28. In some embodiments, the two girth hitch knots can be coupled to twobone anchor178. The two bone anchors178 can be placed on either side (e.g., right side, left side) of the midline of the mandible, as shown inFIG. 26A. In some embodiments, the two girth hitch knots can be coupled to asingle bone anchor178. Thesingle bone anchor178 can be placed at the midline of the mandible (e.g., near the midline, substantially near the midline), as shown inFIG. 28. Thesingle bone anchor178 can be placed on either side (e.g., right side, left side) of the midline of the hyoid bone.
• FIGS. 29A-29C illustrate an embodiment of a hyoid suspension implant192 (e.g., an alternative to, or can be combined with the suture).FIG. 29A illustrates animplant192. Theimplant192 can include animplant head192A, that can have a relatively larger width dimension, and alongitudinally extending tail192B having a relatively smaller width dimension. Theimplant head192A includes a slot or other feature designed to accept thelongitudinally extending tail192B.FIGS. 29B-29C show a method of using theimplant192. Theimplant192 can be passed behind the hyoid bone. Theimplant head192A is passed around the hyoid bone. Thelongitudinally extending tail192B can be passed through the slot in theimplant head192A. Thelongitudinally extending tail192B is tensioned. Theimplant192 wraps around the hyoid bone, as shown inFIG. 29C. In some methods, thelongitudinally extending tail192B is passed around the hyoid bone. Thelongitudinally extending tail192B can be passed through the slot in theimplant head192A. Thelongitudinally extending tail192B can be tensioned. Theimplant192 wraps around the hyoid bone, as shown inFIG. 29C.
• Theimplant head192A, including the slot, and/or the longitudinal extendingtail192B can have additional features. The implant can include a locking mechanism. The locking mechanism can be a ratchet formed within or on theimplant head192A, the slot, and/or the longitudinal extendingtail192B. The locking mechanism can lock theimplant192 against the hyoid bone once theimplant192 has been tensioned.FIG. 30 shows an embodiment of the locking mechanism, surrounding a cross-section of a body structure, such as the hyoid bone. Thelongitudinally extending tail192B includes teeth and/or ratchets that engage the slot. The slot includes teeth and/or ratchets that engage thelongitudinally extending tail192B. The locking mechanism locks theimplant192 in place after theimplant192 has been tensioned. The bone anchors178 can also include teeth and/or ratchets that engage thelongitudinally extending tail192B. Thelongitudinally extending tail192B can include teeth and/or ratchets that engage thebone anchor178. The teeth and/or ratchet can provide a knotless method of locking the implant to the bone anchor.
• Theimplant192 can be manufactured from a biocompatible material (e.g., plastic). Theimplant192 can be formed from any process (e.g., braiding suture). The teeth and/or ratchet can be formed into the implant (e.g., crimped into the suture). The teeth and/or ratchet can take any shape (e.g., balls, triangular teeth, and/or slits).
• FIG. 31 illustrates a method of attaching an implant to a hyoid bone. The method can include the step of drilling a small hole in the hyoid bone (e.g., a through hole). Theimplant194 can be passed through the hole. Theimplant194 can be reduced in diameter in order to fit through the small hole. Theimplant194 can have a collapsed configuration and an expanded configuration. Theimplant194 can be passed through the hole in the collapsed configuration. Theimplant194 can be expanded to the expanded configuration after passing through the small hole. In the expanded configuration, theimplant194 cannot pass through the hole. For instance, theimplant194 can have a generally T-shaped configuration as shown inFIG. 31. The T-shape prevents theimplant194 from passing through the hole in the hyoid bone. A suture106 (e.g., suture, suture tape) can be attached to theimplant194. Theimplant194 can include alongitudinally extending tail194B. Thesuture106 can be coupled to thelongitudinally extending tail194B. Thelongitudinally extending tail194B can be disposed within the hole. Thesuture106 and/or longitudinally extendingtail194B can be connected to the bone or tissue (e.g., mandible, thyroid cartilage).
• Theimplant194 can be constructed from a material suitable for expanding (e.g., super elastic metal or plastic). Theimplant194 can be constrained in the collapsed configuration, having a small diameter for delivery and/or insertion into the hole. Theimplant194 can be constrained by a sheath. Theimplant194 is allowed to expand once delivered and/or once the restraint is removed. The expanded configuration has a larger diameter than the collapsed configuration.
