1 INTRODUCTION

This book includes a number of chapters which describe a variety of palatal surgical procedures for sleep disordered breathing, including traditional uvulopalatopharyngoplasty (UPPP) techniques, Z-palatoplasty (ZPPP), transpalatal advancement pharyngoplasty, laser-assisted uvulopalatoplasy (LAUP), pillar implantation, etc. Most of these procedures can be divided into two mutually exclusive groups based upon several different criteria: by their action on the palate, the setting in which they are performed, and how the surgeon is reimbursed. First, these various procedures usually work by one of two different ways: by either shortening the soft palate or by stiffening it. They also differ in where they are performed: those that are more invasive and which are used for more significant obstructive sleep apnea (OSA) are generally done in the operating room under general anesthesia, and those that are less invasive and which are advocated for less severe forms of sleep disordered breathing (such as primary snoring) are done in the office under local anesthesia. Furthermore, the insurance industry makes a distinction between these two groups of procedures in regards to reimbursement: those done in the OR for OSA are generally reimbursed by insurance, while those done in the office for primary snoring and mild OSA are relegated to self-pay status.

This chapter describes a palatal surgical technique which in many regards bridges these divides, with applicability in both the operating room as an OSA procedure and in the office setting for primary snoring or mild OSA. It is a variation of UPPP which is easily learned, gives reproducible results, and which can be done under local anesthesia in the office in select cases. The procedure can be performed as a limited palatal procedure for snoring or mild OSA, or can be extended to more effectively treat the palate and tonsillar fossas for more significant OSA. In addition, it forms the basis for another effective palatal procedure, the Z-palatoplasty, as described elsewhere in this atlas.

2 THE PROCEDURE

The uvulopalatal flap (UPF) procedure involves the shortening of the soft palate by folding the distal soft palate with uvula forward upon itself. The intervening mucosal surfaces of the folded palate are removed, and the palate is sutured in its new position in two layers with interrupted sutures. The resultant palatal shortening creates a surgical result virtually indistinguishable from a traditional UPPP, but with several important potential differences over UPPP and some of the other procedures, as outlined below.

The UPF procedure was first described by Powell et al.² in 1996 as a UPPP variation for the operating room. A similar technique was described in 1993 by Bresalier and Brandes,³ referred to as the imbrication technique of UPPP in 1999. In 2000, I described the use of this technique in the office under local anesthetic,⁴ which was presented in more detail in 2003 by Neruntarat.⁵ The procedure can also be expanded under general anesthesia to include greater effects in the laterally, by including concurrent tonsillectomy with tonsillar pillar closure^4,6 or by extending incisions superolaterally from the apices of the tonsillar fossas toward the third molar region;⁴ Li et al.⁷ call this modification an extended uvulopalatal flap. The principles of the UPF have been further extended by Friedman with the Z-palatoplasty,⁸ which is the subject of Chapter 33. The Z-palatoplasty is essentially a UPF procedure in which the uvula and distal soft palate are split in the midline. This creates two flaps which are advanced not only anteriorly but laterally to further augment the retropalatal airway in its lateral dimensions. Because of the versatility of the procedure, therefore, the UPF is a useful tool which should be part of the armamentarium of all surgeons who treat sleep disordered breathing.

3 TECHNIQUE

3.1 AWAKE, LOCAL ANESTHESIA, OFFICE PROCEDURE

The procedure can be performed with the patient sitting in an examination chair in the upright or recumbent position. Topical local anesthetic is applied to the entire soft palate and uvula, and additional anesthesia to the nasal surface of the palate can be obtained by spraying the nasal cavities with a 1:1 mixture of tetracaine hydrochloride and phenylephrine hydrochloride. After allowing sufficient time for the topical anesthetic to take effect, the surgical site is infiltrated with 2–4 ml of injectable anesthetic with adrenaline. It is important not to distort the tissue or create blebs of submucosal anesthetic by injecting too much solution or by injecting too superficially. In addition to making the patient more comfortable during the procedure, meticulous injection of anesthetic results in enough vasoconstriction that the surgical field is surprisingly bloodless; any oozing can easily be controlled with a battery-operated ophthalmic cautery unit. Electrosurgical cautery should not be necessary except when the procedure is performed under general anesthesia with concurrent tonsillectomy.

