Patent Publication Number: US-9833303-B2

Title: Pelvic implant and treatment method

Description:
PRIORITY 
     This application is a continuation of U.S. Nonprovisional patent application Ser. No. 14/346,383, filed Mar. 21, 2014, which is a Section 371 U.S. National Stage Application of PCT/US2012/056905, filed Sep. 24, 2012, which claims priority to and the benefit of U.S. Provisional Patent Application No. 61/537,631, filed Sep. 22, 2011, U.S. Provisional Patent Application No. 61/546,877, filed Oct. 13, 2011, U.S. Provisional Patent Application No. 61/547,475, filed Oct. 14, 2011, and U.S. Provisional Patent Application No. 61/558,271, filed Nov. 10, 2011; each of which are fully incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to surgical methods and apparatus and, more specifically, to surgically implantable patterned support devices and methods for forming and using the same. 
     BACKGROUND OF THE INVENTION 
     Pelvic health for men and women is a medical area of increasing importance, at least in part due to an aging population. Examples of common pelvic ailments include incontinence (fecal and urinary), pelvic tissue prolapse (e.g., female vaginal prolapse), and conditions of the pelvic floor. 
     Urinary incontinence can further be classified as including different types, such as stress urinary incontinence (SUI), urge urinary incontinence, mixed urinary incontinence, among others. Other pelvic floor disorders include cystocele, rectocele, enterocele, and prolapse such as anal, uterine and vaginal vault prolapse. A cystocele is a hernia of the bladder, usually into the vagina and introitus. Pelvic disorders such as these can result from weakness or damage to normal pelvic support systems. 
     Urinary incontinence can be characterized by the loss or diminution in the ability to maintain the urethral sphincter closed as the bladder fills with urine. Male or female stress urinary incontinence (SUI) generally occurs when the patient is physically stressed. Physical stresses that can cause urinary incontinence include jumping, coughing, sneezing and laughing to name a few. 
     In its severest forms, vaginal vault prolapse can result in the distension of the vaginal apex outside of the vagina. An enterocele is a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space. Vaginal vault prolapse and enterocele represent challenging forms of pelvic disorders for surgeons. These procedures often involve lengthy surgical procedure times. 
     Many strategies have been implemented over the years to provide mesh implants adapted to enhance therapeutic support of the respective pelvic tissues. For instance, sling and other implant devices are known to provide support of the urethra or bladder neck in treating urinary incontinence in patients. Further, various mesh implants have been adapted to provide pelvic floor support to treat certain prolapse disorders. 
     Many of the implants promoted for treating incontinence, prolapse and other pelvic disorders were born from and inherited the material and geometric restraints of existing stent and hernia implants. While objectively effective in their respective applications, such stent and hernia implants are naturally constructed to address very different issues. Namely, the requisite barrier, rigidity and tissue integration and compatibility needs of a hernia mesh or vascular stent implant can be very disparate from the implant characteristics required in treating pelvic incontinence and prolapse disorders. 
     Although these traditional mesh implants have had a tremendous benefit for those suffering from incontinence and prolapse, there is still room for improvement. As a result, there is a desire to obtain a uniquely applicable, minimally invasive and highly effective implantable mesh support that can be used to treat incontinence, organ prolapse and other pelvic disorders and conditions. 
     SUMMARY OF THE INVENTION 
     The present invention describes implants and methods for treating pelvic conditions such as incontinence (various forms such as fecal incontinence, stress urinary incontinence, urge incontinence, mixed incontinence, etc.), vaginal prolapse (including various forms such as enterocele, cystocele, rectocele, apical or vault prolapse, uterine descent, etc.), and other conditions caused by muscle or ligament weakness. Other uses include providing a support or platform for plastic surgery, hernia repair, and ortho repairs and support, to name a few. Embodiments of the implants can include a tissue support portion and one or more extending arms or anchoring portions. 
     In various embodiments, the implants can be formed of patterned cells by way of a molding, die casting, laser etching, laser cutting, extruding, and the like. Such a pattern cut or formed implant can be constructed of a polymer material to provide a lattice support structure of repeated cells. Unlike woven or knitted conventional implants, the implants of the present invention are a homogeneous unitary construct. 
     Portions of the implant can be formed into sinusoid or other waveform strut members to control and promote elongation, expansion or contraction along single or multiple axes. As such, controlled and designated stress, tension and compression distribution is promoted across specific or localized areas of the construct. Further, the implant can be formed such that regions or portions can include anchoring features to facilitate engagement and attachment of the implant to target tissue sites. In addition to anchoring to internal tissue, it is also possible to have one or more portions of the implant extend out of an incision or orifice in a patient. 
     In addition, each patterned cell of the implant can include uniquely shaped or cut strut members configured to define cell voids, to optimize or increase tissue in-growth, to promote load bearing along select portions of the implant, to compensate for stiffness, elongation, compression, and tensile strength. The material and cell construct of the implant can be configured to promote flexibility while still providing optimal implant strength and tissue support. Further, the stable geometrical and dimensional attributes of the implant provide a flexible device that can be easily positioned and deployed while also avoiding undesirable implant warping or bunching. 
     One or more anchoring portions can include an anchor rod or member extending out from the implant, with a tissue anchor provided at the distal end of the rod. The anchor rod can be an undulating anchor rod having one or more curved or arcuate bends to facilitate adjustment and tensioning. 
     Various anchor devices are provided with various embodiments, including anchoring mechanisms for connecting to the film or generally unitary body of the implant. 
     In addition to molding and laser cutting the struts and other features of the implant, punching, 3-D printing and other methods and techniques can be employed in making the implant. Further, the struts or other portions of the implant can be coated to provide additional control over expansion, compression, and to protect from or promote tissue in-growth. 
     The implants, or portions thereof, can be adapted to provide desirable adjustability, stress distribution, anchoring, stabilization, variable elongation, and the like. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIGS. 1-2  are views of a unitary patterned implant with undulating anchor rods, in accordance with embodiments of the present invention. 
         FIG. 3  is a top view of a unitary patterned implant having anchor rods with an angular bend, in accordance with embodiments of the present invention. 
