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:!.                         if              , :, ii ! i.:i i                 THE UVULOPALATAL FLAP                 TOD C. ...
folding the palate forward on itself might be consideredexcessive.TECHNIQUEAwake, Local Anesthesia, Office ProcedureThe pa...
identified; VPI is more likely if the palate is shortenedbeyond this point, so its location should be noted.   If necessar...
FIGURE 6. The completed dissection. If there is any oozing, it    FIGURE 7. Closure begins with the central part of the fl...
Hemostasis is improved pre-injecting the tonsillar fossae       by Powell et al, 71 have found that this is often not poss...
potential advantages over other variations of the UPPP,                      4. Weingarten D: Snare uvulopalatoplasty. Lar...
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Colgajo uvulo palatal


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Descripciòn de tecnica original de colgajo uvulo palatal en el año 2000. Recomendaciones de la técnica quirúrgica de acuerdo al punto K.

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Transcript of "Colgajo uvulo palatal"

  1. 1. :!. if , :, ii ! i.:i i THE UVULOPALATAL FLAP TOD C. HUNTLEY, MD A number of variations of the uvulopalatopharyngoplasty have been described in the literature for the treatment of sleep-disordered breathing. The most widely performed of these procedures in the office setting is the laser-assisted uvulopalatoplasty. The laser-assisted uvulopalatoplasty, while technically easy to perform, has several drawbacks. The procedure requires the availability of a laser, and it is generally not performed in one session, but is staged over several months in multiple procedures. The following article describes a relatively new palatal technique, a one-stage uvulopalatal flap, which can be performed in the outpatient setting under local anesthesia or under general anesthesia in the operating room. It does not require the purchase of any additional equipment, and is easy to perform. It also offers potential advantages over the traditional uvulopalatopharyngoplasty in maintenance of palatal dynamics, lessened chance of scar contracture, reversibililty, and lessened pain. Since the introduction of the uvulopalatopharyngo- 2. The flap procedure is reversible. If VPI is suspected,plasty (UPPP) for the treatment of snoring by Ikematsu in the sutures may be removed, allowing the palate to fall 19641 and its application by Fujita to obstructive sleep back into its original configuration and remucosalize.apnea in 1981, 2 palatal surgery has been the primary 3. Theoretically there is a decreased risk of scar contrac-procedure in the surgical armamentarium for treatment of ture and nasopharyngeal stenosis, potential significantsleep disordered breathing. Although it is now well recog- complications of the UPPP, 8 because the suture line is bynized that obstructive sleep apnea syndrome (OSAS) is definition placed proximal to the free edge of the palate.more than just a palatal problem, and that obstruction 4. Palatal dynamics are not only maintained but may befrequently occurs in areas in addition to the palate, the also improved during sleep. Because the uvular muscle isUPPP retains a valuable role in treating obstruction at thislevel. not only preserved, but also is repositioned and stabilized In an effort to make the procedure more effective, less toward the hard palate, the retraction of the muscle againstcostly, or easier to perform, a number of authors have since this anchored position might assist in maintaining patencyoffered variations on palatal surgical techniques for sleep of the central retropalatal region during respiration, thusdisordered breathing, including the laser assisted uvulo- improving snoring. Note that this is unproved at thepalatoplasty (LAUP), transpalatal advancement pharyngo- present time.plasty, snare uvulopalatoplasty, cautery-assisted uvulopala- 5. The procedure may be performed in the outpatienttoplasty, radiofrequency volumetric reduction, and setting, as can the LAUP, yet is performed as a single stageothers.3,4,5,6 procedure at one session. Furthermore, one does not need In 1996, Powell et al 7 reported the uvulopalatal flap to purchase a laser to perform the UPE In fact, the(UPF) procedure, which offers several possible advantages procedure generally does not