The extent of reflection of the uvula and distal palate and the extent of resection of the uvular tip are then determined by grasping the uvula with medium-length forceps and reflecting it cephalad toward the junction of the hard and soft palate while simultaneously examining the retropalatal airway diameter with a number 5 laryngeal mirror. The uvula is retracted sufficiently to create a crease between the intervening mucosal edges. Standard UPPP principles are used to determine the extent of shortening desired. Because the patient is awake and able to phonate, the palatal dimple point is easily identified; VPI is more likely if the palate is shortened much beyond this point. Though varying significantly between patients, the final position of the repositioned uvular tip is generally 5–10 mm from the hard–soft palate junction.

If necessary, relaxing incisions can be made extending cephalad from the apices of the tonsillar fossas. This might be necessary if the palate is very low hanging or is tethered to the lateral pharynx by post-tonsillectomy scarring. Note that these incisions, which can measure 5–10 mm, are made further laterally than are the vertical trenches that are part of the classic LAUP. Additional advancement of the lateral soft palate can be achieved by increasing the amount of mucosal resection at the lateral aspect of the incision. Furthermore, the uvula and distal soft palate can be divided in the midline, as described by Friedman,⁸ to create two separate uvulopalatal flaps, which when rotated superolaterally open the oropharyngeal inlet greater in side to side dimensions. Note that though I have done many Z-palatoplasties in the operating room setting, I have done just one in the office setting under local anesthesia.

While still grasping the uvula in its new position, the planned incision is outlined with a marker or with a number 12 blade, as shown in Figure 34.1. This gothic arch-shaped incision generally has its apex within 5–10 mm of the hard–soft palate junction and flares laterally to allow for advancement of the lateral palate. The farther laterally these incisions extend, the greater the elevation of the lateral aspects of the palate. The incision will be carried caudally onto the uvula in a mirror image of the palatal incision. Unless vertical relaxing incisions are necessary, as described previously, it is recommended that the incisions be kept away from the free edge of the palate, to lessen the chance of scar contracture.

Fig. 34.1 The surgical site has been outlined and injected with local anesthetic with adrenalin. The dissection is begun with a #12 blade at the apex of the incision. The tip of the uvula is shaded to mark the area to be amputated to aid in closure of the palate.

The dissection can be performed entirely with a scalpel and with scissors; Metzenbaum or long Iris scissors are adequate. Though the procedure could also be performed acceptably with a needle point cautery unit, the additional expense, tissue destruction, and postoperative pain do not warrant its use, particularly since electrocautery should rarely be necessary for hemostasis if local anesthetic injection and surgical dissection have been meticulous. It is easiest to begin with the scalpel at the apex of the palatal incision and extend inferolaterally on each side. The mucosa within this outlined area is then carefully removed with sharp pointed scissors, as shown in Figure 34.2. As the dissection reaches the tip of the uvula, the tip is usually amputated to reduce the length of tissue brought up to the palate.

Fig. 34.2 The mucosa is removed with scissors. Bleeding from the underlying palatal muscle is usually minimal, and can be controlled with a hand-held ophthalmic cautery unit.

The distal soft palate and uvular remnant are then reflected superiorly and sutured in place with 3–0 or 2–0 polyglycolic acid (Vicryl; Ethicon, Somerville, NJ) suture on a tapered (SH) needle. Though these sutures last longer than needed, they can usually be easily removed 2 weeks postoperatively if the patient desires and if healing is sufficient. Note that the sutures could be removed before healing is complete if symptoms of significant VPI (such as voice change or nasal regurgitation) are noted, thus allowing the flap to fall back down inferiorly to either remucosalize or to be repositioned in a less aggressive position.

The initial suture is a mattress suture that first passes through the mucosa and underlying muscle at the apex of the palatal incision and then passes through the tip of the uvular muscle and adjacent mucosa from the nasopharyngeal side of the uvula. This is shown in Figure 34.3. Tension of this mattress suture can be adjusted to allow for proper positioning of the soft palate edge. Additional mucosa on the palate or flap may now be trimmed, if necessary. The closure is then completed in a two layered interrupted surgical technique. It is highly recommended that this closure be done in layers to minimize the chance of postoperative dehiscence.

Fig. 34.3 the uvula and distal soft palate are folded forward and sutured in place. The first suture is a horizontal mattress suture at the apex of the surgical site. The remainder of the closure is accomplished in layers with interrupted sutures.

Note that the advanced uvula and distal palate are a different color than the rest of the palate. This tissue, which originated on the nasopharyngeal surface of the palate, is brighter red than the oral palatal mucosa. This is explained to the patient preoperatively, as is the fact that the folded-over central palate may be somewhat thicker for some time postoperatively. This seems to thin out somewhat postoperatively, and should not require subsequent thinning or revision. Note that patients who have excessively thick and beefy palates may not be optimal candidates for this procedure, however.