         FIG. 4  is a partial close-up schematic view of struts, cells and a central support axis for a unitary patterned implant, in accordance with embodiments of the present invention. 
         FIGS. 5-8  are top views of different sized patterned implants having undulating anchor rods, in accordance with embodiments of the present invention. 
         FIGS. 9-10  is a perspective view of a patterned implant having eyelets and grommets, in accordance with embodiments of the present invention. 
         FIGS. 11-12  are top views of different sized patterned implants having eyelets and grommets, in accordance with embodiments of the present invention. 
         FIG. 13  is a top view of a patterned implant having portions of different thicknesses, in accordance with embodiments of the present invention. 
         FIG. 14  is an exemplary anchor arm having a rod and a mesh portion, in accordance with embodiments of the present invention. 
         FIGS. 15-16  are exemplary introduction needle tools or devices, in accordance with embodiments of the present invention. 
         FIGS. 17-21  are exemplary paddle measurement devices, in accordance with embodiments of the present invention. 
         FIGS. 22-23  are views of a patterned implant having sinusoidal and undulating strut cell configurations, in accordance with embodiments of the present invention. 
         FIGS. 24-25  are views of a key-type anchor attachment device and technique, in accordance with embodiments of the present invention. 
         FIGS. 26-27  are views of an extending flap and anchor attachment device, in accordance with embodiments of the present invention. 
         FIG. 28  is a schematic cross-section view of an anchor attachment device, in accordance with embodiments of the present invention. 
         FIGS. 29-30  are views of a mesh arm and anchor attachment device, in accordance with embodiments of the present invention. 
         FIGS. 31-32  are schematic cross-sectional views of a two-part anchor and attachment device, in accordance with embodiments of the present invention. 
         FIG. 33  is a view of a mesh anchor arm and attachment device, in accordance with embodiments of the present invention. 
         FIG. 34  is a view of an implant having a spring-like anchor arm device, in accordance with embodiments of the present invention. 
         FIGS. 35-37  are views of mesh arm anchor devices and attachment devices, in accordance with embodiments of the present invention. 
         FIGS. 38-39  are schematic views of an anchor and ratchet attachment device, in accordance with embodiments of the present invention. 
         FIGS. 40-41  are views of an anchor, suture and mesh arm attachment device, in accordance with embodiments of the present invention. 
         FIG. 42  is a view of a buckle-like mesh anchor arm attachment device, in accordance with embodiments of the present invention. 
         FIG. 43-45  are views of implants having anchor arm attachment apertures and devices, in accordance with embodiments of the present invention. 
         FIGS. 46-47  are partial views of a generally 3-D film portion for use with an implant, in accordance with embodiments of the present invention. 
         FIG. 48  is a view of film strands to define at least a portion of an implant, in accordance with embodiments of the present invention. 
         FIG. 49  is a view of an implant having a film perimeter and an interior support portion, in accordance with embodiments of the present invention. 
         FIG. 50  is a view of an implant having at least one discrete treatment and support zone, in accordance with embodiments of the present invention. 
     
    
    
     DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS 
     Referring generally to  FIGS. 1-50 , various embodiments of a patterned implant  10  and methods are shown. In general, the implants  10  can include a support portion  12  and anchoring portions  16 . Various portions of the implant  10  can be constructed of polymer materials, e.g., into a molded generally planar structure or from a thin generally planar film or sheet material. Examples of acceptable polymer materials available in constructing or forming the implant systems  10  and its components can include polypropylene, polyethylene, fluoropolymers or like biocompatible materials. 
     The implants  10 , and portions thereof, could take on a myriad of different sizes, shapes and configurations depending on the particular treatment application, or deployment and support needs. For instance, certain configurations can be for uterine sparing prolapse repair and others for the post hysterectomy patient. 
     The various implants  10 , structures, features and methods detailed herein are envisioned for use with many known implant and repair devices (e.g., for male and female), features, tools and methods, including those disclosed in U.S. Pat. Nos. 7,500,945, 7,407,480, 7,351,197, 7,347,812, 7,303,525, 7,025,063, 6,691,711, 6,648,921, and 6,612,977, International Patent Publication Nos. WO 2008/057261 and WO 2007/097994, and U.S. Patent Publication Nos. 2011/0124956, 2011/0144417, 2010/0261955, 2002/151762 and 2002/147382. Accordingly, the above-identified disclosures are fully incorporated herein by reference in their entirety. 
     Referring generally to  FIGS. 1-13 , various embodiments of the implant  10  are shown. Portions of the implant  10 , such as the support portion  12 , can be formed or patterned by way of a polymer molding process to create a unitary homogeneous non-woven, or non-knitted, device or construct. Other embodiments can be formed from an already unitary homogeneous sheet or film via laser cutting, die cutting, stamping and like procedures. 
     As a result of the manufacturing process, molding or cutting, repeating cells form a lattice structure for at least the support portion  12  of the implant  10 . Portions of the implant can be formed into sinusoid, or other waveform or undulating struts  14  to control elongation or compression along single or multiple axes, to define a desirable pattern density with overall reduced surface area, and to control the distribution and shaping from applied loads. The ability to mold, form or cut the struts  14  in a nearly endless array of sinusoidal or like configurations provides an implant  10  that can better tailor or mimic the anisotropic behaviors of physiological tissue. 
     One or more portions of the implant  10  can be constructed of a polymer coated, or impregnated or molded with a coloring. As such, the entire implant  10 , or simply a portion of the implant such as the support portion  12 , can be colored to stand out relative to the surrounding tissue. Coloring (e.g., blue) of the implant or implant portions can improve visualization and positioning of the implant  10  by the physician during implantation by providing desirable surface contrast. Further, various embodiments of the implant  10  can be constructed of opaque, or translucent, polymer materials. 
     In certain embodiments, such as those depicted in  FIGS. 1-4 , the patterned struts  14  define a general pinwheel design including first angular strut lines  20  and second angular strut lines  22  crossing or intersecting at repeating fixed junctions  24  to define cellular voids  26 . The thickness, size and separation of the struts  14  can be modified to create an implant  10  with different surface area and cellular density attributes. 
