Operative Techniques in Otolaryngology (2015) 26, 7884

The uvulopalatal ap
Tom C. Zhou, BA,a Jennifer C. Hsia, MDb

From the aUniversity of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota; and
the bDepartment of OtolaryngologyHead and Neck Surgery, University of Minnesota, Minneapolis,
Minnesota

KEYWORDS The uvulopalatal ap was initially described by Powell and Riley in 1996 and has become a popular
Obstructive sleep surgical option for treating obstructive sleep apnea (OSA). A number of advantages exist over the
apnea; uvulopalatopharyngoplasty, and these include reduced risk of velopharyngeal insufciency and
Uvulopalatal ap; nasopharyngeal stenosis, potential to be reversible, improved velopalatal opening from preserved uvular
Uvulopharyngoplasty; muscle, low risk of bleeding, and reduced pain. An extensive preoperative workup should be performed
Snoring; to evaluate the patient, and the procedure is indicated in patients who demonstrate velopharyngeal
Sleep disordered obstruction, and who are refractory to conservative medical management. Studies have conrmed that
breathing the uvulopalatal ap results in both objective and subjective improvements in OSA. Complications are
rare and typically minor. As a result, the uvulopalatal ap has become a popular option and the palatal
procedure of choice for OSA for many otolaryngologists.
r 2015 Elsevier Inc. All rights reserved.

Introduction airway. This procedure is preferred over UPPP for a number

The retropalatal region is a common site of obstruction in
patients with obstructive sleep apnea (OSA).1 Since the
development of uvulopalatopharyngoplasty (UPPP), as
described by Ikematsu2 for snoring in 1964 and then by
Fujita3 for OSA in 1981, palatal surgery has been the
primary procedure for treatment of OSA. As originally
described, the goal of UPPP is to remove palatal and lateral
pharyngeal tissues that are highly compliant and collapsible
during sleep. The procedure consists of excising the uvula,
posterior portion of the soft palate, palatine tonsils, and
lateral tonsillar pillars.
In 1996, Powell and Riley modied the UPPP and
introduced the uvulopalatal ap (UPF) technique,4 which
involved reecting the uvula and posterior portion of the
soft palate anteriorly in order to widen the retropalatal
of reasons because it addresses some of the issues with the
original UPPP. First, since no palatal muscles are resected in
a UPF, there is a reduced risk of rhinolalia and nasal
regurgitation from velopharyngeal insufciency (VPI). VPI
is a result of excessive soft palate tissue removal that causes
inadequate pharyngeal closure. In the rare case that VPI was
to develop, the ap could be reversed. Second, risk of
nasopharyngeal stenosis is reduced because very limited
demucosalized tissue is exposed after suturing the reected
uvula to the soft palate. The UPF technique places its
incisions on the oral surface of the soft palate rather than
along the inferior edge of the palate and lateral pharyngeal
wall. This allows a more anterior scarring rather than a
circumferential healing. Lastly, there is less intraoperative
and postoperative bleeding, and patients report less pain.4,5