• FIGS. 32A-32B illustrates a method of attaching an implant to a hyoid bone. The method can include the step of drilling a small hole in the hyoid bone (e.g., a through hole). Theimplant195 can be passed through the hole. Theimplant195 can have a reduced diameter configuration in order to fit through the small hole. Theimplant195 can have a collapsed configuration and an expanded configuration. Theimplant195 can be passed through the hole in the collapsed configuration. Theimplant195 can be expanded to the expanded configuration after passing through the small hole. In the expanded configuration, theimplant195 cannot pass through the hole.FIGS. 32A-32B illustrate an embodiment of theimplant195. Theimplant195 can includebarbs196. For instance, thebarbs196 can have a generally J-shaped configuration as shown inFIG. 32B. The J-shape prevents theimplant195 from passing through the hole in the hyoid bone. Thebarbs196 can be formed from a material suitable for expanding (e.g., super elastic metal or plastic).FIG. 32A shows thebarbs196 in the collapsed configuration. Thebarbs196 can be constrained by a sheath. Thebarbs196 can be constrained by the small hole. Theimplant195 can be coupled to asuture106.FIG. 32B shows thebarbs196 in the expanded configuration. The sheath has been removed. Thebarbs196 can have a larger diameter preventing thebarbs196 from passing back through the small hole.
• FIG. 33A-33B illustrates a method of attaching an implant to a hyoid bone. The method can include the step of drilling a small hole in the hyoid bone (e.g., a through hole). Theimplant197 can be passed through the hole. Theimplant197 can be reduced in diameter in order to fit through the small hole. Theimplant197 can have a collapsed configuration and an expanded configuration. Theimplant197 can be passed through the hole in the collapsed configuration. Theimplant197 can be expanded to the expanded configuration after passing through the small hole. In the expanded configuration, theimplant197 cannot pass through the hole.FIGS. 33A-33B illustrate an embodiment of theimplant197. Theimplant197 can include asuture198. Theimplant197 can have a collapsed configuration wherein thesuture198 extends along a longitudinal axis. Theimplant197 can have an expanded configuration wherein thesuture198 forms a suture ball.FIG. 33A shows theimplant197 in the collapsed configuration. Thesuture198 can be constrained by a sheath. Thesuture198 can be constrained by the small hole.FIG. 33B shows theimplant197 in the expanded configuration. Thesuture198 can have a larger diameter preventing theimplant197 from passing back through the small hole. Theimplant197 can be coupled tosuture106. Theimplant197 and/or thesuture106 may be coupled to a bone or tissue (e.g., mandible).
• FIGS. 34A-34F illustrate an embodiment of asuture passer200. Thesuture passer200 can include afirst section202. Thefirst section202 can include afirst handle204. The first section can include afirst tip206. Thefirst section202 can be coupled to asecond section208. Thefirst section202 can be joined with, for example, a pivot pin to thesecond section208 akin to a scissors tool. Thesecond section208 can include asecond handle210. Thesecond section208 can include asecond tip212.
• Thefirst tip206 can form a jaw. Thesecond tip212 can form a jaw. The jaw can be curved. The jaw can include serrations or other features to improve grip to the bone or other tissue. The curvature of the jaw can allow thefirst tip206 to surround a portion of a body structure, such as the hyoid bone. In some embodiments, thefirst tip206 surrounds approximately 180 degrees of the hyoid bone. In some embodiments, thefirst tip206 surrounds greater than 180 degree of the hyoid bone, approximately 270 degrees of the hyoid bone, greater than 270 degrees of the hyoid bone, etc. The curvature of the jaw can allow thesecond tip212 to surround a portion of the hyoid bone. In some embodiments, thesecond tip212 surrounds approximately 180 degrees of the hyoid bone. In some embodiments, thesecond tip212 surrounds greater than 180 degree of the hyoid bone, approximately 270 degrees of the hyoid bone, greater than 270 degrees of the hyoid bone, etc. Thefirst tip206 and thesecond tip212 can surround the entire hyoid bone or a substantial portion thereof.
• The assembly can include aplunger216. Theplunger216 can include ahead214. Thehead214 can have an enlarged cross-sectional area. Thehead214 can guide theplunger216. Theplunger216 can be flexible and/or elastic. As shown inFIG. 34B, thefirst section202 can include aslot218, either distal or proximal to the pivot. Theslot218 can be sized to accept theplunger216. Theslot218 can be smaller than the diameter of thehead214 to limit thehead214 from passing through theslot218. Theslot218 can be located on the opposite side of the pivot as thefirst handle204. Theslot218 can be tapered. Theslot218 can extend from asurface220 of thefirst section202 to aninterior lumen222 of thefirst section202 as described herein.
• Theplunger216 can include a suture engagement mechanism. The suture engagement mechanism can be similar to the suture engagement mechanisms described herein for example with references toFIGS. 4A-4D. The suture engagement mechanism can include slots, holes, notches or lumens to engage thesuture106. Theplunger216 can engage thesuture106 to pass thesuture106.
• As shown inFIG. 34C, thesecond tip212 can include aninterior lumen224. Theinterior lumen224 can be sized to accept theplunger216. In some embodiments, thesecond section208 can include a slot (not shown). The slot on thesecond section208 can be substantially similar toslot218. The slot can be located on the opposite side of the pivot as thesecond handle210. The slot on thesecond section208 can be tapered. The slot on thesecond section208 can extend from a surface of thesecond section208 to theinterior lumen224 of thesecond section202.
