Cochlear Implant
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For patients who present with bilateral severe-to-profound sensorineural hearing loss who have little-to-no benefit from conventional hearing aids, cochlear implants can restore hearing by directly stimulating the cochlear nerve. A standard mastoidectomy and facial recess approach is performed to visualize the round window niche and membrane. The round window membrane is opened, and the cochlear implant electrode is carefully inserted into the scala tympani. After several weeks, the patient returns for implant activation with a dedicated team of audiologists.
In this case, a 65-year-old patient presented with bilateral, progressive sensorineural hearing loss. He had used hearing aids for many years but in recent years began losing the benefit he initially received. He underwent an audiometric workup specifically for cochlear implant and was deemed a candidate bilaterally. He was right-handed and selected this side to be implanted first.
He denied a history of meningitis, vertigo, significant noise exposure, head trauma, or the use of ototoxic medications such as chemotherapy. He did have a history of ear infections but denied any otologic surgery.
The patient’s physical exam was unremarkable. He used hearing aids in order to communicate but still had significant difficulty with speech understanding. There were no craniofacial abnormalities. His face was symmetrical at rest, and facial function and sensation were normal bilaterally. The external ear was normal in appearance, as were the tympanic membrane and middle ear spacea bilaterally.
The patient had a history of ear infections as a child and adolescent, so a computed tomography (CT) scan was obtained. This demonstrated a well aerated mastoid cavity and facial recess. The cochlea and vestibule had normal morphology. Magnetic resonance imaging (MRI) showed normal cochlear and facial nerves bilaterally.
The prognosis for hearing loss varies depending on the underlying etiology. For patients with congenital forms of hearing loss, it may progress in gradual or stepwise fashion. Similarly, patients with presbycusis typically experience hearing loss in the high frequency range, which makes understanding speech more difficult. Ultimately, these patients should be monitored on an annual or biannual basis, or undergo audiometric testing should they experience a noticeable change in their hearing.1
For patients with mild hearing loss, treatment may involve observation or the early institution of hearing aids if they have difficulty in situations that are frequent in their day to day life (meetings, group conversation, etc.). As hearing loss progresses, recommendations are based on not only hearing thresholds but also speech understanding both in quiet environments as well as in situations with background noise.
In this case, the patient no longer received benefit from conventional hearing aids. While the specific indications from the Federal Drug Administration continue to evolve and are beyond the scope of this particular case, the following factors should be considered in adult patients:
- Severe or profound hearing loss with a pure-tone average of 70 dB hearing level.
- Use of appropriately-fitted hearing aids or a trial with amplification.
- Aided scores on open-set sentence tests of less than 60%.
- No evidence of central auditory lesions or lack of an auditory nerve.
- No evidence of contraindications for surgery.
Please note that these are general steps for surgery, and that significant variation exists in how this is accomplished.
General endotracheal anesthesia is required. No long-active paralytic agents should be used during induction or during the case as facial nerve monitoring is performed.
The patient remains supine on the operating room table. Depending on the surgeon preference a gel-ring may be used to stabilize the head, or it can be laid flat on the table. The bed should be rotated 180 degrees from the anesthesiologist, with the bed controlled by the anesthesia team at the request of the surgeon throughout the case.
As with many other otologic procedures, facial nerve monitoring is recommended during cochlear implant surgery.
Specific ways of prepping the patient vary by surgeon preference. The hair is typically shaved behind the mastoid so that the area can be prepped and the drapes may stick without having hair into the field. However, if securing the implant is not feasible via a standard periosteal pocket, the incision may need to be extended superiorly, and this should be considered when draping the surgical field. A standard Betadine prep may be used, and Ioban can be used to hold the ear forward during the surgery.
A postauricular incision is planned, typically extending 1.5–2.0 cm behind the postauricular sulcus along the temporal line.