3.2 GENERAL ANESTHESIA, WITH CONCURRENT TONSILLECTOMY

The uvulopalatal flap also can be combined with more aggressive pharyngeal mucosal tightening via a tonsillectomy with tonsillar pillar resection, as is generally done with the traditional UPPP. It is performed with the patient in the Rose position with a Crowe–Davis mouth gag and an appropriate sized tongue blade in place.

It is recommended that the tonsillectomy be performed first with care taken to spare as much tonsillar pillar mucosa as possible. Hemostasis is improved by injecting the tonsillar fossas with a total of 5–10 ml of the same local anesthetic with adrenalin as was used to inject the palate previously. This also helps with initial postoperative analgesia. The tonsillar pillar sutures are then placed before the palate is dissected, as illustrated in Figure 34.4. This closure is preferably performed in two layers to obliterate any dead space and to minimize the chance for postoperative dehiscence.

Fig. 34.4 When performed under general anesthesia, the procedure is performed with a tonsillectomy, as is the case with other variations of UPPP. It is recommended that the tonsillectomy and tonsillar fossa closure be completed before performing the UPF portion of the surgery. The tip of the uvula can be reflected superiorly with a retraction suture to help in surgical planning.

A stay suture held by a hemostat can be placed through the tip of the uvula to retract the distal palate cephalad during the tonsillar fossa closure to help align the tissues properly and aid in correct suture placement. This can also help in determining if relaxing incisions extending cephalad from the apices of the tonsillar fossas are necessary (Fig. 34.5), which would be performed next.

Fig. 34.5 The UPF procedure can be extended by incising the distal soft palate superolaterally from the apices of the tonsillar fossas to aid in more aggressively shortening the palate.

After approximation of the tonsillar pillars, the uvulopalatal flap is made as described before, and is sutured in place in a two-layered interrupted surgical technique. If at this point it is determined that the lateral dimensions of the oropharyngeal inlet at the palatal level should be augmented even more, the distal soft palate and uvula could be split in the midline at this point to convert the procedure to a Z-palatoplasty, as described elsewhere in this text.

4 POSTOPERATIVE MANAGEMENT

When performed in the outpatient setting in the office, patients are sent home with prescriptions for an appropriate antibiotic for several days and a narcotic pain medication. If edema is thought to be problematic, a short course of steroids may be offered. Anxiolytics, sleep aids, or other sedating medications are not recommended in the immediate postoperative period. A regular diet is resumed as soon as the patient is comfortable. Residual sutures may be safely removed after 2 weeks.

When the UPF is performed under general anesthesia in the operating room, either solely or in conjunction with tongue base advancement or resection, nasal surgery, etc., the postoperative management is no different than with the traditional UPPP. If performed as part of the treatment of significant OSAS, postoperative continuous positive airway pressure is recommended until a subsequent polysomnogram shows resolution of the problem.

5 COMPLICATIONS

Rare complications can include wound separation, which can be minimized by avoiding chromic sutures that may resorb prematurely and by closing the incisions in two layers. The use of a 2–0 or 3–0 polyglycolic acid suture, as noted before, is recommended.

In addition to wound dehiscence, minor bleeding can be encountered, particularly when combined with a tonsillectomy. Again, if VPI is encountered postoperatively, the suture line may be taken down and the palate may be either re-sutured in a less aggressive position, or may be dealt with again later, once it has remucosalized. On occasion, the bulge of the repositioned uvula may appear prominent enough in the first few weeks that the surgeon is tempted to consider postoperative revision, but this seems to diminish with time. Nevertheless, the use of this technique in a patient with an excessively thick palate or uvula might be inadvisable if the resultant thickness might be considered problematic.

6 SUMMARY

The UPF is easy to perform and is a potentially reversible treatment for the palatal obstruction that can accompany snoring with or without OSAS. It may be accomplished at a single session either in the office setting or under general anesthesia in the operating room. It offers several potential advantages over other variations of the UPPP, though some of these perceived advantages require further study for confirmation.

The original procedure as described by Powell et al.² has been modified by extending incisions into the lateral distal soft palate^4,7 to allow for augmented flap elevation laterally; when an incision is placed in the midline of the uvula to create two flaps (the Z-palatoplasty) as discussed by Friedman,⁸ the lateral dimensions of the oropharyngeal inlet at this level can be augmented even more. This latter modification is thought to provide significant benefit in many cases.

Complications specifically related to the UPF are uncommon. The general surgical complications should be similar to those encountered in traditional UPPP surgery.