• Theinterior lumen222 of thefirst section202 and theinterior lumen224 of thesecond section202 can be aligned when thefirst tip206 and thesecond tip212 are brought together as shown inFIG. 34B. Theinterior lumens222,224 can form a continuous channel for theplunger216 between the proximal slot opening on a sidewall and the distal-facing tip opening. Theinterior lumen222 of thefirst section202 is open at thefirst tip206. Theinterior lumen224 of thesecond section208 is open at thesecond tip212. This allows theplunger216 to pass between thefirst section202 and thesecond section208.
• As shown inFIG. 34D, thesuture passer200 is advanced toward the hyoid bone. Thesuture passer200 can be passed through a submental incision. Thefirst tip206 can be pivoted to surround the hyoid bone. Thesecond tip212 can be pivoted to surround the hyoid bone. Thefirst tip206 and thesecond tip212 can be pivoted separately or simultaneously. Thefirst tip206 can be pivoted by actuating thehandle204. Thesecond tip212 can be actuated by pivoting thehandle210. Thetips206,212 are brought toward each other. In some embodiments, thetips206,212 touch. In some embodiments, thetips206,212 are in close proximity. In some embodiments, a small gap is formed between thefirst tip206 and thesecond tip212. Theinterior lumen222 of thefirst section202 and theinterior lumen224 of thesecond section208 are aligned when thetips206,212 are brought together. In some methods, the action of closing thetips206,212 stabilizes thesuture passer200 against the hyoid bone.
• FIG. 34E shows that theplunger216 can enter theslot218 of thefirst section202. Theplunger216 can be guided by thehead214. Theplunger216 can enter theinterior lumen222 of thefirst section202. Theplunger216 can be advanced toward theinterior lumen224 of thesecond section208. Theplunger216 can enter theinterior lumen224 of thesecond section208. In some methods, theplunger216 can exit the slot in the second section208 (not shown). Thehead214 can abut thesurface220 when theplunger216 reaches the slot in thesecond section208. The enlarged cross-section of thehead214 can prevent thehead214 from entering theslot218. In other techniques, theplunger216 enters the slot in thesecond section208 and exits theslot218 of thefirst section202.
• FIG. 34F show a cross-sectional view of thefirst section202. Theslot218 can be tapered in some embodiments. Theinterior lumen222 can align with theinterior lumen224. Theinterior lumens222,224 can be sized to accept theplunger216. Theplunger216 can be advanced until it protrudes from theinterior lumen222. Theplunger216 can span the gap between thefirst tip206 and thesecond tip212. In other embodiments, theplunger216 extends from theinterior lumen222 directly into theinterior lumen224. Theplunger216 can include a sharpenedtip228 to penetrate any tissue within the gap. Theplunger216 can bridge any potential gap between thefirst tip206 and thesecond tip212.
• In some techniques, thesecond tip212 can engage thesuture106 carried by theplunger216. Thesecond tip212 can include a snare or other feature to engage thesuture106. Thesecond tip212 can unload thesuture106 from theplunger216 as theplunger216 is retracted. In some techniques, theplunger216 is retracted with thefirst tip206.
• In some techniques, thesecond tip212 engages thesuture106. Theplunger216 could include a snare or other feature to engage thesuture106. Theplunger216 can be advanced through thefirst tip202 toward thesuture106. Theplunger216 would engage thesuture106 from thesecond tip212. Theplunger216 can engage thesuture106 as theplunger216 enters theinterior lumen224 of thesecond tip212. Theplunger216 can be retracted to pull thesuture106 through thefirst tip206.
• It is contemplated that various combinations or subcombinations of the specific features and aspects of the embodiments disclosed above may be made and still fall within one or more of the inventions. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with an embodiment can be used in all other embodiments set forth herein. Accordingly, it should be understood that various features and aspects of the disclosed embodiments can be combined with or substituted for one another in order to form varying modes of the disclosed inventions. Thus, it is intended that the scope of the present inventions herein disclosed should not be limited by the particular disclosed embodiments described above. Moreover, while the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the various embodiments described and the appended claims. Any methods disclosed herein need not be performed in the order recited. The methods disclosed herein include certain actions taken by a practitioner; however, they can also include any third-party instruction of those actions, either expressly or by implication. For example, actions such as “passing a suture to suspend the hyoid bone” include “instructing the passing of a suture to suspend the hyoid bone.” The ranges disclosed herein also encompass any and all overlap, sub-ranges, and combinations thereof. Language such as “up to,” “at least,” “greater than,” “less than,” “between,” and the like includes the number recited. Numbers preceded by a term such as “approximately”, “about”, and “substantially” as used herein include the recited numbers (e.g., about 10%=10%), and also represent an amount close to the stated amount that still performs a desired function or achieves a desired result. For example, the terms “approximately”, “about”, and “substantially” may refer to an amount that is within less than 10% of, within less than 5% of, within less than 1% of, within less than 0.1% of, and within less than 0.01% of the stated amount.