An incision is made through the skin and subcutaneous tissue and then elevated anteriorly and posteriorly within this plane. This is done so that the periosteal incision can be staggered away from the skin incision so that in the event of any superficial wound breakdown, the receiver stimulator does not become exposed. A periosteal incision is made along the temporal line and bisecting the mastoid tip, and the periosteum elevated anteriorly. If the surgeon plans to use a subperiosteal pocket, minimal elevation of the posterior and superior flaps should be performed. A small amount of fascia and muscle can also be harvested at this time to be used to stabilize the implant at the round window and in the facial recess.
Next, the lambdoid suture line is identified and the periosteum superior to this is elevated. This is taken posteriorly and then superiorly until resistance from the temporoparietal suture line is encountered. Within these confines, a subperiosteal pocket is created. It should be sized accordingly in order to accommodate the silicone “sizer” for the receiver-stimulator of the cochlear implant. It can either be removed at this time or left in place until the implant is brought onto the field. A three-dimensional mastoidectomy is performed. For some surgeons, if a straight electrode is used, then bone pate may be collected to use for stabilization after insertion. Otherwise, the limits of the mastoidectomy may be narrower than for other chronic ear cases; the tegmen and sigmoid sinus do not necessarily need to be exposed. The posterior bony ear canal should be thinned adequately, however, to allow for exposure and access through a facial recess approach. When the antrum is entered, the short process of the incus and the lateral semicircular canal should be in view. Opening the facial recess can proceed by several methods. Some surgeons prefer to identify the facial nerve distal to the second genu to ensure that it is in an appropriate position and to increase confidence during facial recess exposure. Others may identify facial recess air cells and open from “inside-out” ensuring that a bony covering is left over the facial nerve at all times. Both are appropriate approaches. The chorda tympani nerve should be identified and preserved. When the facial recess is opened, the implant may be opened and should be soaked in an antibiotic solution. With the facial recess opened, the round window and its niche are identified. If this is difficult, one can recall a relationship of 1.5–2 mm between the oval and round windows. When identified, the drill speed should be set no greater than 10,000 revolutions per minute, and the niche drilled superiorly to expose the round window membrane. If encountered, the false membrane should be removed. When exposed, a piece of Gelfoam with dexamethasone solution is placed over the round window membrane. The field should be copiously irrigated with antibiotic solution, and the surgeon should either change gloves or ensure that they are cleaned. The implant is brought onto the field and placed in the subperiosteal pocket. The surgeon removes the Gelfoam from the round window membrane. The membrane can be opened with a variety of instruments (straight pick, beaver blade). Some electrodes require directionality to be oriented towards the modiolus, and then the electrode is inserted slowly into the scala tympani, over the course of at least one minute. If resistance is encountered, the surgeon pauses before attempting to advance further. When full insertion is achieved, the electrode is stabilized and then supported around the round window with the previously harvested fascia and/or muscle. The remaining electrode is coiled within the mastoid cavity and is typically protected with a large piece of Gelfoam.
- The periosteal layer is closed in interrupted fashion with 3-0 Vicryl suture.
- The deep subcuticular layer is closed in interrupted fashion with 4-0 Monocryl suture.
- The skin is dressed with Mastisol/benzoin and Steri-Strips.
- The ear canal should be examined to ensure that the posterior ear canal and tympanic membrane were not violated or disturbed during the surgery.
A mastoid dressing or Glasscock dressing may be used.
- No heavy lifting or straining for at least 10 days (greater than 10 lbs).
- Avoid sneezing or coughing, but do so with the mouth open if necessary.
- If narcotic medication is prescribed, a stool softener should be used.
- Remove the dressing on the first postoperative day.
- Antibiotics are given for five days.
- Some dizziness may be expected after surgery.
- Drill system.
- Basic microscopic ear tray.
- Cochlear implant insertion tray (specific to the company of the selected implant).
Author C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Wackym PA, Tran A. Cochlear Implantation: Patient Evaluation and Device Selection. Cummings Otolaryngology: Head and Neck Surgery 6th Ed. 2015. Elsevier, Philadelphia, PA. pp 2429-43.
