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CPAP as a treatment for OSA dates from 1981, but surgical approaches to OSA patients actually predate CPAP, to 1964 when the Uvulopalatopharyngoplasty (UPPP) was used solely to stop snoring, then in 1981 when UPPP was tried as treatment for OSA itself, generally without much success despite several modifications of the procedure. Some OSA patients show craniofacial abnormalities such as retrognathia (receding chin) or dolichofacial appearance (long face). These patients seem to present an especially likely group for surgical treatment by facial osteotomy (cutting of the bones) and advancement (moving forward) of the maxilla (upper jaw) and mandible (lower jaw). Initial studies of short-term outcome in patients resistant to various other treatments wereencouraging, but so far no studies have followed these patients longer than a year. This study undertakes an open-ended yearly follow-up of 15 such patients who have been operated on with maxillomandibular osteotomy and advancement; this report concerns the data 6-12 weeks and 2 years after the surgery. Patients were recruited from one sleep laboatory beween 1989 and 1992, when 540 patients diagnosed with OSA underwent measurement of head structure (cephalometry). Of these, craniofacial abnormalities led clinicians to offer maxillomandibular advancement surgery as an option to 210. Only 15 patients opted for this surgery, while the rest preferred to continue CPAP. These 15 consisted of one woman and 14 men, now followed for a minimum of 2 years after the surgery. Their mean age was 44 (SD=12) and their mean body mass index or BMI (see Glossary) was 28 (SD=3). Prior to surgery, 12 of the 15 had undertaken CPAP for at least 3 months. Two younger patients persisted in objecting to CPAP and the remaining patient used a dental appliance preoperatively. Cephalometry focused on the posterior airway space, the distance between the base of the tongue and the back wall of the pharynx. All patients to whom surgery was offered had narrowing in this area. Usually this was combined with one of two craniofacial abnormalities: retrognathia or a dolichofacial appearance (see above). They also had subjective symptoms of excess daytime sleepiness and an Apnea Hypopnea Index of greater than 20 events/hour.Patients were excluded if they were older than 70, had other medical or psychiatric diseases, morbid obesity (BMI greater than 32), alcohol or drug abuse. The goal of surgery was to advance both the upper and lower jaw by about 10 mm after these bones were cut, they were kept in place by miniplates or miniscrews. On follow-up, there was almost complete correction of sleep respiratory breathing disorder. The improvement after surgery was similar to the improvement on CPAP. After two years, there was a slight rise in AHI in 12 of the 15, but not sufficient in magnitude to achieve statistical significance, though in three patients the magnitude reached borderline values for diagnosing active illness. Two of these three had mainly obstructive events, one with an AHI of 58 before surgery, less than 10 right after surgery, but up to 13 on two-year follow-up. The second had an initial AHI of 67, which surgery reduced to an insufficient degree (20/hr), which worsened further (to 29) at two year follow-up. The third patient with relatively poor outcome had mainly central apneas, which persisted after surgery though the obstructive apneas disappeared, the AHI before treatment being66 and after two years, 32. Most persisting respiratory disturbances in all patients were incomplete upper airway obstructions or central events. The overall quality of sleep improved markedly after surgery with increase in deep (stage 3 & 4) NREM sleep and decrease in light (stage 1) NREM sleep, as well as an increase in REM sleep.  Results of surgery appeared good except for two patients with initially mixed apneas who showed mainly central apneas two years later. The authors attributed the overall improvement i=to enhanced tension of the pharyngeal musculature plus mechanical enlargement of the posterior airway space. They recommended that such surgical treatment be preceded by more "conservative" treatment which might unmask other, coexisting respiratory disorders such as central apneas, that were lead away from surgery as a solution. Surgery is not indicated if sleep breathing abnormalities persist after removal of upper airway obstruction by CPAP. It seems most successful in primarily obstructive apneas particularly if associated with craniofacial abnormalities. In these cases, they recommended this procedure as the initial surgical approach, reserving UPPP or chin advancement (genioplasty) for later use if necessary. They recognized that this ran contrary to the opinions of other investigators who would reserve the maxillomandibular advancement as a "third-stage" surgical procedure after UPPP, genioglossus advancement, and hyoid suspension had failed. They also considered primarily indicated for patients who refused the prospect of lifelong CPAP.

I have been one of those who have long considered the maxillomandibular osteotomy/advancement procedure, a seemingly formidable undertaking with extensive revision of facial architecture, as a surgical procedure "of last resort." I have been impressed by the high percentage of success with this procedure, up to 90-95%, reported by Riley and Powell at Stanford, dealing with extremely treatment-resistant patients. I had thought of this as not so much an alternative for people who, for whatever reason, didn't want to accept long-term CPAP, as for people who found CPAP only partially effective, which this article does not seem to support, though it does seem to suggest that peatients with craniofacial abnormalities may show suboptimal response to CPAP. Speaking solely for myself, I recollect that as a child my dentists took pictures of my face to demonstrate my receding lower jaw and chin, which they though might have something to do with my many dental problems. Of course, at that point obstructive sleep apnea was scarcely known. Furthermore, if one imagined what a patient with "craniofacial abnormalities" might look like, one would think of someone so deformed as to frighten little children in elevators, whereas most people looking at me might not have noticed this feature of my face at all, especially facing me front-on. This, I think, is a misleading caricature of what the authors are talking about. I doubt that their patients would earn much in carnival sideshows! In fact, I have seriously considered undergoing this very procedure, having had no productive (or even countertherapeutic) results with two previous surgeries--a conservative UPPP followed by a revised UPPP plus genioglossus advancement and hyoid suspension. In my case, the main motivation would be to rid myself of persistent excessive daytime sleepiness, although as my own sleep doctor points out, if CPAP can resolve all respiratory-related arousals without resolving daytime sleepiness, it is unlikely that surgery could do anything more. Rather, one would have to look for an explanation in some coexisting condition, such as narcolepsy or idiopathic hypersomnolence, assuming that other possible contributing factors (such as restless legs, period leg movements of sleep, medication effects, etc) have been excluded. The only instance in which he would recommend this surgery would be if optimized CPAP failed to suppress a significant number of respiratory-related arousals. Having thought much about his reasoning, I have to agree with him. There is no reason to believe that surgical treatment could do more than stop obstructive sleep apneas/hypopneas (and perhaps upper airway resistance syndrome) which could also be adequately controlled in most people by properly adjusted CPAP. There is no reason to believe that it would be helpful for other sleep disorders, such as narcolepsy or idiopathic hypersomnolence. The latter case is infrequent and, by its name, of unknown cause, but from the opinion of another of my sleep doctors, I have to consider the possibility that longstanding, untreated obstructive sleep apnea might lead to changes in the brain's mechanism of sleep-wake control that could alter daytime alertness on a lasting basis even after the original cause was removed. I particularly appreciated the authors' advice to relegate the all-too-common UPPP to a second or later place in the surgical hierarchy. A good deal of data so far suggests that it is scarcely more effective on core symptoms of OSA than a robust placebo, with rather short-lived effects, and worse yet, may serve to disguise snoring as a cardinal overt sign of sleep apnea and to make subsequent treatment with CPAP more difficult. It is probably in widespread use because it is easy to do, but patients considering it should consider that it is quite painful to recover from, and has not only questionable effectiveness but possibly counterproductive effects. In my case, my AHI actually increased after the surgery, which only much later I came to understand, as discussed in connection with a previous article. So this must be added to the usually unmentioned risks of UPPP.

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