Workup and indications

Address reprint requests and correspondence: Dr Jennifer Hsia, MD,
Department of OtolaryngologyHead and Neck Surgery, University of
Minnesota, 420 Delaware St SE, MMC 396, Minneapolis, MN 55455. The UPF can be performed in isolation or in combination
E-mail address: jchsia@umn.edu. with other OSA surgeries. During the clinic visit, the initial
http://dx.doi.org/10.1016/j.otot.2015.03.006
1043-1810/r 2015 Elsevier Inc. All rights reserved.
Zhou and Hsia The Uvulopalatal Flap
evaluation includes a complete patient history and physical
examination. A polysomnography is required to document
the presence of OSA. A thorough otolaryngology examina-
tion is performed with specic attention to the tonsil size,
palate position, and tongue size and position. Preoperative
weight should be obtained to calculate body mass index.
Using this information, the patient can be classied using
the Friedman clinical staging system.6 Fiberoptic endoscopy
with Muller's maneuver is performed to determine the level
of possible airway obstruction.
UPF is indicated as a primary procedure in patients with
OSA who demonstrate velopharyngeal obstruction and have
failed medical management for their OSA such as
continuous positive airway pressure. There is no absolute
contraindication, but relative contraindications include
patients with excessively long or bulky soft palate or
patients classied as Friedman stage III. Patients with thick
palates may develop excessive tissue bulk created from the
repositioning of the muscular layer of the soft palate.
Studies have demonstrated that patients with Friedman stage
I disease are most likely to benet from UPPP with a
success rate of 80.0%, whereas patients with Friedman stage
III disease have a success rate of 8.1%.7 Although these
studies reected patients who underwent the original UPPP,
the targeted anatomic changes in UPF are similar and
therefore we expect similar results, but with decreased risk
of VPI or nasopharyngeal stenosis.
Technique
The procedure is typically performed in the operating
room under general anesthesia. The patient is intubated
under conventional methods with the oral endotracheal tube
placed at midline. A shoulder roll may be used for neck
extension and to improve the view of the operative eld.
The McIvor or Crowe-Davis retractor is used to hold and
secure the endotracheal tube and to keep the tongue in place.
If tonsils are present, tonsillectomies are performed in the
standard fashion. The soft palate is injected slowly with 1%
lidocaine with 1:100,000 epinephrine. It is crucial to
minimize distortion of the tissue from injecting too rapidly
or supercially. The tip of the uvula is then grasped with a
toothed forceps and reected anteriorly toward the junction
of the hard and soft palate. While the tip of uvula remains
midline in the sagittal plane, the tip can be manipulated
anteriorly or posteriorly to estimate the extent of the
resection. Next, the planned diamond-shaped incision on
the soft palate is outlined with a marker or with a needle tip
electrocautery. An incision through the mucosal layer but
supercial to the muscular layer is created on the oral
surface of the soft palate, starting rst on the palate at the
point where the uvular tip is reected back. The incision
continues laterally on the soft palate. The extent of the
lateral edge of the incision may vary depending on how
much lateral velopharyngeal expansion is necessary. The
incision then comes together and converges at the tip of the
uvula (Figure 1).
79
A 12-blade or curved scissors is used to demucosalize the
outlined area by dissecting under the submucosal plane.
Underlying glandular tissue should be removed to expose
the soft palate and uvular muscles. The uvula is again
reected anteriorly as performed previously. Using a 3-0 or
2-0 polyglycolic acid (Vicryl) suture on a tapered needle, a
horizontal mattress suture is used to approximate the tip of
the uvula and the soft palate at the soft-hard palate junction.
Tension in the suture is adjusted to obtain the desired result.
The remainder of the mucosa is approximated with simple
interrupted sutures. Excess tissue can be trimmed during the
suturing process. Relaxing incisions can be made through
the tonsillar pillars in order to improve the arch from
reecting the uvula and to eliminate excessive tension on
the closure.
Depending on surgeon's preference and patient's comor-
bidities and OSA severity, the patient may be admitted
overnight for observation or can be discharged home after
an uneventful recovery in the post-anesthesia care unit.
Retrospective studies have suggested that patients can be
safely discharged home after UPF surgery.8,9
Patients are sent home with pain medications and are
advised to start on a soft diet for 2 weeks, especially if
tonsillectomy was performed. They can then advance to a
regular diet as tolerated. A follow-up appointment is made
in 2-3 weeks to ensure proper wound healing. Postoperative
polysomnogram should be planned once soft palate edema
has resolved, typically after 4-6 weeks.
Results and discussion
The UPF has become an important tool in the surgical
armamentarium for treating OSA and for treating snoring.
Since 1996 when it was rst described by Powell et al,4 the
UPF has become a popular option and, for some
otolaryngologists, the palatal procedure of choice for
OSA.10 The advantages of UPF over UPPP include reduced
risk of VPI and nasopharyngeal stenosis, potential to be
reversible, improved velopalatal opening from preserved
uvular muscle, low risk of bleeding, and reduced pain. A
number of studies have conrmed the success of the UPF,
and the results of these studies are summarized in the
Table.4,5,11
Powell and Riley found that patients who underwent
UPF or UPPP had signicant improvements in snoring, and
that there was no difference in the improved snoring
between the 2 procedures.4 Interestingly, they found better
reduction in snoring with increased palatal tissue reposition-
ing in the UPF group. In contrast, this correlation was the
reverse in the UPPP group. Based on these ndings, Powell
and Riley speculated that the repositioned uvular muscle in
UPF may actually improve palatal dynamics by assisting
with the opening of the velopharyngeal space and hence
improve snoring.
In 2003, Neruntarant demonstrated that the UPF can be
performed as an ofce procedure under local anesthesia in
select patients.5 This is a major advancement because
80 Operative Techniques in Otolaryngology, Vol 26, No 2, June 2015