Cite this article
C. Scott Brown, MD, Calhoun D. Cunningham III, MD. Cochlear implant. J Med Insight. 2023;2023(178). https://doi.org/10.24296/jomi/178Procedure Outline
Table of Contents
- Landmarks
- Reviewing Anatomy
- Create Subperiosteal Pocket
- Drill Electrode Channel
- Round Window Membrane Incision
- Electrode Insertion
- Fascia Graft
Transcription
CHAPTER 1
Our skin incision is a lazy S type postauricular incision.We’ll carry this incision all the way through the skinand subcuticular layer.and then connect with our superior vertical limb.Can I have a pair of pickups, please?Superiorly, we’ll carry this incision down to the level ofthe temporalis fascia,through this loose areolar connective tissueand then further elevate inferiorly.Okay, can I have a Weitlaner now, please?The small one.We're down now to the level of the temporalis fascia.Bovie?Now can I have a large, self-retaining...This underlying temporalis muscleand muscle periosteal layer is now incised in a similar fashion.What's the Bovie on guys? Can we go up to 40?Now, a Lempert elevator, please?We will now back elevate this temporalis muscleand periosteal flap to expose the mastoid cortex.Anteriorly exposed to seejust the posterior bony external auditory canaland as it curves superiorly.Bovie.Hold that.Now we’ll reposition our Weitlaner.Suction.Can I have that suction, please?Is this? Yeah.So now, we have the root of the zygoma, external auditory canal,spine of Henle, mastoid tip,posterior border on the mastoid.Okay, next we’ll take the drilland the microscope.Rotate that - the base around that way a little bit.Suction. Can I have a bipolar?It’s okay. 45 is fine.
CHAPTER 2
Can I have the drill, please?We’ll look at the landmarks for our mastoidectomy.Anteriorly, the posterior external auditory canal.Superiorly, the root of the zygoma, which correspondsto the level of the tegmen and the mastoid tip.Water on.Okay. Yeah, that's good.Yep, this is a 4 cutting burr.As our initial dissection, we're going to gothrough the cortical bone, and reallywe just want to get down to the level of the antrum.We’re seeing a little bit of the sigmoid sinus there,so she may have alittle bit of an anterior-positioned sigmoid.I'm going to try to leave someoverhanging edges as I drill the mastoid,which is a little bit different from whatwe do if we're doing a mastoidectomyfor chronic ear disease.And, now we are down at the level of the antrum.There is the sigmoid sinusthat we can see underneath this here,and I'm also going to undercut some of this bonetowards the tip as well asalong the posterior aspectto help facilitate placement of the electrode later on.Table away, please?Other way.Keep going - keep going, keep going, keep going.keep going - okay.There’s my lateral semicircular canal.If you can see there, Scott.I'm going to thin the posterior canal wall as we startto work toward the facial recess.It’s like what you said -you're less focused on getting the tegmen and the sinusor anything like that? Correct.Really we want to get down to the level of the antrum,so we can start opening the facial recess.It's very important though that when we do themastoid dissection, we undercut this boneespecially inferiorly - asthe electrode comes in from posteriorly,it allows it to then coil upin this area of the mastoid tip.So we do want to leave overhanging edges in this instance.Now a 3 diamond burr, please?I need a 3 diamond. Can I have a bulb irrigator?For the resident, can you talk about the boundariesof the facial recess and what defines the facial recess? Yes.Can I have a number 7 suction, please?
