Owing to its limited success in curing obstructive sleep apnea–hypopnea syndrome (OSAHS) [1], many adjunctive procedures and modifications were proposed after the introduction of the classic uvulopalatopharyngoplasty (UPPP) by Fujita et al. [2] in 1981. However, its role as part of a comprehensive treatment plan remains solidly accepted in most situations in which the palate, with or without the tonsils, is contributing to airway turbulence and obstruction. The goal of UPPP is to widen the airspace in three areas: (1) the retropalatal space; (2) the space between the tongue base and the palate; and (3) the lateral dimensions. This is accomplished through two components: (1) the palatoplasty component, which involves palatal shortening with closure of mucosal incisions; and (2) the pharyngoplasty component, which comprises a classic tonsillectomy with pharyngeal closure. These goals, however, are not always achieved with classic UPPP. In spite of our best efforts, patients may end up with an extremely narrow palatal arch, in which the diameter of the oropharyngeal inlet is decreased owing to a forward approximation of the posterior palatal mucosa. The resulting new shape of the free edge of the palate is triangular, rather than square (Fig. 37.1). Further contraction of the wound occurs owing to scarring secondary to the resection of the posterior tonsillar pillars, and additional narrowing is caused, which further affects long-term results [3]. Additionally, patients who previously underwent tonsillectomy are poor candidates for classic UPPP, owing to scarring or absence of the posterior pillar from the previous tonsillectomy. These patients have an already narrowed space between the soft palate and the posterior pharyngeal wall, and often do not have any redundant pharyngeal folds. Important modifications of the classic UPPP proposed by Fairbanks, [4] in which the posterior pillar is advanced lateral cephalad in order to widen the retropalatal space, are, hence, not possible. It is well known that when UPPP fails, the severity of obstruction may actually worsen [5]. It became apparent that appropriate selection criteria needed to be implemented in order to identify patients with a higher likelihood of cure after UPPP. A staging system introduced by Friedman et al. [6] determined that patients with anatomic stage I disease (Friedman tongue position, FTP, I and II), with large tonsils, have a better than 80% chance of success; whereas patients with stage II and III disease (FTP III and IV) are less than ideal candidates, and should therefore undergo a combined procedure that addresses both the palate and the hypopharynx (Table 37.1). The Z-palatoplasty (ZPP) technique was developed as a more aggressive technique for patients with stage II and III disease. This includes all patients who have had previous tonsillectomy, as well as patients with small tonsils, and those with unfavorable tongue positions.

Z-palatoplasty

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发表日期：

2025年

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Michael Friedman,
Paul Schalch

摘要

Owing to its limited success in curing obstructive sleep apnea–hypopnea syndrome (OSAHS) [1], many adjunctive procedures and modifications were proposed after the introduction of the classic uvulopalatopharyngoplasty (UPPP) by Fujita et al. [2] in 1981. However, its role as part of a comprehensive treatment plan remains solidly accepted in most situations in which the palate, with or without the tonsils, is contributing to airway turbulence and obstruction. The goal of UPPP is to widen the airspace in three areas: (1) the retropalatal space; (2) the space between the tongue base and the palate; and (3) the lateral dimensions. This is accomplished through two components: (1) the palatoplasty component, which involves palatal shortening with closure of mucosal incisions; and (2) the pharyngoplasty component, which comprises a classic tonsillectomy with pharyngeal closure. These goals, however, are not always achieved with classic UPPP. In spite of our best efforts, patients may end up with an extremely narrow palatal arch, in which the diameter of the oropharyngeal inlet is decreased owing to a forward approximation of the posterior palatal mucosa. The resulting new shape of the free edge of the palate is triangular, rather than square (Fig. 37.1). Further contraction of the wound occurs owing to scarring secondary to the resection of the posterior tonsillar pillars, and additional narrowing is caused, which further affects long-term results [3]. Additionally, patients who previously underwent tonsillectomy are poor candidates for classic UPPP, owing to scarring or absence of the posterior pillar from the previous tonsillectomy. These patients have an already narrowed space between the soft palate and the posterior pharyngeal wall, and often do not have any redundant pharyngeal folds. Important modifications of the classic UPPP proposed by Fairbanks, [4] in which the posterior pillar is advanced lateral cephalad in order to widen the retropalatal space, are, hence, not possible. It is well known that when UPPP fails, the severity of obstruction may actually worsen [5]. It became apparent that appropriate selection criteria needed to be implemented in order to identify patients with a higher likelihood of cure after UPPP. A staging system introduced by Friedman et al. [6] determined that patients with anatomic stage I disease (Friedman tongue position, FTP, I and II), with large tonsils, have a better than 80% chance of success; whereas patients with stage II and III disease (FTP III and IV) are less than ideal candidates, and should therefore undergo a combined procedure that addresses both the palate and the hypopharynx (Table 37.1). The Z-palatoplasty (ZPP) technique was developed as a more aggressive technique for patients with stage II and III disease. This includes all patients who have had previous tonsillectomy, as well as patients with small tonsils, and those with unfavorable tongue positions.