Claims (22)

1. A suture passer comprising:

a proximal handle;

an elongate shaft having a proximal end, a distal end, and a longitudinal axis;

a suture passing element coupled to the distal end of the shaft, wherein the a suture passing element is movable with respect to the shaft, and configured to swivel with respect to the shaft in an arc of at least about 90 degrees.

2-20. (canceled)

21. A suspension line for tensioning tissue, comprising:

a suture having a first thickness dimension;

an elastomer surrounding a portion of the suture having a second thickness dimension greater than the first thickness dimension; and

at least one bearing element configured to allow the suture to move with respect to the elastomer while maintaining the flexibility of the suture.

22. The suspension line ofclaim 21, wherein the at least one bearing element is at least partially covered by the elastomer.

23. The suspension line ofclaim 21, wherein the at least one bearing element comprises a knot.

24. The suspension line ofclaim 21, wherein the at least one bearing element comprises a bead.

25. The suspension line ofclaim 21, wherein the at least one bearing element comprises a coil.

26. The suspension line ofclaim 25, wherein the coil comprises polypropylene.

27. The suspension line ofclaim 21, wherein the elastomer comprises silicone.

28. The suspension line ofclaim 21, wherein the elastomer is at least partially radiopaque.

29. The suspension line ofclaim 28, wherein the elastomer is compounded with a radiopacifier.

30-54. (canceled)

55. An method comprising:

providing a suture having a first strand, a second strand, and an arc between the first strand and the second strand;

placing the arc on one side of the hyoid bone;

placing the first strand and the second strand on the other side of the hyoid bone;

forming a girth hitch around the hyoid bone; and

securing the first strand and the second strand to a bone anchor

56. The method ofclaim 55, wherein the bone anchor is located on the mandible.

57. The method ofclaim 55, further comprising a second suture comprising a third strand, a fourth strand, and a second arc between the third strand and the fourth strand.

58. The method ofclaim 57, further comprising coupling the third strand to the first strand.

59. The method ofclaim 58, further comprising pulling the third strand to form the girth hitch.

60. The method ofclaim 57, further comprising placing the second arc under the first arc

61. The method ofclaim 57, further comprising pulling the suture such that the second arc is on one side of the hyoid bone and both the third and fourth strands are on other side of the hyoid bone.

62. The method ofclaim 55, further comprising an elastomer surrounding a portion of the suture.

63. The method ofclaim 55, further comprising at least one bearing element on the suture.

64. The method ofclaim 63, wherein the at least one bearing element is at least partially covered by the elastomer.

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