Palatal and Oropharyngeal Surgery for Obstructive Sleep Apnea

Palatal and oropharyngeal surgery represents the cornerstone of surgical management for obstructive sleep apnea (OSA), encompassing a spectrum of techniques ranging from minimally invasive office-based procedures to complex anatomical reconstructions. This chapter traces the evolution of palatal surgery from Ikematsu’s original description in 1952 and Fujita’s uvulopalatopharyngoplasty (UPPP) in 1981, to the modern paradigm of individualized, phenotype-driven interventions guided by drug-induced sleep endoscopy (DISE). Rather than viewing palatal surgery as a single procedure with fixed steps, contemporary practice conceptualizes it as a modular toolkit of complementary maneuvers—including tissue excision, relaxing and releasing techniques, posterior pillar lateralization, suspension, and advancement—selected and combined according to each patient’s unique anatomy and collapse pattern. Six specific approaches are detailed. Radiofrequency ablation of the soft palate offers a minimally invasive, office-based solution for primary snoring and mild OSA through submucosal fibrosis and stiffening. The uvulopalatal flap achieves functional palatal shortening through tissue repositioning rather than resection, preserving muscular integrity and minimizing velopharyngeal insufficiency. Relocation pharyngoplasty lateralizes and superiorly redirects the palatopharyngeus muscle to expand the retropalatal airway and address lateral wall collapse. Barbed repositioning palatopharyngoplasty employs knotless barbed sutures to achieve distributed lateral wall stabilization with reduced operative time and morbidity. Transpalatal advancement pharyngoplasty anteriorly advances the soft palate anchored to the hard palate, substantially enlarging the retropalatal space beyond what soft tissue techniques alone can achieve. Each technique is presented with its underlying principles, indications, contraindications, step-by-step surgical approach, postoperative management, and complication mitigation strategies, supporting their integration into individualized multilevel OSA surgery.