Since its inception in 1984, skeletal surgery has become a pivotal component in managing obstructive sleep apnea (OSA), evolving from isolated mandibular advancement to comprehensive multi-level interventions. This chapter provides an overview of contemporary skeletal surgery techniques for OSA, integrated within frameworks like the Stanford protocol. It details patient evaluation methodologies, including clinical examination, imaging, and the role of drug-induced sleep endoscopy (DISE) and virtual surgical planning (VSP). Key surgical procedures are reviewed: genioglossus advancement (GGA) for tongue base stabilization, surgically assisted maxillary expansion (e.g., DOME) addressing transverse deficiency and nasal obstruction, and maxillomandibular advancement (MMA), a cornerstone procedure significantly expanding the airway at multiple levels. The evolution of MMA from salvage to primary therapy in selected phenotypes is discussed, alongside technological advancements enhancing precision such as VSP and custom surgical guides/splints. The chapter also covers tailored anesthetic management strategies crucial for OSA patients undergoing these procedures and addresses the identification and management of potential intraoperative and postoperative complications, including nerve injury, malocclusion, and hardware-related issues. Skeletal surgery offers a robust and effective treatment modality within the multidisciplinary approach to OSA.