Figure 1 Uvulopalatal ap technique.

patients with OSA are at a high risk of developing
respiratory and cardiopulmonary complications from gen-
eral anesthesia.12 A safe and effective procedure that can be
easily performed under local anesthesia eliminates this risk.
Neruntarat5 also demonstrated an improvement in
snoring using the outpatient procedure he described. A
10-cm visual analog scale was used by an observer to assess
snoring. Overall, 49 of 56 (88%) patients who underwent
UPF were cured based on a denition of Z50% reduction
in the postoperative visual analog scale. In addition, there
was improvement in the mean Epworth Sleepiness Scale, in
mean snoring index, and means percentage of time spent in
loud snoring.
In another study, Neruntarat evaluated the short-term and
long-term success of UPF at 6 months and at Z48 months
after surgery, respectively.11 Successful surgery for OSA
was dened as a Z50% reduction in apnea-hypopnea index
(AHI) along with a nal AHI r 20. Overall, 58 of 83
(69.9%) patients had successful surgery in the short term,
but fell to 43 of 83 (51.8%) patients in the long term. Thus,
15 of 58 (25.8%) patients who had short-term success ended
up failing in the long term. Body mass index Z30 kg/m2
and AHI Z 45 were independently associated with failure to
respond to UPF surgery. In comparison, the short-term and
long-term success rate of UPPP is 60%-64% and 48%-
50%.13,14 The same study also showed that 76 of 83 (91.5%)
patients were cured of snoring in the short term and 69 of 83
(83.1%) patients were cured in the long term. In addition,
there was signicant improvement in mean Epworth
Sleepiness Scale and mean snoring scale.
 Zhou and Hsia
Table Outcomes of the uvulopalatal ap technique and the modied techniques
Flap technique, Sample size Selection criteria Comparison group Findings Complications
studies

Uvulopalatal ap
Powell et al4 n 80 Prospective study UPF vs UPPP Improvements in snoring is similar between UPF group (n 59)

The Uvulopalatal Flap

UPF and UPPP
(59/80 UPF and 80 Consecutive patients selected Similar improvements in palatal length based 1 Minor bleed
21/80 UPPP) on lateral cephalometric head lm 1 Wound separation
measurements 1 Transient bandlike
sensation at palate edge
1 Wound infection
Patients with excessively long or bulky soft Positive correlation in UPF group between UPPP group (n 21)
palate and markedly redundant lateral amount of tissue repositioned and 1 Minor bleed
pharyngeal wall mucosa were treated with improvement in snoring score compared
UPPP instead of UPF with negative correlation in UPPP group

Neruntarat5 n 56 Prospective study open to 150 consecutive UPF 49 Of 56 (88%) patients were curedn of n 56
patients with sleep-related breathing snoring
disorder
Inclusion criteria: primary complaint of Improved mean Epworth Sleepiness Scale
snoring (8.1-5.2), mean snoring index (245.8-42.5
Exclusion criteria: patients with primary events/h), and mean percentage of time 2 Transient nasal
complaints of apneic events and severe spent in loud snoring (10.2%-3.8%) regurgitation
nasal obstruction and patients with OSA 1 Transient foreign body
sensation
Mild-to-moderate pain for
5-7 d in 52 of 56

Labra et al19 n 50 Prospective study UPF and UPPP 48 Of 50 (96%) were cured of snoring based No complications reported
on subjective assessment by bed partner
50 Consecutive patients improved mean snoring index (214-12
inclusion criteria: patients with complaint of events/h)
snoring

