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Uvulopalatopharyngoplasty

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"uvulopalatopharyngoplasty" AND "obstructive sleep apnea"

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Uvulopalatopharyngoplasty (UPPP)

Overview

UPPP is the most commonly performed surgical procedure for obstructive sleep apnea (OSA) worldwide. It was first described by Fujita et al. in 1981 and targets the retropalatal airway by removing excess soft tissue.
  • Cummings Otolaryngology Head and Neck Surgery
  • Murray & Nadel's Textbook of Respiratory Medicine

Surgical Technique

Classic Fujita Technique (1981)

The original UPPP involves:
  1. Excision of the uvula
  2. Removal of 1-2 cm of oral palatal mucosa in a curvilinear fashion along the anterior pillars
  3. Excision of the excess length of the soft palate
  4. Pulling the nasopharyngeal mucosa anteriorly and laterally to widen the nasopharyngeal airway

Simmons Modification (UK)

  • Excision of the tonsils, uvula, half of the anterior and posterior pillars, and full thickness of the lower part of the soft palate
  • Incision made posterior to the fold of the levator sling, followed by suturing of the anterior and posterior pillars in continuity with the inferior margin of the remaining soft palate

Contemporary Modifications

Numerous modifications involving local flaps have been described to maximize oropharyngeal airway size and reduce complications. Most modern approaches focus on palatal muscle expansion and stabilization with targeted suturing vectors rather than ablative resection. The uvulopalatal flap was specifically designed as a reversible soft palate procedure to allow reversal in case of velopharyngeal insufficiency.
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery
  • Murray & Nadel's Textbook of Respiratory Medicine

Indications

  • Mild to moderate OSAHS in patients who do not respond to medical therapy (CPAP) or cannot tolerate PAP
  • Retropalatal obstruction as the primary site of collapse
  • Friedman stage I patients (enlarged tonsils, otherwise uncrowded/unobstructed airway) - best success rates with isolated soft palate surgery
  • Part of multilevel surgery to maximize overall surgical success
  • As preparatory surgery before hypoglossal nerve stimulation (HNS): complete concentric collapse of the velum seen on Drug-Induced Sleep Endoscopy (DISE) is an exclusion criterion for HNS; palatopharyngoplasty can reverse this collapse pattern and increase candidacy for HNS
  • Washington Manual of Medical Therapeutics
  • Murray & Nadel's Textbook of Respiratory Medicine

Success Rates

Outcome MeasureRate
Short-term success (snoring reduced ≥50%)76%
Long-term success (snoring)45%
AHI reduction ≥50% (OSA)~50%
UPPP is often unsuccessful in unselected patients because it fails to address multilevel obstruction (retropalatal + retrolingual). Most patients exhibit multilevel obstruction, and fiberoptic laryngoscopy is important to identify the level(s) before surgery.
Laser-assisted UPPP (LAUP) is notably worse - it worsened AHI in 44% of patients per meta-analysis, and most OSA specialists have abandoned ablative techniques.
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery
  • Washington Manual of Medical Therapeutics

Complications

Perioperative

  • Post-operative pain: a constant complaint; patients must be warned
  • Exacerbation of sleep apnea and respiratory obstruction (from sedatives, muscle relaxants, or post-operative edema)
  • Airway compromise severity is proportional to the baseline severity of sleep apnea
  • Serious non-fatal complications: 1.5% (prospective multicentre study)
  • Mortality: 0.2%

Late Complications

ComplicationFrequency
Velopharyngeal insufficiency28.5% (most common)
Bleeding0-6%
Dry throat10%
Infection0-10%
Swallowing problems0-9%
Velopharyngeal insufficiency is related to scarring and excessive palatal resection.

Effect on Future CPAP Use

UPPP may compromise future nasal CPAP therapy due to loss of the soft palate seal, causing excessive mouth air leak. Patients post-UPPP tolerate lower CPAP pressures and have poorer compliance. Face mask CPAP can address this but has worse compliance than nasal CPAP.
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery

Position in the Treatment Algorithm

UPPP is considered a second-line treatment for patients with mild to moderate OSAHS who:
  • Cannot successfully use PAP therapy, AND
  • Have retropalatal obstruction
In experienced centers, other staged surgical options include:
  • Mandibular osteotomy with genioglossus advancement
  • Hyoid myotomy with suspension
  • Maxillomandibular advancement (MMA) - significant AHI reductions reported
For severe or life-threatening OSA (cor pulmonale, arrhythmias, severe hypoxemia, significant alveolar hypoventilation), tracheostomy remains an option when other measures fail.
  • Washington Manual of Medical Therapeutics

Summary of Key Points

  • UPPP is the world's most commonly performed sleep surgical procedure but has significant limitations due to multilevel obstruction in most OSA patients
  • Modern techniques are non-ablative (preserving the uvula where possible) and focus on muscle expansion/stabilization
  • Patient selection is critical - best results in Friedman stage I, retropalatal-predominant obstruction
  • DISE (Drug-Induced Sleep Endoscopy) assessment beforehand is standard of care
  • Often performed as part of multilevel surgery rather than in isolation
  • Can serve as a bridge to HNS therapy by converting concentric palatal collapse to a pattern compatible with hypoglossal nerve stimulation
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