require a cautery unit forover other available techniques. The procedure involves hemostasis, unless of course a concurrent tonsillectomy isadvancement of the uvula and distal palate by creating a performed.flap of tissue that is sutured forward toward the hard 6. There is the potential for less pain than with otherpalate. This advancement flap is combined with advance- available techniques that involve more extensive tissuement of the lateral free edges of the soft palate by flaring destruction or ablation.the incisions laterally. This results in palatal shortening,which when fully healed is indistinguishable from the A similar technique was recently described by Bresaliertraditional UPPP, but with several important potential and Barndes, referred to as the imbrication technique. 9 Thedifferences. procedure, as outlined by the authors, is similar to what is diagramed in Figure 3. Bresalier and Brandes, however, do 1. Because the procedure does not involve significant not describe the outpatient applications of this procedure.tissue removal, velopharyngeal incompetence (VPI) shouldbe minimized. Because of the previous real or perceived advantages, the UPF has been my palatal procedure of choice for OSAS since Powell first introduced it to me in 1995. Since 1998, I have also offered it to select patients with primary snoring or mild OSAS who wish to be treated in the office under From the Head and Neck Surgery Associates, Indianapolis, IN. Address reprint requests to Tod C. Huntley, MD, 7440 N Shadeland, local anesthesia. Virtually any patient who might beSuite 200, Indianapolis, IN 46250. offered a LAUP should be able to undergo the UPF, with Copyright © 2000 by W.B. Saunders Company the possible exception being those patients with exces- 1043-1810/00/1101-0008510.00/0 sively thick palates, where the tissue bulk created by30 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 1 (MAR), 2000: PP 30-35
  2. 2. folding the palate forward on itself might be consideredexcessive.TECHNIQUEAwake, Local Anesthesia, Office ProcedureThe patient is instructed to take a dose of an appropriateoral antibiotic i hour preoperatively and is administered asteroid dosepack (the patient also is instructed to take theentire first day dosage at one time with food) on themorning of surgery. On rare occasions, 10 mg of oraldiazepam is administered 1 hour preoperatively for pa-tients who are particularly nervous or who have a signifi-cant gag reflex. The procedure is explained in adequatedetail to the patient. The patient is informed that althoughthe application of local anesthetic to the pharynx and distalsoft palate does result in loss of sensation, he or she willstill be able to breathe and handle his secretions adequatelyduring the procedure. The procedure is performed with the patient sittingcomfortably in an examination chair in the upright posi-tion. The surgeon is protected with goggles, mask, gloves, FIGURE 1. Local anesthetic with adrenalin is injected in theand protective clothing. Topical local anesthetic (such as shaded area after the mucosa has been sprayed with a topicalHurricaine [Beutlich Pharm, Niles, IL] or Cetacaine JAil- anesthetic. By allowing several minutes to elapse beforescrips, Vernon Hills, IL]) is applied to the entire soft palate continuing with the procedure, hemostasis is good enough thatand uvula. Additional topical anesthetic in the form of 20% cautery should not be necessary.benzocaine gel can be applied with a cotton applicator, ifdesired. I also frequently spray the patients nose with a 1:1mixture of tetracaine hydrochloride and phenylephrinehydrochloride at this point. It is helpful to allow at least 5 to 10 minutes for any suchtopical anesthetic to take effect before the surgical site isinfiltrated with injectable anesthetic. I prefer a mixture of 2mL of 1% lidocaine with 1:100,000 epinephrine, 2 mL of0.5% bupivicaine with 1:200,000 epinephrine, and 0.5 mLsodium bicarbonate for injection. Between 2 and 4 mL ofthis solution is injected submucosally at the surgical site(Fig 1). It is important not to distort the tissue or createblebs of submucosal anesthetic by injecting too muchsolution or by injecting too superficially. In addition tomaking the patient more comfortable during the proce-dure, meticulous injection of anesthetic results in enoughvasoconstriction that the surgical field is surprisinglybloodless; any