Reevaluating Palatal Surgery for Obstructive Sleep Apnea
October 7, 2025
A recently published review article in the Journal of Clinical Sleep Medicine led by a multidisciplinary team from the Department of Otolaryngology and the Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine at UPMC and the University of Pittsburgh reexamines the role of modified uvulopalatopharyngoplasty (UPPP) in the treatment paradigm for obstructive sleep apnea (OSA).
The review, “Modified Uvulopalatopharyngoplasty in Modern Obstructive Sleep Apnea Treatment,” originated from ongoing discussions within the International Surgical Sleep Society (ISSS), where members of the surgical sleep community identified a need to address persistent gaps in how palatal surgery is perceived, evaluated, and integrated into treatment decision-making in light of the new evidence emerging around the development and use of modified UPPP techniques.
Thomas Kaffenberger, MD, assistant professor of Otolaryngology was the first author of the review. Joining Dr. Kaffenberger from the Department of Otolaryngology was Ryan Soose, MD, associate professor of Otolaryngology and chief of the Division of Sleep Disorders.
Co-authors of the review from the Division of Pulmonary, Allergy, and Critical Care Medicine were Charles W. Atwood, Jr., MD, FCCP, FAASM, associate professor of Medicine and director of the Sleep Disorders Program at the VA Pittsburgh Healthcare System, and Patrick Strollo, MD, FACP, FCCP, FAASM, professor of Medicine and Clinical and Translational Science, vice chair for Veterans Affairs, and vice president of the Medical Service Line, at the VA Pittsburgh Healthcare System.
Collaborating with the UPMC faculty on the review were sleep medicine and sleep surgery experts B. Tucker Woodson, MD, from the Medical College Wisconsin; Stuart G. MacKay, MBBS, FRACS, University of Wollongong Department of Otolaryngology in New South Wales, Australia; and Edward M. Weaver, MD, MPH, from the University of Washington Department of Otolaryngology in Seattle.
“At one of the ISSS meetings, people were asking, ‘What more can we do to support and validate sleep surgery in the eyes of the broader medical community?’ This article was born out of those discussions and the work of ISSS,” says Dr. Kaffenberger.
Clarifying the Role of Modified UPPP
Mischaracterizations of UPPP remain common, despite decades of surgical refinement and improved outcomes. The traditional and historical UPPP was a very common surgery for sleep apnea patients who could not tolerate CPAP. However, it had significant limitations both in efficacy and morbidity. In the past two decades, the field has really focused on ways to minimize the morbidity while improving the effectiveness of surgery. In general, the modified UPPP techniques now focus on reconstruction and airway stabilization rather than soft tissue resection. Expansion sphincter pharyngoplasty, barbed reposition pharyngoplasty, and the Australian modified UPPP are among the best described and studied in the literature, and are discussed in depth in the review.
“There is still a lot of stigma around UPPP, and frankly, it was earned with the older, first-generation techniques. But the modern UPPP variants that have been developed and studied are fundamentally different. They’re safer, more effective, and much more selective. It is time to broadly reevaluate the role of palatal surgery in treating OSA,” Dr. Kaffenberger says.
The review from Dr. Kaffenberger and colleagues emphasizes the durability and symptom improvement observed with modified UPPP in appropriately selected patients, including those with concentric palatal collapse, small or absent tonsils, or for whom continuous positive airway pressure devices or neurostimulation with techniques like hypoglossal nerve pacing are not an option.
Newer, High-Quality Evidence on Modified UPPP Approaches
Among the most significant recent evidence on the efficacy of modified UPPP approaches are the “Effect of Multilevel Upper Airway Surgery vs. Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial,” published in the Journal of the American Medical Association in 2020, and the “SKUP3 Randomised Controlled Trial: Polysomnographic Results After Uvulopalatopharyngoplasty in Selected Patients With Obstructive Sleep Apnoea,” published in Thorax in 2013 collectively showed that surgical treatment in properly selected CPAP-intolerant patients can outperform continued medical management. The SAMS trial showed durable symptom improvement and AHI reduction following multilevel surgery that included a modified UPPP.
“The critique for years has been that there is no high-quality data for sleep surgery. But that’s not true anymore. We now have solid randomized trial evidence, long-term follow-up, and better-defined patient selection criteria that continues to improve as we learn more,” Dr. Kaffenberger says.
The review also discusses mean disease alleviation (MDA) as a metric for comparing all sleep apnea therapies in real-world settings. MDA incorporates adherence rates, which give a more accurate picture of treatment effectiveness than raw efficacy alone.
Expanding Treatment Options in a Changing Therapeutic Landscape
The review positions modified UPPP within the broader and rapidly evolving field. Over the past decade, the therapeutic options for OSA have expanded to include oral appliances, hypoglossal nerve stimulation, and pharmacologic therapies, most notably tirzepatide, which was recently approved by the U.S. Food and Drug Administration for OSA in patients with obesity.
“It’s a different world than it was 10 or even five years ago. Some providers still think UPPP means soft palate resection, postoperative dysphagia, and no long-term benefit. That’s not the procedure anymore,” Dr. Kaffenberger says. “But with all these options, the key question remains: what’s the best fit for this patient? Not every patient wants or qualifies for an implant. Some don’t want to be on lifelong medication. That’s where modified UPPP still plays a role.”
A Message for Clinicians: Surgical Relevance in a Broad Therapeutic Landscape
The expansion of OSA treatment options, including neurostimulation and emerging pharmacologic therapies, has not reduced the importance of modified UPPP for the right patient populations as part of a modern, multimodal treatment strategy.
“As a field, in the past, we have for the most part dismissed UPPP. But that conversation is changing,” Dr. Kaffenberger says. “Given the very well known and troublesome downstream consequences of untreated or undertreated OSA, the modified UPPP options out there now can fill in some of those gaps.”
One of the review’s messages is a call to the broader medical community, including primary care providers, pulmonologists, and sleep specialists to reconsider long-held assumptions about palatal surgery.
“These modified procedures are supported by evidence. They are durable, and they are an important option for many patients who are out of alternatives,” Dr. Kaffenberger says.
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