     By arranging the density of the cell patterns with the embodiments of the implants  10  of the present invention, it is possible to tailor the elongation, load or strength properties of the implant  10  according to specific needs and support requirements. Moreover, more than one material can be used to construct the implant  10  to further control desired load and stress properties, e.g., combining different polymers such as polypropylene, PEEK, PET, PTFE, PGA, PLA, etc. Polymers could also be combined with metallic elements to alter strength and elongation profiles of the implant  10 . The stronger materials would take up stresses from higher load regions faster, thereby allowing for a method to selectively control performance characteristics of the implant  10 . Moreover, a polymer or metal frame could be provided along the periphery or other select areas of the implant  10  to provide additional strength or rigidity properties. 
     As demonstrated in  FIGS. 2-4 , embodiments of the implant  10  can include a symmetry axis or structure A. The axis A can take on a unique shape and configuration as shown in the figures to provide desired compression and expansion characteristics generally central to the width or length of the implant  10 . Alternatively, the axis A can take on shapes and dimensions similar to that of the surrounding sinusoidal cell configurations. In addition to providing physical compression and support characteristics, the axis A can serve as an important marker or line of reference during implantation. As such, the axis can be colored or otherwise marked to visually stand out relative to the implant  10  as a whole. In various embodiments, the axis A can be colored or marked along a length shorter than its entire length. Variations on the visual marking of the axis A are envisioned for embodiments of the present invention. 
     The dimensional design of the implant struts  14  can be configured to promote targeted strength and flexibility. For instance, the material width at the fixed junctions  24  can be measurably greater than the material width of the struts  14  intermediate the junctions  24  to allow for increased strength at the junctions. Strengthened and widened junctions  24  can handle and absorb greater stress or torque resulting from implant positioning, twisting and general manipulation. Conversely, thinner strut portions  14  intermediate the junctions  24  promote can increase flexibility and controllability of the implant  10  during positioning and device manipulation. This flexibility will also provide an implant  10  adapted to properly conform to unique patient anatomy and lay flat against such anatomy to provide optimal support distribution, tissue in-growth and like characteristics. In one embodiment, the junctions  24  can range in material size or width from 0.017 inches to 0.020 inches. The intermediate strut portions  14  can range in material size or width from 0.014 inches to 0.017 inches. Other dimensional ranges and proportions are envisioned for embodiments of the struts and strut portions depending on the particular application, strength, flexibility, stress distribution or other performance needs of the implant. Of course, the structures of the implant  10  can be provided in other sizes as well. 
     The struts  14  and cells can extend to provide or define a strut perimeter  14   p  that can include the looped or curved shape of the cells to provide atraumatic cell geometry. For example, such a configuration provides an implant  10  with perimeter structures that minimize or eliminate poking or snagging on tissue within the patient during implantation and after. 
     Additional benefits are presented with the homogenous non-woven design and targeted strength regions (e.g., fixed junctions  24 ) of the implant  10 . Namely, a flexible but strong implant  10  is provided, while still maintaining a low surface area, lower inflammatory response, less scarring and increased density. 
     The patterned implant  10  also provides benefits over traditional knitted or woven mesh in the area of compression and the reaction to longitudinal extension strain. Traditional knitted or woven mesh implants can tend to compress and narrow during longitudinal stretching, thereby displaying a positive Poisson affect or ratio. Conversely, the sinusoidal cell and strut configurations of certain embodiments of the patterned implants  10  of the present invention can display a Negative Poisson affect or ratio. In particular, as the implant  10  is loaded or stretched (e.g., at ends, anchors, corners or upon the planar surfaces), the strut and cell structures can resist compression and measurably expand to provide a stable and generally planar surface area for tissue or organ support. The combination of the struts and fixed junctions facilitate this Negative Poisson affect. 
     The cross section of the non-woven strut members  14  are generally circular, oval or otherwise formed to have rounded portions with exemplary embodiments of the present invention. This is a significant advantage over the bunched woven or knitted filament mesh stands of conventional implants. The rounded portions of the struts  14  of the present invention provide an improved implantation feel and a consistent surface adapted to lay flat and retain its shape against target tissue, and to reduce or eliminate snagging or resistance during deployment and positioning. In addition, it provides a desirable tactile feel and surface for the physician to grasp and manipulate during implantation, and as the implant  10  passes along tissue. 
     Embodiments of the implant  10  can include one or more transition portions or zones  40 , as shown in  FIGS. 1-3 . In general, the zones  40  provide a material transition between the cellular construct of the support portion  12  and anchoring or like features  16  of the implant  10 , e.g., anchors, eyelets, etc. The transition zones  40  can take on various sizes, shapes and designs to provide increased strength and stress absorption/distribution for portions of the implant  10  being pulled, pushed and twisted during deployment and positioning of the implant  10 . Embodiments of the zones  40  can include arcuate lattice or cell structures fanning out from or into the support portion  12  and the anchoring portions  16 . The zones  40  can be tapered into or away from the support portion  12  or anchoring portion  16  to facilitate stress and tension distribution such that the struts  14  and cell structures of the support portion  12  are protected from tearing, ripping or other material breaches. 
     The structure and design of anchoring features of portions  16  of the implant  10  can vary greatly depending on the particular implantation and support needs of the particular device. In certain embodiments, the anchor portions  16  can include first and second anterior and opposing anchors extending out angulary from an anterior end region of the implant  10 . A tissue anchor  50  is provided at a distal end of the anchor rod  48  such that the rod  48  extends intermediate the anchor  50  and the transition zone  40 . The tissue anchor  50  can include one or more tines  51  adapted to engage and/or penetrate soft tissue, e.g., the obturator internus muscles. The anchor rod  48  can be generally cylindrical in certain embodiments, or generally flat or rectangular in other embodiments. The anchor rod  48  is adapted to absorb and comply with twisting or other like motions imposed on the anchor portion  16  during deployment and positioning of the implant  10 . 