oozing can easily be controlled with topicalsilver nitrate. On only a couple of occasions have I neededa hand held ophthalmic cautery unit; electrosurgical cau-tery (eg, Bovie cautery) is not available in m y officeoperative suite, but it has never been necessary during theprocedure. Electrosurgical coagulation is generally neces-sary in the tonsillar fossae for a concurrent tonsillectomywhen the procedure is performed under general anesthe-sia, however. The surgeon then determines the extent of reflection ofthe uvula and distal palate, as well as the extent ofresection of the uvular tip. This is done by grasping theuvula with medium length forceps (Metzenbaum, Russian,etc) and reflecting this tissue cephalad toward the junctionof the hard and soft palate, while simultaneously examin-ing the retropalatal airway diameter with a number 5laryngeal mirror (Fig 2). The uvula is retracted sufficientlyto create a crease between the intervening mucosal edges.Standard UPPP principles can guide the surgeon in deter-mining the amount of shortening the palate needs and can FIGURE 2. The amount of palatal shortening to be performed istolerate without creating VPI. Because the patient is awake estimated by reflecting the distal palate and uvula forward whileand able to phonate, the palatal dimple point is easily inspecting the retropalatal airspace with a mirror,TOD C. HUNTLEY 31
  3. 3. identified; VPI is more likely if the palate is shortenedbeyond this point, so its location should be noted. If necessary, relaxing incisions can be made extendingcephalad from the apices of the tonsillar fossae (Fig 3). Thismight be necessary if the palate is very-low hanging or istethered to the lateral pharynx by post-tonsillectomy scar-ring. Note that these incisions, which can measure 5 to 10mm, are made further laterally than are the verticaltrenches that are part of the classical LAUP. Additionaladvancement of the lateral soft palate can be achieved byincreasing the amount of mucosal resection at the lateralaspect of the incision. While still grasping the uvula in its new position, theplanned incision is outlined with a marker or with anumber 12 blade. This Gothic Arch-shaped incision gener-ally has its apex at or near the hard-soft palate junction andflares laterally to allow for advancement the lateral palate.The incision will be carried caudally onto the uvula in amirror image of the palatal incision. Unless vertical relax-ing incisions are necessary, as described previously, it isrecommended that the incisions be kept away from the freeedge of the palate, to lessen the chance of scar contracture. The dissection can be performed entirely with a scalpelhaving a number 12 blade and scissors (Metzenbaum orlong Iris scissors are adequate). Because the procedurecould be performed acceptably with a needle point cauteryunit, the additional expense, tissue destruction, and postop-erative pain do not warrant its use, particularly because FIGURE 4. A #12 blade works well for the mucosal incisions.cautery has not been found necessary for hemostasis. It is Note the flaring of the incisions laterally, to allow foreasiest to begin with the scalpel at the apex of the palatal advancement of the lateral soft palate. The distal uvula (shadedincision (Fig 4) and extend inferolaterally on each side. The area) is amputated.mucosa within this outlined area is then meticulouslyremoved with sharp pointed scissors (Fig 5). As the dissection reaches the tip of the uvula, the tip is sometimes amputated, to reduce the length of tissue brought up to the palate. Figure 6 shows the completed dissection. The distal soft palate and uvular remnant are then reflected superiorly and sutured in place. I recommend a 3-0 or 2-0 polyglycolic acid (Vicryl; Ethicon, Somerville, NJ) suture on a tapered (SH) needle for this closure. These last longer than needed, but can usually be easily removed 2 weeks postoperatively if the patient desires and if healing is sufficient. Note that the sutures could be removed before healing is complete if symptoms of significant VPI (such asFIGURE 3. If the tonsillar pillars show excessive webbing, or ifthe soft palate is particularly long, additional advancement may FIGURE 5. The targeted mucosa is removed careful dissectionbe obtained by making relaxing incisions that extend superiorly with sharp pointed scissors. Bleeding should be extremelyfrom the apices of the tonsillar fossae. minimal and cautery should not be needed.32 THE UVULOPALATAL FLAP