Neruntarat11 n 83 Prospective study UPF Evaluated efcacy of UPF in the short term (at n 83
6 mo postoperatively) and in the long term
(at Z48 mo postoperatively)
58 Of 83 (69.9%) patients responded 5 Transient nasal
successfully in the short term while 43 of regurgitation
83 (51.8%) responded in the long term
83 Patients selected out of 412 consecutive 91.5% (76 of 83) Were curedn of snoring in 4 Transient dysphagia
patients the short term and 83.1% (69 of 83) were
cured in the long term

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Table (continued )

Flap technique, Sample size Selection criteria Comparison group Findings Complications
studies

Inclusion criteria: primary complaint of Improved mean Epworth Sleepiness Scale 7 Transient foreign body
snoring and OSA and had oropharyngeal (16.4-6.4 in the short term to 7.7 in the sensation
obstruction long term) and in mean snoring scale using
VAS (8.6-2.4 in the short term to 3.2 in the
long term)
Exclusion criteria: patients with BMI Z 30 kg/m2 and AHI Z 45 were Mild-to-moderate pain for a
hypopharyngeal and nasal obstruction independently associated with failure to few days in 76 of 83
respond to UPF surgery

Extended uvulopalatal ap
Li et al15 n 33 Prospective study EUPF 27 Of 33 (81.8%) patients responded n 33
successfully to surgery
33 Consecutive patients 14 Of 33 (42.4%) patients achieved 1 Minor bleed
respiratory disturbance index (RDI) o5
Inclusion criteria: patients with OSA and Improved mean RDI (41.6-12.5), mean 2 Wound dehiscence
narrowed retropalatal space snoring index (241.6-94), and mean
Exclusion criteria: patients with macroglossia minimal oxygen saturation (80.4%-87.8%) 1 Occasional nasal
or retrognathia regurgitation

Operative Techniques in Otolaryngology, Vol 26, No 2, June 2015

Li et al18 n 55 Prospective study EUPF 44 Of 55 (80.0%) patients responded to n 55
surgery
Improved mean RDI (43.6-12.1), mean 4 Globus sensation
snoring index (208.7-107.4), and mean
minimal oxygen saturation (78.9%-84.8%)
55 Patients Quality-of-life improvement in 7 of 8 sections 3 Mild nasal regurgitation
in the 36-Item Short Form Health Survey
(SF-36) following surgery
Inclusion criteria: patients with OSA and Improved mean Snoring Outcomes Survey
narrowed retropalatal space score (36.0-74.7), mean Spouse/Bed
Partner Survey score (32.8-76.9), and mean
Epworth Sleepiness Scale (11.8-7.5)

Z-Palatoplasty
Friedman et al16 n 50 Prospective experimental (ZPP) arm compared ZPP vs UPPP Decrease mean number of days of narcotic ZPP group (n 25)
with retrospective control (UPPP) arm pain medication usage (6.4 d for ZPP vs 1 Tongue base infection
9.4 d for UPPP) secondary to TBRF
Decrease mean number of days to return to 3 Postnasal drip
normal diet (6.4 d for ZPP vs 10.3 d for UPPP)
25 of 25 (100%) Patients in ZPPP group had 1 Dysphagia
snoring improved and 24 of 25 (96%) 11 Foreign body sensation
patients in UPPP group had snoring
improved
 Inclusion criteria for ZPP arm: patients with 17 Of 25 (68%) patients in ZPPP group had 12 Temporary VPI

Zhou and Hsia

OSA, without tonsils, Friedman stage II or surgical success and 7 of 25 (28%)
III, and obstruction at the level of the soft patients in UPPP group had surgical
palate success
(25/50 ZPP and Inclusion criteria for UPPP arm: matching set Improved mean snoring level (ZPP: 9.6-2.6; UPPP group (n 25)
25/50 UPPP) of patients who underwent UPPP UPPP: 7.4-2.4) and mean Epworth 2 Tongue base infections
Sleepiness Scale (ZPP: 12.5-8.3; UPPP: secondary to TBRF

The Uvulopalatal Flap

14.2-8.7) 4 Postnasal drip
11 Dysphagia
17 Foreign body sensationi
7 Temporary VP
All patients received adjunctive tongue base Quality-of-life improvement in 6 of 8 sections
reduction by radiofrequency (TBRF) in the 36-Item Short Form Health Survey
(SF-36) following ZPP surgery