       FIGS. 1-2 and 5-8 , for instance, depict various embodiments of the implant  10  having undulating anchor rods  48 . Undulating or curved sections  48   c  facilitate stretching and accommodation for anatomical variation in prolapse patients, or other treatment uses. Again, one or more arcuate, curved or transitional bend portions  48   c  can be included along the length of the rods  48  between the transition portion  40  and the anchor  50 . Embodiments can include a different number of curved sections  48   c  (e.g., one, three, four, five, etc.) depending on the anatomical structure of the patient, the size of the bends, the length of the rod, or other procedural and structural considerations. As depicted, the curved sections  48   c  can be defined by bends of varying radiuses and lengths. For instance, the curved section  48   c  proximal the anchor  50  can have a generally larger length and radius (e.g., compared to the curved sections  48   c  nearest the transition zone  40 ) such that the anchors  50  are provided in an anchoring position and orientation ideal for the particular tissue path and target tissue site. The rods  48 , and corresponding sections  48   c , can be constructed of a polymer or like material as disclosed herein, such that it can be pulled on to expand or extend the length of the rod  48  at the sections  48   c  to allow for adjustability and the anatomical variations in patients. 
     Further, sections of the anchor portion  16 , including the anchor rod  48 , can be generally rigid, or flexible, depending on the particular strength and anchor displacement needs. In addition, the anchors  50  can be rotatably or pivotably affixed to the rods  48 , any other portion of the anchor portions  16 , or the transition zones  40 . Any of the anchors depicted or described herein can be integrally formed with a portion of the implant  10 , or separately attachable or detachable therefrom. 
       FIG. 3  shows an embodiment of the implant  10  including a generally linear rod  48  having an angular bend  48   a  section (e.g., off-axis). The end of the angular bend  48   a  can include an anchor device  50 . As such, the anchor device  50  is adapted to better accommodate and engage with a tip of a needle, as described herein, to reduce or eliminate interference of the needle and facilitate corresponding navigation to engage the anchor  50  in the target tissue to locate the implant  10  for support and treatment. 
     Further, embodiments of the implant  10  can be constructed in various dimensional and proportional configurations, as shown in  FIGS. 5-8 . Namely, the overall shape and size (e.g., width and length) of the implant  10  can vary depending on the particular procedural needs for the patient. The various optional implants  10  can be included in a surgical kit for the physician to select from before or during a particular treatment procedure. The inclusion of various sized and shaped implants  10  can be used as an alternative to providing a single implant  10  with tails or other portions that can be removed or added. In addition, multiple configuration options enables deployment of the implant  10  into patients having different anatomical features, dimensions and geometry. 
       FIGS. 5-6  demonstrate two smaller embodiments of the present implant  10  defined by various length dimensions L 1 , L 2  and L 3 , as well as width dimensions W. While a myriad of acceptable dimensional configurations are envisioned for use with the present invention, depending on the particular patient and surgical requirements, these figures depict exemplary configurations. 
     For instance, as shown in  FIG. 5 , the distance between the two eyelet or other top anchoring portions, L 1 , can be approximately 74 mm; the distance between certain transition zones, L 2 , can be approximately 47 mm; the overall distance between the bottom anchors, L 3 , can be approximately 98 mm; and the width of the support portion, W, can be approximately 32 mm. For the embodiment of  FIG. 6 , the distance between the two eyelet or other top anchoring portions, L 1 , can be approximately 74 mm; the overall distance between the bottom anchors, L 3 , can be approximately 98 mm; and the width of the support portion, W, can be approximately 40 mm. 
     Two generally larger implants  10  are depicted in  FIGS. 7-8 . As demonstrated with the embodiment of  FIG. 7 , the distance between the two eyelet or other top anchoring portions, L 1 , can be approximately 82 mm; the overall distance between the bottom anchors, L 3 , can be approximately 98 mm; and the width of the support portion, W, can be approximately 46 mm. As shown in  FIG. 8 , the distance between the two eyelet or other top anchoring portions, L 1 , can be approximately 74 mm; the length of the support portion (or the general distance between transition portions), L 2 , can be approximately 46 mm; the overall distance between the bottom anchors, L 3 , can be approximately 98 mm; and the width of the support portion, W, can be approximately 54 mm. Again, various other configurations and dimensional embodiments can be included without deviating from the spirit and scope of the present invention. 
     A grommet  19  (or locking eyelet) or blocking eyelet structure can be provided integral with an eyelet  18 . The blocking eyelet  19  can a member or feature molded into the grommet  19  to allow for release of grommet teeth during implantation to allow for removal or back tracking of the anchor arm or like device from the grommet  19 . However, other embodiments can include a separately engageable grommet  19  component, as previously depicted and disclosed (e.g.,  FIG. 1 ). The various dimensional values shown in these figures are for illustrative purposes only. 
     Referring generally to  FIGS. 3, and 9-12 , the support portion  12 , or the anchor portions  16 , can include one or more eyelets  18 , with transitioning zones  40  extending or spanning intermediate the eyelets  18  and the strut  14  cell structures. An aperture extends through each of the eyelets  18 . The eyelets  18  can simply include corresponding apertures for engagement with anchoring members or devices, or the eyelets  18  can be integrally formed with a grommet  19  having a plurality of extending or angular teeth  19   a . In other embodiments, the grommet  19  can be separately attached or seated. 
     The teeth  19   a  are adapted to engage and retain various anchoring structures, such as anchor mesh, separate anchor members, extensions, apertures or protruding members. The eyelets  18 , and any corresponding material or structures associated with the eyelets  18 , can be provided along any side, end or body portion of the implant  10 , depending on the particular anatomical and treatment application. Moreover, a variety of sizes, quantity and shapes are envisioned for the eyelet  18  configurations for embodiments of the implant  10 . For those embodiments having an integrated grommet portion, the configuration can result in a reduced mass or low profile locking eyelet, compared to those where a separate and distinct grommet is provided. 
       FIGS. 9-12  show exemplary embodiments of the implant  10  having exemplary eyelet  18  and support  12  configurations, shapes and designs, which not require integrated anchor rods  48 . Again, numerous shape and size configurations can be employed depending on the particular deployment and treatment uses for the implants  10 . As explained herein, the grommet portions  19  can be integrated with the eyelets  18  (e.g., as a reduced mass or low profile locking eyelet) or separately engaged when slid along a separate anchor arm. 