  4. 4. FIGURE 6. The completed dissection. If there is any oozing, it FIGURE 7. Closure begins with the central part of the flap. Ashould respond well to topical silver nitrate administration. mattress suture is placed, and the tension on the flap can be adjusted to vary the amount of advancement.voice change or nasal regurgitation) are noted, thus allow-ing the flap to fall back down inferiorly and remucosalize. primarily with the electrocautery unit. Secondly, this tech- The initial suture is a mattress suture that first passes nique is less apt to result in over-resection of the tonsillarthrough the mucosa and underlying muscle at the apex of pillar mucosa than is a cautery dissection technique, whichthe palatal incision and then passes through the tip of the can make for more difficult closure of the tonsillar fossae.uvular muscle and adjacent mucosa from the nasopharyn-geal side of the uvula (Fig 7). Tension of this mattresssuture can be adjusted to allow for proper positioning ofthe soft palate edge. It is not infrequently noted at thispoint that additional mucosa on the palate or flap must betrimmed. The remaining simple interrupted sutures arethen placed (Fig 8). Note that the advanced uvula and distal palate are adifferent color than the rest of the palate. This tissue, whichoriginated on the nasopharyngeal surface of the palate, isbrighter red than the oral palatal mucosa. This is explainedto the patient preoperatively, as is the fact that the folded-over central palate may be somewhat thicker for some timepostoperatively. This seems to thin out postoperatively,and should not require subsequent thinning or revision.General Anesthesia, with Concurrent Tonsillectomy The uvulopalatal flap also can be combined with moreaggressive pharyngeal mucosal tightening via a tonsillec-tomy with or without tonsillar pillar resection, as isgenerally done with the traditional UPPP. It is performedwith the patient in the Rose position with a Crowe-Davismouth gag and an appropriate sized tongue blade in place. It is recommended that the tonsillectomy be performedfirst. Though an adequate tonsillectomy can certainly beperformed via a number of techniques, it is m y opinionthat a careful "dissect and snare" technique is best for 2reasons. First, it results in less tissue damage (and thereforehopefully less pain) than when the dissection is carried out FIGURE 8. The closure is completed with interrupted sutures.TOD C. HUNTLEY 33
  5. 5. Hemostasis is improved pre-injecting the tonsillar fossae by Powell et al, 71 have found that this is often not possiblewith a total of 5 to 10 mL of 0.25% bupivicaine with in patients with significantly elongated or webbed palates,1:100,000 epinephrine, which also is used to inject the which is frequently encountered in the OSAS patientpalate, as outlined previously. This also helps with initial population. Such patients frequently benefit from thepostoperative analgesia. Additional help comes from the relaxation incision in the distal soft palate as mentioneduse of topical adrenaline-soaked tonsillar sponges. After earlier, which generally connects with the palatal suturewaiting a couple of minutes, the sponges are removed, and line. I have not found this to be problematic with anyjudicious electrocautery results in a very dry bed. patients. The tonsillar pillar sutures should be placed beforedissecting the palate. As described by Fairbanks, 1° resultsare optimized when the posterior tonsillar pillar is ad-vanced superolaterally to the anterior pillar mucosa. This POSTOPERATIVE MANAGEMENTclosure is often performed in 2 layers to obliterate any dead When performed in the outpatient setting in the office,space and to minimize the chance for postoperative dehis- patients are sent home with prescriptions for an appropri-cence. I prefer 2-0 polyglycolic acid sutures for this closure. ate antibiotic for several days and a narcotic pain medica-A stay suture held by a hemostat is placed through the tip tion. If edema is thought to be problematic, a short courseof the uvula to retract the distal palate cephalad during the of steroids may be offered. Anxiolytics, sleep aids, or othertonsillar fossa closure. This helps align the tissues properly sedating medications are not recommended in the immedi-and aids in correct