CHAPTER 3
So...That's open big.How about a 5?This just looks huge.Okay. So let’s look at our mastoid anatomy now.May I have a gimmick?So we have tegman superiorly,mastoid antrum with lateral semicircular canal posteriorly,sigmoid sinus,and then mastoid tip inferiorly.Our next step is we're going to open the facial recess.The facial recess is bounded by the fossa incudis superiorly,the facial nerve medially,and the chorda tympani nerve laterally.Diamond burr now.Let’s extend that.So this is very different from the cutting burr you were using, right?So this is a regular diamond burr.Diamond burrs are often graded as fine diamond or coarse diamond.The coarser the diamond,the more cutting power it has, but in general,diamond burrs are considered safer,especially around soft tissue structures,as they're less likely to cut right through them,although you can still injure soft tissue with a diamond burr.Diamond burrs are good also to stop bony bleeding.So here, I'm justcontrolling some of these small vessels on the sigmoid sinus.Table away, please.More water, Lorna.Okay, go through this - okay -so through the reflection we can actually see the -start to see the incus underneath the antral opening here.I'm going to start mydissection of the facial recess drawing at the -drilling at the level of the short process of the incusand carrying that all the way downtowards the mastoid tip,thinning the posterior canal wall as I go.More water, please.I am careful even though we're doing a cochlear implantespecially in the case -if a patient has residual hearing,we obviously we don't want to drill on theincus or the short process.Here we're starting to see some air cellsin the facial recess, so we're going to continue drilling at that level.Again, here'sthe short process of the incus.We’re drilling at the same level towards the mastoid tip.More water.Lorna, is there any way to increase the water, please?When drilling - yeah absolutely -when drilling around structuressuch as the facial nerve or vascular structures,it’s very important to use lots of irrigation.For one it keeps the - the diamondclear of bone dust.Lorna, I’m still not getting enough water.We're going to continue.Now I'm actually thinning the buttress of the incus right here.We want to get that pretty thin, and it provides us with more exposurethrough the facial recess.As I'm drilling in the facial recess, especially medially,I'm always looking for anychanges in the bone, which may represent the facial nervelikewise looking for thechorda tympani nerve, superiorly.We're starting to possibly be seeing chorda there.So there’s chorda.So here we're starting to see chorda tympaniwith a small red blood vessel over the surface.Maybe...All right, can I have a 2 diamond now, please?So just while you're drilling over the facial nerve,it's important to note too that ifthe patient is not paralyzed, and we havefacial nerve monitoring electrodes set up as well.That is correct.Especially in cochlear implant surgery because we are drilling right abovethe facial nerve, there's lots ofareas where you could possibly injure the nerve,either directly from the drill itselfor possibly heat transferredfrom the rotation of the shaft of the drill, andso it's very important to always have the facial nerve in mind.We alwaysuse facial nerve monitoring during cochlear implant surgery.It’s very important that thepatient not be paralyzed by anesthesia during the surgery.I want a 2 diamond.And - well tell her to get a 1 diamond too while she's down there.Water on, Lorna. I need more.Now with a smaller diamond,we're going to continue opening the facial recess.There’s the rest of the chorda going in there.Lorna, is there no way toget more water out of here?We're wide open. Wowee.It might be those irrigators. Well, I think it is, but...So we see chorda tympani nerve running along thelateral aspect of the fascia recess.Facial nerve medially, and we're going to continueto drill between these two structures,carrying our dissection as close as we canto the chorda to give usas much room as possible.And now we are starting to see into the middle ear.I can start to see stapes.Whitney...Right there?Now, we are in our facial recess.We’re going to remove bone more inferiorlyto get better exposure of the round window niche.Is there anything you need to watch outfor, or you’re kinda just drilling?You know, as you’re drilling low through thefacial recess,keep in mind that the facial nerve may swing out laterally,quickly, so as you remove this bone,always keep in mind that the facial nervecould be there so that you don't come across it.Also, when you'redrilling in and out of the facial recess,it’s important to stop the drillas you come in and out to avoid possible injury to the nerve.And as I’m drilling,I'm going to be applying a little bit more pressureon the superior aspect of the facial recesstowards the chorda as opposed to the facial nerve.That’s the round window there? Yeah.