     Various thickness and size differences between the various areas (e.g.,  12 ,  18 ,  40 , etc.) are shown as well. These unique structural constructs can be implemented so that various portions of the implant  10  are thicker and stronger (e.g.,  18 ,  40 ) to handle the twisting and torque of deployment and adjustment, while other portions or struts (e.g.,  12 ,  14 ) can be thinner to promote flexibility and manipulation. 
     As demonstrated with the embodiment of  FIG. 11 , the distance between the two top eyelet or anchoring portions, L 4 , can be approximately 68 mm; the length of the support portion, L 5 , can be approximately 46 mm, the overall distance between the bottom eyelet or anchoring portions, L 6 , can be approximately 54 mm; the width of the support portion, W 1 , can be approximately 40 mm; and the width or distance form the top eyelet portions to the bottom eyelet portions, W 2 , can be approximately 45 mm. As shown in  FIG. 12 , the distance between the two top eyelet or anchoring portions, L 4 , can be approximately 76 mm; the length of the support portion, L 5 , can be approximately 46 mm, the overall distance between the bottom eyelet or anchoring portions, L 6 , can be approximately 54 mm; the width of the support portion, W 1 , can be approximately 60 mm; and the width or distance form the top eyelet portions to the bottom eyelet portions, W 2 , can be approximately 63 mm. Again, various other configurations and dimensional embodiments can be included without deviating from the spirit and scope of the present invention. 
     As shown in  FIG. 13 , embodiments of the implant  10  can include portions constructed of struts  14  or other members having different or varying thicknesses (e.g., depth of strut in cross-section) and/or widths. For instance, at least a section T 1  of the support portion  12  can be formed or constructed of struts having a thickness in the range or approximately 0.010 inches to 0.013 inches. Further, struts  14  extending between the support portion  12  and the transition portion  40  can be formed or constructed of struts having a thickness T 2 . T 2 , in certain embodiments can be measurably thicker than T 1 , and in a range of approximately 0.013 inches to 0.015 inches. To provide additional thickness and reduced flexibility, still other portions of the implant  10 , including members or struts extending from the eyelet or grommet portions can be defined by a thickness T 3 , which can be in a range of approximately 0.015 inches to 0.018 inches. In general, the thinner the strut or member is, the more flexible it is. Conversely, the thicker the strut or member is, the more rigid and stable that portion of the implant  10  can be. Thinner portions are preferred for those sections of the implant  10  that need to contour, bend, twist or better conform to the surrounding tissue, or where a portion of the implant  10  requires increased adjustment and twisting capability during deployment and positioning. Thicker sections of the implant  10  are better adapted to withstand higher levels of torque, pressure and tension—e.g., sections of the implant  10  adapted to directly or indirectly anchor to tissue. 
     One of ordinary skill in the art will understand that a myriad of other shapes, sizes and configurations can be employed based on the teachings provided herein. Further, the implant  10  and support portion  12  can be constructed and sized to serve as an elongate incontinence sling, or as a larger prolapse implant. 
     Various embodiments of the present invention can include struts  14  that have variable widths or thicknesses, can be tapered, can include apertures, or can include defined shapes and/or patterns, e.g., sinusoids, squares, elliptical, triangular, elbowed, straight, or other simple or complex shapes and patterns. Unique strut  14  designs and cellular patterns can be included within a single implant  10  to provide different zones, having different stress, load distribution or compression characteristics. Other strut  14  designs and patterns can be employed as well to achieve the functionality described and depicted herein. 
     The implants  10  described herein can be implanted into a patient by use of various different types of surgical tools, including insertion tools, which generally are tools useful to engage and place a tissue anchor or a connector that is secured to an extension portion of an implant. Various types of insertion tools are known, including those in the previously-incorporated references, and these types of tools and modifications thereof can be used according to the present description to install the implant  10 . 
     Examples of various insertion techniques and tools are included in  FIGS. 14-16 , and the incorporated references. Each tool  60  can include a handle  62 , needle  64  and engaging distal tip  66 . The handle  62  can include an actuation mechanism  63  in operative communication with the distal tip  66  and adapted to selectively control engagement and/or disengagement of the distal tip  66  with portions of the implant  10  (e.g., anchors  50 ). In various embodiments, the distal tip  66  of a certain tool  60  is adapted to engage with, deploy, position and anchor or insert an anchor fixation arm  68  into the sacrospinous ligament of the patient, with a length or portion of the fixation arm  68  fed through and secured to the eyelet  18  and grommet  19  feature of the implant  10 . The anchor fixation arm  68  can include a rod or extension  68   a , a mesh portion  68   b , and a distal anchor  68   c . Certain embodiments of the anchor fixation arm  68  can include an external sheath adapted to shroud portions of the arm  68  during deployment (e.g., the mesh  68   b  and anchor  68   c ). 
     In one embodiment of the surgical procedure for implanting the implant  10  within a female patient to treat vaginal prolapse, an incision is made in the anterior vaginal wall of the patient, and a full thickness dissection is made of the anterior wall. Tissue is generally cleared from the sacrospinous ligaments. The tissue anchors  50  (adapted as anterior fixation anchors) are loaded on to the distal tip  66  of an anterior fixation tool  60 . The tissue anchors  50  are then inserted into the obturator internus muscle with a finger-guided needle  60 , bilaterally. The implant  10  can be trimmed and sutured to the anatomy as required. Next, the fixation arm  68  is loaded onto a corresponding needle tool  60 , advanced through to the sacrospinous ligament and the distal anchor  68   c  of the arm  68  is inserted through the ligament to provide fixation. Again, an actuation mechanism  63  can be activated to disengage the arm  68  or its respective anchor  68   c  from the tool  60 . Various embodiments of the arm  68  can include an outer sheath or sleeve, which can be removed, such as those disclosed in U.S. Patent Application Publication No. 2011/0112357 and 2009/0240104, each of which is incorporated herein by reference in its entirety. Alternatively, the sheath can remain in place to provide bidirectional adjustment of the arm  68  within the eyelet/grommet aperture configuration of the implant  10 . Again, this ligament fixation can occur bilaterally. 
