Uvulopalatopharyngoplasty (also known by the

abbreviation An abbreviation (from Latin ''brevis'', meaning ''short'') is a shortened form of a word or phrase, by any method. It may consist of a group of letters or words taken from the full version of the word or phrase; for example, the word ''abbrevia ...

s UPPP and UP3) is a surgical procedure or

sleep surgery Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by ...

used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include: * The

tonsil The tonsils are a set of lymphoid organs facing into the aerodigestive tract, which is known as Waldeyer's tonsillar ring and consists of the adenoid tonsil, two tubal tonsils, two palatine tonsils, and the lingual tonsils. These organs play an ...

s * The

adenoid In anatomy, the adenoid, also known as the pharyngeal tonsil or nasopharyngeal tonsil, is the superior-most of the tonsils. It is a mass of lymphatic tissue located behind the nasal cavity, in the roof of the nasopharynx, where the nose blends ...

s Tissues which may typically be remodeled include: * The

uvula The palatine uvula, usually referred to as simply the uvula, is a conic projection from the back edge of the middle of the soft palate, composed of connective tissue containing a number of racemose glands, and some muscular fibers. It also conta ...

(see uvulotomy) * The

soft palate The soft palate (also known as the velum, palatal velum, or muscular palate) is, in mammals, the soft tissue constituting the back of the roof of the mouth. The soft palate is part of the palate of the mouth; the other part is the hard palate. ...

* The

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struc ...

Procedure

UPPP involves removal of the tonsils, the posterior surface of the soft palate, and the uvula. The uvula is then folded toward the soft palate and sutured together as demonstrated in the figures. In the US, UPPP is the most commonly performed procedure for obstructive sleep apnea with approximately 33,000 procedures performed per year. The surgery is more successful in patients who are not obese, and there is a limited role in morbidly obese (>40 kg/m²) individuals.

Procedural details

Standard procedure

UPPP is typically administered to patients with obstructive

sleep apnea Sleep apnea, also spelled sleep apnoea, is a sleep disorder in which pauses in breathing or periods of shallow breathing during sleep occur more often than normal. Each pause can last for a few seconds to a few minutes and they happen many times ...

in isolation. It is administered as a stand-alone procedure in the hope that the tissue which obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier.

Role in the "Stanford Protocol" operation

UPPP is also offered to sleep apnea patients who opt for a more comprehensive surgical procedure known as the " Stanford Protocol", first attempted by Doctors Nelson Powell and Robert Riley of

Stanford University Stanford University, officially Leland Stanford Junior University, is a private research university in Stanford, California. The campus occupies , among the largest in the United States, and enrolls over 17,000 students. Stanford is consider ...

. The Stanford Protocol consists of two phases. The first involves surgery of the soft tissue (

tonsillectomy Tonsillectomy is a list of surgical procedures, surgical procedure in which both palatine tonsils are fully removed from the back of the throat. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep ...

, uvulopalatopharyngoplasty) and the second involves skeletal surgeries (

maxillomandibular advancement Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower j ...

). First, Phase 1 or soft tissue surgery is performed and after re-testing with a new sleep study, if there is residual sleep apnea, then Phase 2 surgery would consist of jaw surgery. The goal is to improve the airway and thereby treat (or possibly cure) sleep apnea. It has been found that obstructive sleep apnea usually involves multiple sites where tissue obstructs the airway; the base of the tongue is often involved. The Protocol successively addresses these multiple sites of obstruction. Note that

genioglossus advancement Genioglossus advancement (GA), also known as genial tubercle advancement (GTA), is a surgical procedure or sleep surgery in which the base of the tongue is pulled forward, usually to increase airway size due to deformity or a sleep breathing di ...

can be performed either during Phase 1 or Phase 2 surgeries. Phase 2 involves maxillomandibular advancement, a surgery which moves the jaw top (maxilla) and bottom (mandible) forward. The tongue muscle is anchored to the chin, and translation of the mandible forward pulls the tongue forward as well. If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase 2 than for Phase 1 – approximately 90 percent benefit from the second phase, and the success of the Stanford Protocol Operation therefore is due in large part to this second phase. There is debate among surgeons as to the role of Phase 1 surgery. In 2002, an Atlanta-based surgical team, led by Dr. Jeffrey Prinsell, publishe
results
which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries.

Success

Effectiveness in isolation

When UPPP has been administered in isolation, the results are variable. As explained above, sleep apnea is often caused by multiple co-existing obstructions at various locations of the airway such as the

nasal cavity The nasal cavity is a large, air-filled space above and behind the nose in the middle of the face. The nasal septum divides the cavity into two cavities, also known as fossae. Each cavity is the continuation of one of the two nostrils. The nasal c ...

, and particularly the base of the

tongue The tongue is a muscular organ (anatomy), organ in the mouth of a typical tetrapod. It manipulates food for mastication and swallowing as part of the digestive system, digestive process, and is the primary organ of taste. The tongue's upper surfa ...

. The contributing factors in the variability of success include the pre-surgical size of the tonsils, palate, uvula and tongue base. Also, patients who are morbidly obese (body mass index >40 kg/m²) are significantly less likely to have success from this surgery.

Effectiveness of "The Stanford Protocol" operation

Over one thousand people have undergone The Stanford Protocol operation and received follow-up sleep study testing. 60 to 70 percent of patients have been entirely cured. In approximately ninety percent of patients, a significant improvement can be expected.

Multilevel approach

In the recent years, many surgeons have tried to address the multiple levels of obstruction by performing multiple procedures on the same surgical day, called the "multi-level approach". Typical surgeries in a multi-level approach may include: Nasal-level surgeries * turbinoplasty, septoplasty, septorhinoplasty Soft palate-level surgeries * uvulectomy, uvulopalatopharyngoplasty, tonsillectomy Hypopharyngeal-level surgeries *

hyoid suspension Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing air ...

* tongue suspension * tongue base reduction *

UPPP with tonsillectomy improves postoperative results of obstructive sleep apnea depending on tonsil size. The success rate increases with increasing tonsil size. This approach improves postoperative results in well-selected patients.

Laser-assisted uvulopalatopharyngoplasty

Risks

One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. After surgery, complications may include these: * Sleepiness and

related to post-surgery medication * Swelling, infection and bleeding * A sore throat and/or difficulty swallowing * Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery. * Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea. * Patients who have had the uvula removed will become unable to correctly pronounce

uvular consonant Uvulars are consonants articulated with the back of the tongue against or near the uvula, that is, further back in the mouth than velar consonants. Uvulars may be stops, fricatives, nasals, trills, or approximants, though the IPA does not provi ...

s, found in French, German, Hebrew, and others. * Long term complications with pain, feeling sick and lesser sleep quality than before the LAUP. In 2008, Labra, ''et al.'', from Mexico, published a variation of UP3, by adding a uvulopalatal flap, in order to avoid such complications, with a good rate of success.