CHAPTER 4
We start to see the round window niche now.It's very important -I prefer to do the round window approach, soa round window insertion, and a very importantaspect to this is removing bonefrom the posterior superior aspect of theround window.Sometimes the pyramidal process can be quite prominent,and so I willoften drill a little bit of this bone awayso that it doesn't interfere with our trajectory of the electrode.And here we are seeing -let me have a Rosen needle, please?Irrigation off.
We have pyramidal process here,stapedial tendon, and capitulum of the stapes.Well these suctions are huge - this is not normal.I’m going to remove just a little bit more of this bone inferiorly.Okay.All right, now may I have a 1-mm diamond burr?So now we havethe promontory.Water off, please.Can I have the Rosen, please?Water off all the way, really clamp it tight because it still comes out.So, we have promontory here.And the round window membranejust underneath the niche, which can be seen -You don't have a different Rosen do you?I do. It's a sharper one, but... One that’s not all bent up.Round window membrane, round window niche.At this point we are going to drill away this bonesuperiorly and posteriorly of the niche.And take this bone back almost until it's flush with the membrane itself.Water on.So Scott, you see the niche here. We don't seethe membrane that clearly, yet because it’s still -there’s a little membrane over itlike an adhesion.So what is really important when youdo round window insertions is you got totake this bone posteriorly and superiorly.Otherwise, you just can't get the right angle for insertion.So we’re starting to see the membrane better there, right?A little bit better.This suction is huge.Is anybody using other methodsfor taking down the round window niche or just drilling?I think drilling is probably the standard, yeah.So now we can actuallysee the membrane much better.Can I have IS joint knife? Now,There's always a little bit of bleeding from these mucosal vessels.I don’t like these suction irrigators,but I mean I don't have a choice I don't think.So you always get a little bleeding from thesemucosal vessels on the promontory.So the little round kni - IS joint knife willjust kind of push these back and kind of get them so the blood isrunning in an area oppositefrom where we're trying to operate.Now we actuallyare getting a nice view of the round window membrane.There are some adhesions on the membrane.We’ll try and clean those up a little bit.There we go.We’ll kind of just bring these adhesionsthese little mucosal adhesions down.And we have a very nice viewof the round window membrane now.Now we're very close,there’s - let me have that IS joint knife one more time.So we have a great view of the membrane.But see there’s a little lip still here.When we go in, when we're inserting, we'renot inserting in this directionwe want to insert in the direction of thebasal turn of the cochlea,which is more angled in this direction. Andso that's why it's important to get bone offposteriorly and superiorly here,and if this bone over the pyramidal processis really prominent, sometimes I'll drillthat down a little bit.Drill.Trans-lab approaches, if you have bone that sort of the lateral and outside,you can’t angle your instrument in deeper. Right, exactly.One of the criticisms of the round window approach,is that - is that thereis the hook portion of the basal turn of the cochlea,which is just here -when you enter in through the round window, it drops downbefore it goes anteriorly, and so if you - if you went directly inthrough the round window membrane,it can't make that turn. You’ll end up goingright through the basilar membrane,but if you angle in the direction fromfrom this direction, then we canget around that turn quite easily and very smoothly.Okay, that's very good. Now, can I have an irrigating syringe?So we will review our anatomy now.
So can I have a gimmick, Lorna?So we have -lateral semicircular canal, facial nerve,chorda tympani nerve,pyramidal process of the stapes, stapedial tendon,and then directly looking at the round window membrane.Can I have that drill one more time, Lorna?Annoying vessel here.Water off.Oh, it’s just not going to stop is it?Do you have a little bone wax? Yes.So - and can I have a gimmick?What's that?Can I have a gimmick?Oh, I’ve got you a good suction here now. A real one. Is it - is it a size 3?Yes. Okay.Do you have a little cotton ball or something?Just put it under the light so I can see it.Okay, now let’s - can I have my eye shields back? We're going to drill.Next part is we need to drillour seat for the implant.