     Once the arms  68  are fixated within the target ligaments (on each side), the eyelet  18  and grommet  19  on each side of the implant  10  is slid over and along the respective arm  68  (e.g., rod  68   a  and mesh  68   b  portions). As such, the grommet teeth  19   a  will grab onto and secure the mesh  68   b  of the fixation arm  68  therein. Final tension and adjustment can be provided at the fixation and related portions of the implant  10 . Next, excess lengths of the fixation arms  68  extending out from the eyelet  18  can be trimmed and removed. The vaginal incision can then be closed with sutures to complete the procedure. 
     Various embodiments of a sizing tool  100  are depicted in  FIGS. 17-21 . The tools  100  can be used by the physician to determine the anatomical geometry and, as a result of the measurement, the correct implant  10  to use for the procedure. The tool  100  can include a paddle-like design having a handle portion  102  and a head portion  104 . The handle  102  can include a scale or unit measurement printed, engraved or otherwise provided thereon. The head  104  can include various patterned cell portions  106 , and indicia  105  to denote the respective size of the tool. This size marking  105  can match up and assist the physician in determining the appropriate sized implant  10  to use for the procedure. The exemplary embodiments show measurements in millimeters, which can correspond to the measurement of the width W (as described and depicted herein) of the implant  10 . As such, the physician can insert the tool  100  into the dissection plane to determine which implant  10  will be best suited for the particular anatomical geometry of the patient and that patient&#39;s particular treatment and support needs—e.g., selected from a kit including implants  10  of varying sizes. In certain circumstances, it can be preferred to select an implant  10  slightly smaller than the dissection plane measurement. 
     Referring generally to  FIGS. 22-23 , various serpentine structures to define the strut and cell structures for certain embodiments of the implant  10  is disclosed. An in-phase serpentine pattern with horizontal sinusoidal struts  80  intersecting serpentine struts  82  at centerline point  81 , midway between the peaks  80   a  and troughs  80   b  of the struts  80  at the general centerline of the serpentines is shown. As the struts  82  are subjected to loading in the longitudinal (vertical) direction, the radii in the peaks and troughs will open and the amplitude will decrease until, ultimately, the stretched serpentine construct becomes nearly straight and extended along the centerline. Torsion will tend to deform the sinusoids somewhat (e.g., opening the angles/radii made with the serpentines). As a result, the overall implant  10  structure, or support portion  12 , will tend to expand laterally slightly (widen) as it expands longitudinally (e.g., expands along width W). Further, joining/connecting the sinusoid struts  80  to the serpentine struts  82  in locations off of the centerline can yield mechanical behavior which is desirable in certain situations. 
     The sinusoid struts  80  can be joined to the serpentine struts  82  at an off-center location. As such, the struts  80  do not quite extend to the centerline of the struts  82 . As the struts  82  are expanded and tend toward the centerline, the sinusoidal struts  80  will be placed under tension. Relative to the centerpoints, along a given horizontal row, one end of the struts  80  will be pulled to a position above the centerpoint while the other will be pulled to a position below the center point of the struts  82 . As a result of the tensile state of the sinusoid struts  80 , the overall structure of the implant  10 , or the support portion  12 , will tend to decrease laterally (e.g., length L or horizontally) upon expansion. The amount of decrease in the horizontal length can depend upon the location of these attachments. The joining of the struts  80  to the struts  82  at a location short of the serpentine strut centerline can also stabilize the serpentine struts  82 . When the struts  82  deform, they can exhibit some out-of-plane bending (that is, the apex points can flare up or buckle out of the plane or into the plane). If the sinusoid struts  80  are attached at locations short of the serpentine centerline, they tend to resist this out-of-plane bending. 
     The sinusoid struts  80  can also be joined to the serpentines at a location beyond the serpentine strut  82  centerline position. The excess length and over-center positioning of these sinusoid struts  80  can cause them to experience compression as the struts  82  elongate. As a result, the overall structure of the implant  10  will tend to expand or widen horizontally in a manner that is proportional to the location of the attachment of the struts  80  relative to the centerline of the struts  82 . 
     Various implants  10 , or support portions  12 , can include arrangements of cells including different shapes and constructs, such as polygon shapes. These differently shaped cells (defined again by struts) can, for example, can be included along a portion of the support portion  10  adapted to better support the various organs and anatomical structures around the vagina while permitting the vagina to stretch and elongate, as needed. These different cell constructs can take on a myriad of shapes and sizes, including hexagonal, octagonal, diamond and like-shaped cells arranged in different combinations. These differently shaped cells can be included with (e.g., composite implant  10  or support portion  12 ), or in lieu of, any of the pinwheel, sinusoidal or serpentine cell constructs provided herein. As such, implants  10  with specialized or targeted mechanical properties can lead to an implant having more precise treatment and deformation characteristics. These various cell and strut constructs can be molded together, laser cut from a thin film or sheet, or defined or joined by various processes and methods. 
     Various embodiments of the implant  10 , as depicted in  FIG. 22 , can be adapted to expand or elongate slightly in the lateral (horizontal) direction as it deforms longitudinally by including one or more “squid-like” strut arms  86  configured to transmit loads from the anchor portions  16  (such as eyelets) to the support portion  12 —e.g., anchors can engage with the obturator internus muscles at the introital end and engage with the sacrospinous ligament at the apical end. The strut arms  86  can have different lengths and thicknesses depending on the locations at which they are joined to the implant  10  or support portion  12 . 
     The various implants  10  and strut configurations described herein can allow for adjustment and tensioning of the implant and anchoring portions during implantation to permit the physician to optimize placement and tension for bladder neck and like support. Further, the anchors can rotate, twist, or pivot during deployment and implantation rather than being held rigidly in one orientation relative to the implant  10 . The physician can place the anchors in different locations and accommodate the many different anatomies encountered in the patient population, and adjust the tension of the anchoring for different levels of prolapse around the bladder neck or like anatomical areas. 
     Various anchoring portions  16 , anchor arms, anchors  50  and other means for providing anchoring connections and techniques are also provided with certain implants  10 . 
