26. Fixation Devices
Background
Multiple devices have been described for fixation during browlift, midface lift, and neck rejuvenation.
Plates and screws 1 : Screws can be removed during follow-up
K-wires 2 : Can be either temporary or permanent
Bolsters 3
Fibrin glue 4
Absorbable tack 5
Direct needle suture fixation
More recent methods of fixation use bioabsorbable devices that anchor soft tissues; however, permanent implantable devices are still in plastic surgeons’ armamentaria.
Barbed suture is a useful adjunct for rhytidectomy, body contouring, and breast surgery.
Fixation For Browlifts, Midface Lifts, and Necklifts
Direct Needle Suture Fixation
Uses permanent or absorbable suture depending on the surgeon’s preference
Endotine Tack (coapt Systems)
Made of 82:18 ratio of polylactic acid/polyglycolic acid
Triangular tack 0.5 mm thick
Five tines up to 3.5 mm thick and a bone bolt 3.75 mm thick
To secure the tack, the Endotine drill bit is used to drill through the outer cortex of the calvarium. Octyl-2-cyanoacrylate (ISO-DENT, Ellman International) cement is used to fix device into the calvarium.
Soft tissues are secured to the tack using digital pressure.
Bioabsorbable
Degrades through hydrolysis and enzymatic activity.
The polyglycolic component goes through hydrolysis quicker than the polylactic acid component.
The tack is completely absorbed in 12 months.
Advantages
Speedy, direct fixation
Bioabsorbs in 12 months
Can be used in conjunction with an endoscope
Low learning curve
Disadvantages
Possibility of palpability until device absorbs
Postoperative tenderness over the device
Difficult to address temporal laxity and severe brow ptosis with the Endotine device
Added cost to surgical procedure for the device
Ultratine Tack (Coapt Systems)
The FDA approved the device in 2006.
Composed of polylactic acid and polyglycolic acid
Ratio is unknown at this time given proprietary nature.
Undergoes hydrolysis at a faster rate than Endotine
50% of the device is absorbed in 4 months, and 70% is absorbed in 10 months.
Fixated to calvarium and soft tissues in same method as Endotine
Advantages
Absorbs more rapidly than Endotine
In one study with 12 patients who underwent coronal browlift, with one side fixated with Endotine and the other with Ultratine, decreased palpability and increased satisfaction noted on the Ultratine fixated side. 10
Disadvantages
Potential loss of fixation from quickened absorption
Reports of inflammatory retention cysts that histologically demonstrated chronic granulomatous inflammation that has necessitated surgical correction 8
Added cost to the surgical procedure for the device
Endotine Ribbon (coapt Systems)
Used for ptosis of cheeks, jowls, and neck
A 16 cm long ribbon 0.5 mm thick and 5 mm wide
Seventeen rows of double tines that are 2.5 mm tall, with holes between the tines. The proximal third of the device has no tines and is used as a “leash” and area for fixation.
Fixated to fascia with absorbable or permanent sutures
Same components and composition as Endotine tack
Bioabsorbable. This device loses its mass at 3 months and is absorbed in 12 months.
Advantages
Useful adjunct for correction of ptosis at the cervicomental junction
Can address temporal laxity 12
Same composition as Endotine tack and is absorbed in 12 months
Disadvantages
Does not address anterior cervical banding
Potential for palpability of the ribbon in patients with thin soft tissue
Possible early loss of fixation when absorbable suture is used for fixation of the device
Added cost to the surgical procedure for the device
Mitek Anchor (Ethicon)
Can be used for medial and/or lateral canthoplasty
Allows fixation of soft tissues to bone
Three different sizes, with Mini-Mitek anchor most appropriate for facial aesthetic surgery
The anchor portion is 1.8 mm in diameter, 5.4 mm in length. It is composed of a titanium alloy and has two barbs that are 180 degrees apart and angled retrograde for fixation against the cortical bone.
For fixation, a hole is drilled into the desired bone, and the anchor is inserted into the drilled hole.
Attached to the anchor is a double-armed suture of 3-0 Ethibond Excel (Ethicon) suture for fixation of soft tissues (braided polyester).
Advantage
Ability to secure soft tissues to bone with relative ease
Disadvantages
Potential for device to be palpable in area of thin soft tissue
Permanent device
Added cost to the surgical procedure
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