CHAPTER 5
So with a freer, we’re going to make kind of asubperiosteal pocket for the implant.We're going to make a subperiosteal pocket that the implant will sit in under the muscle,but we will also drill a seat for the implant.So, now we are making the seat for our implant.This helps prevent migration of the implant.Most manufacturers probably recommend drilling a seat,but you don't necessarily have to do this.Many people just make a subperiosteal pocket and place thedevice in the pocket.There is a small risk though that it could over time migrate,so I prefer to usually drill a seat.Let me have the Silastic implant.Can I have a marking pen?
Okay.Now, we’re going to make the electrode channel.Yeah, water on.So the electrode will be fully recessed in a channel here.Okay, diamond burr now - 3 diamond.And with our diamond burr, we’ll control any further bleeding.So we want to get all of this bone dust out of here.More water, please.One more.This thing can really, literally just lay flat on the skull,but they do recommendmaking a little anterior lip here.So, you don't have to drill a full well,but just more of a lip across anterior edge,and that just keeps it frombeing able to - and I usually drill a little bit of a ledge superiorlyand inferiorly just to keep it from being able to move too much,but it's essentially pretty flat.Now that lip would only keep it frommigrating anteriorly though, right?Yeah, so it could migrateposteriorly, and there's no way -there's not really a way you can drilla posterior lip, but that's wherefixation kind of helps prevent that.You don't have to drill this ledge, some people don't.They just put it into a pocket.
CHAPTER 6
Now we'll take the implantand then the Mersilene and the screws.And it sits down in there quite well.Mayo scissors.This is Mersilene tape,which is often used for cerclages,and it's a nice littlestrap that can be used to anchor the implant.Let's have a Senn retractor.This is a permanent material.Can I have a 15 blade for a moment?Just push back that periosteum a little bit.Okay, and if someone can hold this.Can I have a screw?And we're just going to anchor this in there.Be very cautious with our electrode.You can come out with that - I got it.And then Lorna, if you can hold up here.Did you just - you're just -you just anchored that in the bone on theinferior aspect, correct?On the anterior.Okay. Yeah.Here, I’m going to have to come over here.Lorna, hold on for one secondlet's come back this way, right like that.Can I have a pair of smooth forceps?15 blade?And we'll just cut off the excess - let's have smooth forceps.I got them. Here we go.All right, now our device is now secure.We'll go back to the microscope.And can I have a 5 suction now?And I'm going to need a24 suction in just a minute.Table away, please.Do we have any Decadron?Like a little liquid Decadron we can load intoa tuberculin syringe?Yeah, can I have a vial?Keep going.Okay, that’s good.No, I'm going to squirt this around the round window.Okay, let me draw that up, Robin. Okay.So, 4 mg. Okay, yep.18.Don't stick me.If you’ll just keep that back there for a moment. Now the 5 suction.The plain 5 suction.I’m just going to at least scrub for closure.Can I have an irrigating syringe for a second, Lorna?Are you supposed to what, Lorna?I will in just a second.Yeah, I will in just a second.Okay Lorna, let me go back to a plain 3 suction.Yep, and then in a second I’m going to go a 24.Yeah, it takes a while get all this liquid out of here.Okay, now a 24 suction.And then that Decadron.
CHAPTER 7
So, she really has pretty severeto profound hearing loss in this ear,but she does have a little tiny bit ofresidual hearing, and I guess these don't bend so well.So I am going to put a little bit of Decadron - 4 mg/ml around theround window membrane.Steroid now.And we'll just put a few drops around there.Kind of lessen that a little bit. Now,next can I have a 5910, sickle knife.
I like to make a little small vertical incisionin the round window membrane,so that the posterior part of the round window membranealmost serves as a little bit of a shelfto help guide the electrode in.I’m going to get rid of this and push it down.Can I have a Barbara needle for a second?There.I want the 5910.So we're going to make a small incision,vertical incision in the round window...Okay, and then...A small vertical incision.And then,the electrode forceps and the alligators.