     Referring to  FIGS. 24-25 , the tissue anchors  50  can include an additional molded attachment feature  50   a  which acts as a key to fit into a keyway, slot or aperture  110  provided with a portion of the implant  10 , such as the anchor portions  16 . The feature  50   a  can be generally circular, extend from the anchor  50 , and can be pushed through and slid along the slot  110  to lock the anchor  50  in place for implantation. As such, different anchors  50  can be selectively attached to the implant  10  via the slot  110 . 
       FIGS. 26-27  depict an additional material or feature provided at a portion of the implant  10 , such as the anchor portions  16 , in the form of a flap  112 . This flap  112  can be folded along a hinge or bendable portion  114  (e.g., thinner material construct) over to create a reinforced section of the implant  10  to receive an anchoring device, thereby resisting tearing or material breakdowns when loads are applied to the implant  10  upon deployment. While a suture  115  is shown attaching an anchor  50  to an aperture  116  in the flap  112 , other means of connectivity and anchoring can be employed with such an embodiments as well. 
     Referring to  FIG. 28 , a separate flange element  118  can be pushed through an aperture or portion of the film or unitary implant  10 , such as the anchoring portion  16 , during manufacturing or formation and then a secondary thermal process can be performed to modify the element  118 . This process and structure can serve to bond the anchor  50  to the element  118  at a weldment portion  119  to create a rivet-like configuration for the anchor and implant. The anchor  50  can then rotate as it is not directly bonded to the implant  10 , only to the element  118 . 
     Referring to  FIGS. 29-30 , the anchor  50  can be attached to mesh material  120 , such as a portion of the implant  10 , a separate anchor arm, and the like. A section of the mesh  120  is pulled through an aperture  122  in the implant  10 , such as at the portion  16 , and then a stopper feature  124  is molded or otherwise attached to the mesh  120  at an end opposite the end having the anchor  50 . The stopper  124  can be attached to the underside of the implant  10  or portion  16 , while still allowing for a wide range of anchor  50  movement, e.g., longitudinal and lateral movement, during deployment and implantation. 
     Referring to  FIGS. 31-32 , embodiments of the anchors  50  can be composed of two separate components  50   b ,  50   c . The components  50   b ,  50   c  are placed on either side of a portion of the unitary film implant  10 , such as the anchor portion  16 , and then pressed or otherwise joined together. The components  50   b ,  50   c  can be made to form a snap fit, or can be thermally bonded together with a secondary process. In certain embodiments, a post  126  is provided with at least one of the components, with the other of the components including an aperture  128  to receive and interlock with the post  126 . The post  126  likewise extends through an aperture in the implant  10  to provide the disclosed attachment of the anchor  50 . As such, a rigid attachment can be provided while still allowing for rotational movement of the anchor  50  relative to the implant  10 . 
     As shown in  FIG. 33 , a piece or length of mesh  130  can be threaded through an aperture  132  in the implant, such as the anchor portion  16 . Ends of the mesh length  130  can be joined, such as via bonding or molding, to make a permanent connection between the mesh ends. The resulting construct is a mesh arm having an anchor  50  extending therefrom. This configuration can allow the anchor arm to move up and down, rotate left-to-right, and twist in many directions. 
     Referring to  FIG. 34 , metal or polymer spring-like devices  134  are provided with the implant  10 . The devices  134  can be helical, coiled, or take on like constructs to provide an anchor arm adapted to expand contract according to tension or load on the anchor  50 . In certain embodiments, the devices  134  can be connected to the implant  10  at the anchor portions  16 —e.g., via apertures  136 . The spring devices  134  allow for directional freedom and can allow for a certain amount of adjustability for tensioning the implant  10 . 
     As shown in  FIGS. 35-36 , apertures  138  can be cut or otherwise formed in the implant  10  to include jagged teeth-like features similar to other locking eyelets described herein. Then, implant anchoring arms  142 , including a mesh portion  144 , can be used to allow for adjustability in placement of the anchors  50 , and for tensioning. The teeth can allow for movement in one direction through the apertures  138 , while generally preventing backing out of the arms  142  from the apertures  138  in the opposite direction. 
       FIG. 37  depicts an embodiment of the anchoring arms  142  having a plurality of extending tines or teeth-like features  150  to provide a ratcheting mechanism by which the arm  142 , which can include a mesh portion  144 , can be pulled through an aperture  138  in the implant  10  having desirable geometry. As such, the arm  142  is intended to only slide through in one direction. The teeth  150  can collapse or deform upon insertion through the aperture  138  and self-expanding when positioned on the other side of the implant  10  surface. Consequently, the arm  142  will generally be prevented from backing out the opposite direction due to the teeth  150 . The physician can pull on the arm  142  until the right amount of tension is in the arm  142 , and then cut off the remaining arm segment. The distance between and the number of teeth  150  will provide various length and tensioning options for the anchoring arm configuration. 
     Referring to  FIGS. 38-39 , the ratcheting mechanism or feature is contained within the anchor  50 . For instance, a step or sharp feature  152  (or a jagged, angled or other like feature) can be included within a through-aperture  154  of the anchor  50 . The feature  152  can be tapered so that a piece of mesh  144 , or other anchoring arm structure, can pass through the anchor aperture  154  in one direction only. The sharp edge of the feature  152  restricts movement in the other direction. 
     Referring to  FIGS. 40-41 , the anchor  50  can include an extending suture  158 , with the suture  158  being threaded through or along mesh anchoring arm  142  to provide a means of tensioning the arm  142  after the anchor  50  has been engaged with the target tissue. A plurality of apertures can be provided at multiple locations along the length of the arm  142  to distribute the tension along the entire length of the arm  142 . The various arm or anchoring attachment mechanisms and described herein can be used to attach the mesh arm  142 . 
     As shown in  FIG. 42 , a generally flat eyelet  160  having locking-type teeth features  162  can function as a means of tensioning and adjusting the length of the mesh anchoring arm  142 . Mesh portions  144   a ,  144   b  can be pulled like a belt (e.g., portions  144   a ,  144   b ) through a belt buckle (e.g., the eyelet  160 ), until the desired amount of tension is achieved. The remaining mesh can then be trimmed. The locking eyelet  160  functions as a one-direction locking mechanism similar to those disclosed herein. One of the mesh portions  144   a  can be attached or provided with the implant  10 , such as the anchoring portion  16 , while the other mesh portion  144   b  can include the anchor  50 . 
