1

Introduction

It became clear at the dawn of the third millennium that the real origin of obstructive sleep-disordered breathing (OSDB), snoring, and obstructive sleep apnea/hypopnea syndrome (OSAHS) was the hypercollapsibility of the upper airway walls (UAWs), more frequently located at the retropalatal and/or retrolingual level. This is primarily resulting from the inability of neuromuscular structures to maintain sufficient parietal tension to resist the internal negative pressures created by inspiratory pulmonary expansions during sleep, and so any structural narrowing of the upper airway (UA) must be considered a factor predisposing to collapse.

As pointed out by Cahali in 2003, this modern physiopathologic interpretation radically changed the target of OSDB surgery from resectively enlarging the UA lumen, as in the case of uvulopalatopharyngoplasty, which does not always guarantee satisfactory results and is characterized by a high level of postoperative morbidity, to increasing the static tension of the UAWs.

In 2010, we started to imagine the UA as a complex structure consisting of two coaxial tubes ( Fig. 41.1 ): (1) a rigid outer tube of static bony and fibrous tissue (the posterior nasal spine [PNS] of the bony palate, the hamuli pterygoidei [PH], and the pterygomandibular raphes [PMR]); and (2) a soft inner soft tube characterized by two components: (a) a passively static component (mucosa, submucosa, annexed glands, lymphatic structures, and adipocytes) that is possibly responsible for the structural narrowing of the UA lumen that can be easily detected upon ear/nose/throat (ENT) examination in awake patients, and (b) a second dynamic component consisting of the UA muscles whose activity continuously depends on neural control modulated by the central nervous system (CNS) and that may become inadequate during sleep, thus allowing the onset of the inspiratory UAW collapse responsible for snoring and OSAHS. Only the drug-induced sleep endoscopy (DISE) can ascertain the site (retropalatal, retrobasilingual, laryngeal) and pattern of UAW collapse (anteroposterior, laterolateral, circular) and indicate where neuromuscular control is weaker and the collapse-predisposing narrowing has to be treated.

Transverse section of the UA at the palatal level: the rigid components of the outer tube (posterior nasal spine, posterior border of the bony palate, hamuli pterygoidei and pterygomandibular raphes) surround the soft inner tube components (mucosa, submucosa, palatal and pharyngeal muscles).

As it is not possible to modify CNS functions during sleep, we had the idea of transferring the rigidity of the outer tube to the inner tube exactly where and how it is needed by using intratissutal threads and a custom-made surgical approach, with the dual aim of slightly increasing the basal tension of the DISE-verified weaker muscular walls just enough to resist negative inspiratory pressures even when neural activation is inadequate and preserving the integrity of the muscle components to save their complex functions (particularly speech and deglutition).

2

Intratissutal Threads

To reduce the invasiveness of existing surgical procedures for increasing UAW tension (Z-palatoplasty, lateral pharyngoplasty, expansion sphincter pharyngoplasty, relocation pharyngoplasty, and transpalatal advancement pharyngoplasty ), and given the good tolerability of permanent threads inside the human soft palate reported by Hur, we conceived the “Roman blinds technique (RBT)” for the treatment of snoring and mild OSAHS caused by retropalatal collapse in 2009. Absolutely nonresective, well tolerated, reversible within 4 weeks, repeatable, and free of dysfunctional sequelae, this technique requires the insertion of three threads through the fibromuscular layer of the soft palate to form three parallel loops inside the velum. Each loop then needs to be tied around natural, solid, and noncollapsible holds (the posterior nasal spine [PNS] and the two hamuli pterygoidei ) to obtain a sound anterograde fibromuscular coarctation that is capable of lifting and stiffening the soft palate and enlarging the oropharyngeal inlet, thus increasing the tension of the walls of the palatopharyngeal tract.

3

Barbed Sutures

The use of intratissutal threads received significant impulse from the introduction of barbed sutures (BS), special knot-free tissue closure devices that allow the homogeneous distribution of tensile forces, thus guaranteeing an optimal biological response and improving both postoperative comfort and scar potential. We were the first to use bidirectional BS inside the palatopharyngeal structures , and now prefer polydioxanone (PDO) BS, which are totally absorbed within 180 days, after having observed that the reactive fibrosis they induce is capable of maintaining the results of the operation by the fourth postoperative week.

In our experience, fibromuscular tissue is ideal for BS because of its rapid scarring response, optimal grip (which can be made even better by crossing the muscle fibers orthogonally), and the possibility to modulate the BS mechanical effects (MEs) inside it.

• 
  

  ME1: Micropleatings: The BS is inserted through the fibromuscular layer of the palate while it is still entirely embedded, on both faces, by mucosa, submucosa, and annexed glands, and is thus capable of coarctating, tensioning, and slightly shortening it.

  
  
• 
  

  ME2: Foldings : The palatal muscles can be folded with the BS if preliminarily exposed by the removal from its oral face of a semilunar strip of mucosa and the annexed minor salivary glands, thus shortening, tensioning, stiffening, and reshaping the soft palate.

  
  
• 
  

  ME3: Muscle transposition: The removal of the palatine tonsils (or the mucosal covering of the tonsillar fossae in previously tonsillectomized patients) creates enough space to move the palatopharyngeus muscle against the pterygomandibular raphe with the BS, thus tensioning and stiffening both the lateral and posterior pharyngeal walls (the cranial portion of the palatopharyngeus muscle is connected to the superior pharyngeus constrictor muscle).

4

Barbed Snore Surgery (BSS)

This rationale allowed us to develop barbed snore surgery (BSS), an innovative approach to retropalatal OSDB that is both modular and customizable (on the basis of anatomic and DISE findings) and currently consists of the following techniques: barbed Roman blinds technique (BRBT), barbed anterior pharyngoplasty (BAPH), barbed lateral pharyngoplasty (BLPh), and Alianza (BRBT and BAPh together). Furthermore, BSS can be integrated in a multilevel surgical program.