Uvulopalatopharyngoplasty Uvulopalatal Flap

Ikematsu (57) is credited with developing the uvulopalatopharyngoplasty (UPPP) for the treatment of habitual snoring. This technique was later adapted to treat SDB and snoring by Fujita et al. (29) in 1981. Since this time, multiple variations have

TABLE 6 Fujita Classification of Obstructive Regions

Type I: Palate (normal base of tongue) Type II: Palate and base of tongue Type III: Base of tongue (normal palate)

Source: From Ref. 28.

been developed to treat the obstructing tissues of the soft palate, lateral pharyngeal walls, and tonsils.

UPPP is an excellent technique to alleviate isolated retropalatal (Table 6) obstruction (Fujita Type I). Performed under general anesthesia, a portion of the palate, uvula, lateral pharyngeal walls, and tonsils may be removed (Fig. 2). This is conservative surgery, which an experienced surgeon can perform with ease. Results vary depending upon the skill of the surgeon, the technique selected, and the severity of disease. Unfortunately, there is often a stigma associated with UPPP due to the intensity of postoperative pain and variable cure rates.

A meta-analysis of the cure rate of UPPP was performed by Sher et al. (46) in 1996. UPPP was found to have a success rate of 39% for curing OSA. Such a high failure rate is most likely related to the fact that a large percentage of these patients had coexisting, unrecognized hypopharyngeal obstruction. Undoubtedly, UPPP can clear the palatal airway of excessive tissue and, if utilized appropriately, can improve SDB. While capable of improving select patients, UPPP is seldom credited with curing moderate or severe SDB. In fact, this procedure may be over-utilized as an isolated surgical procedure to cure SDB by those who have failed to identify tongue base obstruction. However, if UPPP is used appropriately or combined with

Redundant Pharyngeal Tissue

FIGURE 2 (See color insert.) Uvulopalatopharyngoplasty. (A) This patient demonstrates tonsillar hypertrophy, an elongated uvula and redundant tissue of the lateral pharyngeal wall resulting in a narrowed airway space. (B) Removal of the tonsils, lateral pharyngeal wall mucosa, and soft palate mucosa has enlarged the airway. (C) Excised surgical specimen.

FIGURE 2 (See color insert.) Uvulopalatopharyngoplasty. (A) This patient demonstrates tonsillar hypertrophy, an elongated uvula and redundant tissue of the lateral pharyngeal wall resulting in a narrowed airway space. (B) Removal of the tonsils, lateral pharyngeal wall mucosa, and soft palate mucosa has enlarged the airway. (C) Excised surgical specimen.

Uppp Before And After

FIGURE 3 (See color insert.) Uvulopalatal flap technique. (A) The mucosal crease is identified by reflecting the uvula. This marks the superior limit of dissection. (B) Incision is planned on the lingual aspect of the soft palate. (C) Wound is closed with 3-0 Vicryl sutures. These sutures may be removed to release the flap if velopharyngeal insufficiency should occur. Source: From Ref. 121.

FIGURE 3 (See color insert.) Uvulopalatal flap technique. (A) The mucosal crease is identified by reflecting the uvula. This marks the superior limit of dissection. (B) Incision is planned on the lingual aspect of the soft palate. (C) Wound is closed with 3-0 Vicryl sutures. These sutures may be removed to release the flap if velopharyngeal insufficiency should occur. Source: From Ref. 121.

procedures aimed at other anatomical sites of obstruction the results can be much more gratifying.

The uvulopalatal flap (UPF) was introduced by Powell et al. as a modification of the UPPP in 1996 (Figs. 3 and 4). The goal was to reduce the incidence of velopharyngeal insufficiency (VPI) by using a potentially reversible flap that could be "taken down" early in the recovery period if complications arose. In addition, the UPF technique was found to have less postoperative pain on a visual analog scale, as compared to traditional UPPP. The reason for reduced pain is due to the fact that no sutures are placed on the free edge of the palate (58). The indications for performing the UPF are the same as UPPP. However, this flap is contraindicated in patients with excessively long and thick palates. In these patients, the flap created will be too bulky and could potentially eliminate a favorable outcome.

Major complications (myocardial infarction, complete airway obstruction, and severe hemorrhage) following UPPP are less than 1.5% (59). More commonly, patients complain of postoperative pain and mild palatal swelling. Voice changes, taste disturbances and dysphagia have been reported, but are typically transient. Although rare, VPI and nasopharyngeal stenosis are often the result of poor surgical technique. The temptation to maximize results by removing large portions of the palate should

Uvulopalatopharyngoplasty
FIGURE 4 (See color insert.) Uvulopalatal flap (UPF). Postoperative view of a UPF.

be resisted to prevent VPI. Judicious resection of tissue and proper patient selection can aid in preventing these complications.

Sleep Apnea

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

Get My Free Ebook


Post a comment