Our electrodes - want - you want these to be facingthe modiolus, so that the stylet is usually pointed downtowards the six o’clock location.We're going to be advancing this electrode off the stylet.And the angle I'm coming in is - I'm going to get it in the opening firstbut then I'm going to angle more superiorly.Can I have now the electrode?Once we get to the blue marker, we're going to grab the -I'm sorry, the jeweler's forceps -we're going to grab the stylet,and very carefully advance this, and slowly off our stylet.All the way down.Now can I have the jeweler's - or, actually, hold that.Here's the stylet.And we are almost at the blue marker ring. We’ll just give ita little bit of a push in, and now we are completely in.Can I have a Rosen?Or actually, do you have a pitchfork, Lorna?That's okay.And so we now - let's have asomething to point with, like a Barbara.So the blue marker ring,the electrode is advanced to the second blue marker ring,so we have a nice full insertion of our electrode today.Next I'm going to take a very small piece of fascia.
Can I have a Senn retractor?And we'll put a very small fascia graft around that electrodeat the level of the cochlea - round window toseal that area a little bit better,but it's already a pretty snug fit right now.Let's have a pair of Metzenbaums.I've got it, yep.Hold that Lorna.Can I have iris scissors and a pair of smooth forceps?Now, can I have a 15?Okay.Lift up a little more, straight up, Lorna.Can I get a fascia press?Okay, let's...Now...A 15 blade.Okay, can I have a Barbara?Okay.And now we will place this graft gently around theelectrode at the level of the round window.Perfect.Okay.And that is that.Now, we have the electrode still out of the mastoid.Can I have the jeweler's forceps?We are now going to let this sortof coil up in the mastoid,and again, we previously left these overhanging edgesthat helps this electrode tocoil up in hereand settle nicely.Back here.All right.There, and that is that.
CHAPTER 8
And now we will go ahead and start closing.Can I have a pair of eye shields, please?Okay, 3-0 Biosyn. Yeah - uh, no, biosyn.Table back towards me.No, no, I just use the Biosyn for the whole thing.Yep.Okay, that’s good.If you’ll just hold this ear down for me, Lorna.This is a 3-0 Biosyn. I just typically use the Biosyn for thedeep and more superficial layers - the same stitch.We're going to actually reapproximate this muscle periosteal layer.Now is the Mersilene tape somethingyou just kind of decided on yourself to do,or had you seen that somewhere?No, we used to,you know, we always used thesuture, like a large heavy Prolene or nylon suture,and I can't rememberwhere I - actually, I must have seen it somewhere,but we had it availablehere, the Mersilene.They use it for cerclages and just started using it.Kind of thought it would be a pretty simple thing to put twoscrews through the - through it, andit just secures it place.I imagine this is why you like the 7-incision as well. Yeah.The periosteum...I mean people have gone to much more minimal incisions.It's hard to get backyou know, get your implant far enough back,and also drill a well ifyou like to do that.But a lot of people will make a smallerincision, and without this extra limb here, and just make asubperiosteal pocket and tuck the implantinto that pocket. And that works fine, butevery now and then you may get a device that over -overtime, you know, migrates superiorly.And a lot of - most of the time,that doesn't cause a lot of issues.I have seen patients beforewho have had implants that weren't fixed, and that itstarted causing pain once it migrated,and so we just repositioned it, but I still kind of liketo secure it in a seat, or a well,or at least in a ledge that will keep it frommoving forward.I'd love to be able to show this - this one was a really niceexposure that you could - that you could see it all really well,and it went in very, very smoothly.This electrode is pretty easy to put in.Let’s get these electrodes out.And so we wrap around the head and make sure the gauzeis above the ear, and we want to go very low on the neckso you're below the occiput.Otherwise, it will ride up her neck and right off of her top of her head.So feel it come way - make sure it's over the ear,way down low on the neck.Bring one now up over the top to secure that top portion.Yeah, can I have that - you can put it back under now.I'll get the scissors. Come back this way, Lorna.You got any scissors on you?Awesome.