suture placement (Fig 9). It also helps ate postoperative period. A regular diet is resumed as soonthe surgeon decide if relaxing incisions are necessary(described previously), which would be performed next. as the patient is comfortable. Residual sutures may be After approximation of the tonsillar pillars, the uvulo- safely removed after 2 weeks.palatal flap is made as described before, and is sutured in When the UPF is performed under general anesthesia inplace. Though it may be desirable to avoid connecting this the operating room, either solely or in conjunction withincision with the tonsillar pillar suture line, as suggested tongue base advancement or resection, nasal surgery, etc, the postoperative management is no different than with the traditional UPPP. If performed as part of the treatment of significant OSAS, postoperative continuous positive airway pressure is recommended until a subsequent poly- somnogram shows resolution of the problem. COMPLICATIONS Rare complications can include wound separation, which can be minimized by avoiding chromic sutures that may resorb prematurely. I instead recommend a polyglycolic acid suture, as noted before. Interestingly, the single patient of mine whose palatal suture line dehisced (on day 5) was the only one whose palate was closed with chromic. This patient had undergone the procedure in the office for primary snoring. I allowed the exposed ventral palatal muscle to remucosalize, and as it healed it shortened and stiffened somewhat and drew forward, similar to what is described with a cautery-assisted palatal stiffening proce- dure. The patients snoring improved sufficiently that he and his wife desired no additional treatment. In addition to wound dehiscence, minor bleeding can be encountered, particularly when combined with a tonsillec- tomy. Again, if VPI is encountered postoperatively, the suture line may be taken down and the palate may be dealt with again later, once it has remucosalized. In several patients, the bulge of the repositioned uvula has been prominent enough early on that I thought it might need to be thinned with a laser at a later date. In each case, however, the bulge diminished significantly in the ensuing 4 to 8 weeks, and no revision was necessary. SUMMARYFIGURE 9. When performed under general anesthesia, the The UPF is easy to perform and is a potentially reversibleprocedure generally includes a tonsillectomy, as with the treatment for the palatal obstruction that can accompanytraditionsal UPPP. Placement of retraction suture through the snoring with or without OSAS. It may be accomplished at auvula helps align the palate and uvula while the pillars are single session in either the outpatient setting or underapproximated. general anesthesia in the operating room. It offers several34 THE UVULOPALATAL FLAP
  6. 6. potential advantages over other variations of the UPPP, 4. Weingarten D: Snare uvulopalatoplasty. Laryngoscope 105:1033-1036,though some of these perceived advantages require further 1995study for confirmation. Complications are uncommon. 5. Zinder D, Postrna G: Outpatient cautery-assisted uvulopalatoplasty. Laryngoscope 105:1256-1257,1995 6. Powell N, Riley R, Troell RJ, et al: Radiofrequency volumetric tissue reduction of the palate in subjects with sleep disordered breathing.REFERENCES Chest 113: 1163-1174, 1998 7. Powell N, Riley R, Guilleminault C, et al: A reversible uvulopalatal 1. Ikematsu T: Study of snoring, 4th report: Therapy. Jpn J Otol Rhinol flap for snoring and sleep apnea syndrome. Sleep 19:593-599, 1996 Laryngo164:434-435, 1964 8. Fairbanks D: Uvulopalatopharyngoplasty complications and avoid- 2. Fujita S, Conway WA, Zorick F, et al: Surgical correction of anatomic ance strategies. Otolaryngol Head Neck Surg 102:239-245, 1990 abnormalities in obstructive sleep apnea syndrome: Uvulopalatopha- 9. Bresalier H, Brandes W: Uvulopalatopharyngoplasty: Prevention of ryngoplasty. Otolaryngol Head Neck Surg 89:923-934, 1981 complications with the imbrication technique. Ear Nose Throat J 3. Ikematsu T, Fujita S, Simmons FB, et al: Uvulopalatopharyngoplasty: 78:920-922,1999 variations, in Fairbanks D, Fujita S (eds): Snoring and Obstructive 10. Fairbanks D: Operative techniques of uvulopalatopharyngoplasty. Sleep Apnea (ed 2). New York, NY, Raven Press, 1994, pp 97-145 Op Tech Otolaryngol Head Neck Surg 2:104-106, 1991TOD C. HUNTLEY 35