Modied UPF with lateral pharyngoplasty

Kim et al17 n 92 Retrospective study Modied UPF with 72 of 92 (78.3%) Patients responded Transient nasal regurgitation,
lateral successfully bleeding, dysphagia, and
92 Patients included out of 121 patients pharyngoplasty Improved mean Epworth Sleepiness Scale foreign body sensation
with OSA who underwent modied UPF (11.1-6.6), mean snoring scare using VAS (number not reported)
with lateral pharyngoplasty (7.9-3.6), mean AHI (39.1-7.9), mean
Inclusion criteria: patients who completed minimal oxygen saturation (77.0%-86.4%),
questionnaires and polysomnography and relative snoring time (2.9%-1.8%)
studies
85 Of 92 patients received concomitant
tonsillectomy
61 Of 92 patients received concomitant
turbinate or nasal septal surgery
BMI, body mass index; EUPF, extended uvulopalatal ap; ZPP, Z-palatoplasty; ZPPP, Zetapalatopharyngoplasty.
n
Snoring was considered cured if Z50% reduction in 10-cm visual analog scale (VAS) as evaluated by an observer was achieved.

Successful response to surgery is defined as Z50% reduction in apnea-hypopnea index (AHI) and a final AHI r 20.

Snoring was considered improved if Z50% reduction in snoring level (scale: 0-10) as evaluated by bed partner and a final snoring level r5.

83
84
The initial success of UPF has led to variations of the
technique. In 2003, Li et al15 reported the extended UPF.
The UPF was expanded to include removing the palatine
tonsils and closing the tonsillar fossa, and this resulted in
increased lateral dimension of the velopharyngeal inlet.
Friedman et al16 described the Z-palatoplasty in 2004. This
technique builds on a double Z-plasty where the uvula and
posterior soft palate was split in the midline and reected
anteriolaterally. The scar contraction tension lines further
opens up the airway. Kim et al17 revealed a new technique
in 2013 that leaves the uvula intact. The distal soft palate is
repositioned anterosuperiorly with a sling suture through the
soft palate and uvular muscular layer, and the posterior
tonsillar pillar is pulled anteriorly toward the anterior pillar.
He termed this the modied UPF with lateral pharyngo-
plasty. The combination of a lateral pharyngoplasty with the
UPF helps to better address the lateral walls of the
oropharynx. The expansion pharyngoplasty technique20
can also be used to help address the lateral wall, and the
objective and subjective improvements in OSA symptoms
have been reported for each of these procedures and are
further summarized in the Table.15-18
Complications
As the UPF procedure simply involves demucosalization
without resection of the deeper muscular layer, the risks of
serious complications is minimalized. In fact, there are no
serious complications from UPF surgery in the literature. Even
minor complications are rare and these include minor bleeding,
wound infection, wound dehiscence, transient foreign body
sensation, transient nasal regurgitation, and transient dyspha-
gia. The number and types of complications from studies on
the UPF are shown in the Table. Patients typically experience
mild to moderate pain for a week, and this pain can be
minimized with proper postoperative pain regimen.
One major advantage of the UPF is the potential for
reversibility. If patients developed voice changes and nasal
regurgitation owing to VPI, the suture line can be removed
to allow the ap to revert back to its original state. Once the
soft palate and uvula has remucosalized, surgery may be re-
performed, this time limiting the amount of reected palate
and uvula. In addition to VPI, the UPF can be reversed for
any other reason including patient dissatisfaction. Despite
this option, there has not been any report of the reversal of a
UPF surgery.
The UPF technique is safe enough that it can be
performed as an ofce procedure under local anesthesia in
select patients. This reduces other complications that are
associated with general anesthesia, especially in the high-
risk OSA population.
Conclusion
The UPF is a safe and effective treatment of OSA. The
numerous advantages over UPPP make UPF the preferred
Operative Techniques in Otolaryngology, Vol 26, No 2, June 2015
palatal procedure for OSA. Complications are rare and
typically minor. Its success has led to numerous modica-
tions in the original UPF technique. Although the success
rate of UPF is comparable to, if not better than, UPPP,
regular follow-up is recommended as some patients will
relapse over the long term.
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