1

Introduction

It is obvious to the reader of this textbook that there is a plethora of obstructive sleep apnea (OSA) palatal surgeries. Because palatal anatomy varies between individuals, different palatal techniques have been devised to treat the pharyngeal “sphincter” by addressing the lateral pharyngeal muscles or advancing the palate anteriorly while sparing the uvula.

The uvulopalatal flap (UPF) procedure is a variation of uvulopalatopharyngoplasty (UPPP). It is a palatal surgical technique that is both reproducible and easy to teach to residents. It can be performed in the operating room with concurrent lateral pharyngeal wall techniques or as a sole procedure for patients with less complex anatomy. It can also be performed in the office under local anesthesia for treatment of snoring or mild OSA.

The UPF is a versatile procedure that was first described by Powell et al. in 1996 as a UPPP variation for the operating room. A similar technique was later described by Bresalier and Brandes, which they referred to as the “imbrication technique.” In 2000, I presented the use of the UPF in the office under local anesthesia, and this use was expanded upon in 2003 by Nerunterat. When performed in the operating room, the UPF can include concurrent tonsillectomy with treatment of the lateral pharyngeal walls by tonsillar pillar closure, by utilizing additional incisions extending superolaterally from the lateral palate, or by a concurrent lateral pharyngoplasty. This procedure has been further modified by Friedman with his Z-palatoplasty (ZPP) procedure, which is essentially a two-piece UPF with paired uvulopalatal flaps created by splitting the uvula and distal soft palate in the midline that are separately advanced anterolaterally. These and other modifications allow the UPF to be adapted to different palatal configurations and allow it to be performed both in the office and in the operating room, depending on the needs of the patient.

2

UPF Overview and Justifications of the Procedure

The procedure involves folding the distal soft palate uvula forward upon itself. The intervening mucus membranes are then removed, and the palate is shortened by closing the incision with interrupted sutures. This results in a surgical result that is virtually indistinguishable from a traditional UPPP, but with several important potential differences:

• 1.
  

  The procedure is adjustable and potentially reversible. If the palatal shortening appears to have been too aggressive, suture placement may be altered and the demucosalized tissue can be allowed to heal secondarily. Alternatively, if velopharyngeal insufficiency (VPI) is suspected postoperatively, the sutures can be removed to allow the palate to fall back into its original position to remucosalize, like what is seen in the cautery-assisted palatal stiffening operation (CAPSO). If additional palate surgery is then thought to be needed later, the procedure could be repeated more conservatively.

  
  
• 2.
  

  The procedure has the theoretical advantage over the traditional UPPP of less scar contracture and reduced risk of nasopharyngeal stenosis, as the suture line lies proximal to the free margin of the soft palate.

  
  
• 3.
  

  The procedure spares the palatal and uvular muscles, but repositions and stabilizes them more anteriorly. Because of this, palatal dynamics should not only be maintained, but could potentially improve during sleep. Though unproven, it has been suggested that contracture of the uvular and distal palatal muscles in their new positions during respiration might help maintain airway patency in the central palatal region.

  
  
• 4.
  

  UPF can be performed as a single-stage office procedure, but unlike the laser-assisted uvulopalatoplasty, it does not require the purchase of a laser. As it does not involve the purchase of implants, it is less costly than pillar implantation, though the UPF is certainly more invasive and time consuming. Office UPF should not require electrocautery for hemostasis, and bleeding can be effectively controlled with a battery-powered ophthalmic cautery unit. In addition, because the procedure involves tissue removal, palatal shortening, and suturing, it is technically a form of UPPP that can be reimbursed by insurance (CPT code 42145) for patients who meet UPPP criteria, even when performed in the office setting.

  
  
• 5.
  

  There is the potential for less pain with the UPF then with other more destructive procedures such as laser-assisted uvulopalatoplasty (LAUP) or traditional UPPP.

3

Indications

The ideal patient has excessive soft palate length without significant palatal thickness. UPF can be performed under local anesthesia in the office with minimal or no oral sedation for nonapneic snoring or mild OSA. It is therefore an alternative to the modified CAPSO, LAUP, snare uvulectomy, injection snoreplasty, or even pillar implantation. Such patients should be comfortable with having a procedure in the office setting and should have anatomy conducive to such awake surgery, with minimal lingual guarding or gag reflex.

When performed under general anesthesia as part of more aggressive upper airway reconstructive surgery, the ideal patient is one with a relatively thin but long soft palate that is oriented obliquely in the sagittal plane. A palate that is retrodisplaced due to a long, hard palate or a long, vertically oriented, retrodisplaced soft palate might benefit from another palatal procedure such as a transpalatal pharyngoplasty. UPF may be performed with a tonsillectomy and can incorporate concurrent procedures that address the lateral pharyngeal walls, as outlined elsewhere in this textbook.

4

Contraindications

Because this procedure involves the folding of the distal soft palate forward upon itself, the palate will be somewhat thicker postoperatively. It should therefore be performed with caution in the excessively thick palate, though submucosal and even muscular excision can be performed to thin the palate. It is not the first choice for the patient whose palate is not elongated and whose retropalatal airway would not be improved by palatal shortening.

When performed in the office under local anesthesia, UPF requires a cooperative patient who is not anxious, who can control his secretions, has minimal gag reflex and minimal lingual guarding, and has no trismus.

5

Alternative Treatment Options

Depending on the patient’s specific anatomy and the surgeon’s preferences, alternative treatment options could include any of the number of other palatal surgical procedures described elsewhere in this book.