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