     Referring to  FIG. 43 , an elongate or continuous anchoring arm  142  is adapted to pass through two or more eyelets  162  on the implant  10  (mesh or unitary film-like implant) so that the physician can manually adjust the take-off angle of the arm  142  from the implant  10  and place the anchor  50  in the desired target tissue location. The physician can also slide the implant  10  along the arm  142  at the eyelets  162  to get optimal implant  10  placement within the dissected cavity. The arm  142  can be constructed of a mesh, or made of some other thread, wire, or flexible polymer material. 
     As shown in  44 - 45 , the implant  10  can include a plurality of eyelets  164 . The eyelets  164  can provide optional placement and connecting options for the anchoring arms  142 . The physician can then select the appropriate aperture or multi-aperture pattern from the eyelets  164 , which gives increased placement options for the implant  10 , proper take-off angles of the arms  142 , and selective tensioning via the arms  142 . The plurality of eyelets  164  can be provided, or formed in, various portions of the implant  10 , including the top, bottom, sides, anchoring portions  16 , and the like. 
     Referring generally to  FIGS. 46-47 , various embodiments of polypropylene film  170  for use to form all or a portion of the implant  10  are provided. These embodiments of the film  170  are three-dimensional, defining a series of peeks  170   a  and troughs  170   b.    
     Implant  10  portions including the 3-D film constructs  170  can provide additional strength for the implant  10  without sacrificing flexibility. In fact, the 3-D features can improve flexibility. Tissue in-growth can also be enhanced due to the surface and film shapes. The sheet or film  170  can be formed into a 3-D shape during the extrusion process or through a secondary thermal forming process. Further, the sheet  170  can serve as the base material from which to cut out the disclosed implant  10  portions via a laser or other manufacturing processes and techniques. The 3-D patterns of the film  170  defines ridges or ripples (e.g., via the peeks  170   a  and troughs  170   b ). The ridges add structural integrity to the implant  10  and are adapted to support a heavier load. The ridges can also serve as a means of providing significant flexibility in a particular direction, depending on the direction or orientation of the ridges. 
       FIG. 48  demonstrates a portion of the implant  10  formed of woven film members or stands  172 , rather than conventional filaments, to create a weave pattern for added strength. The woven portions  172  can increase the strength of the implant  10  while maintaining desired flexibility. The thickness and width of each strand  172  can vary to achieve the desired mechanical properties and to achieve the appropriate amount of tissue in-growth. The woven design can add strength to the implant without adding too much stiffness. A myriad of strand dimensions can be selected to control the flexibility of the implant  10 . 
     Referring to  FIG. 49 , the implant  10  can include a thin film frame  180  to create or define the basic footprint for the implant  10 . Then, a warp-knit or like mesh  182  (e.g., IntePro Lite) is thermally bonded to the interior perimeter of the frame. The structural integrity and stiffness of the frame  180 , due to its thickness (e.g., about 0.010 inches), can maintain the basic shape of the implant  10  while healing and scarring take place after implantation. The frame  180  also assists in preventing bunching and constricting during and after implantation. The mesh also  182  can facilitate porosity for tissue in-growth. In various embodiments, the mesh portion  182  can be included only at select areas of the implant  10 . 
     The implant  10  embodiment of  FIG. 50  includes a specific geometry adapted to hold the bladder in place after an anterior prolapse repair. However, the implant  10  and the benefits of the localized support zones can serve many other treatment applications for tissue repair implants. For instance, there can be an oval (mesh or film) portion  184  located in the middle of support portion  12  of the implant  10 . The struts (film) or filaments (mesh) defining the portion  184  can be generally dense. The portion  184  can be connected or provided with the implant  10  via extending spring-like struts or members  186  to act as a hammock for holding the bladder. The remaining portions  185  of the implant  10  can be constructed of a less dense grid of struts or filaments to allow for in-growth and incorporation into the surrounding tissue. The spring-like members  186  connect the two grids or portions  184 ,  185  of the implant  10 . The members  186  permit the implant  10  to stretch during sudden stress events (e.g., coughing, sneezing, etc.) without causing permanent deformation to any of the struts. After the stress event, the spring-like struts  186  pull on the dense portion  184  to bring the bladder back into the correct anatomical position. As such, the implant can accommodate stress events, while still maintaining structural integrity for the typical “non-event” loads. 
     As detailed herein, various structures and components of the present invention can be integrally formed into a unitary body via a molding process. For instance, an injection molding machine (e.g., Milacron Roboshot S2000i 33B machine) having internal vacuum and cooling lines can be employed. In general, a dry resin, such as a polypropylene resin (e.g., Pro-fax PD 626), is maintained at approximately 170° F. for several hours. In addition, the mold device can be heated to approximately 130° F. Then, the mold vacuum lines can be started and the injection molding cycle initiated. The mold cavities will be filled and the device will be cooled for a period of time (e.g., 18 seconds). Upon completion, the mold is opened and part ejection will activate with evacuation. The mold can then be closed and the cycle repeated for additional injection molded implants. Other known molding processes and systems can be employed with the present invention as well. 
     Embodiments of the implant  10  can be formed or cut along a precise cutting tool path (e.g., using the DPSS 266 laser system), to cut the implant  10  and strut  14  features and designs in an already unitary film or sheet of polymer material. Alternatively, the implant features and portions can be stamped into such a unitary film or sheet material. 
     The implants  10 , their various components, structures, features, materials and methods may have a number of suitable configurations and applications, as shown and described in the previously-incorporated references. Various methods and tools for introducing, deploying, anchoring and manipulating implants to treat incontinence and prolapse as disclosed in the previously-incorporated references are envisioned for use with the present invention as well. 
     All patents, patent applications, and publications cited herein are hereby incorporated by reference in their entirety as if individually incorporated, and include those references incorporated within the identified patents, patent applications and publications. 
     Obviously, numerous modifications and variations of the present invention are possible in light of the teachings herein. It is therefore to be understood that within the scope of the appended claims, the invention may be practiced other than as specifically described herein.