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6 Advancements andInnovations inSleep Surgery
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of advancing the genial tubercle, genioglossus muscle, and tongue base anteriorly to
prevent hypopharyngeal collapse during sleep [30–32]. There are two main types of
GGAs: (1) those that incorporate just the genial tubercle without including the inferior border of the mandible—also referred to as genial tubercle advancement—and
(2) those that include the inferior border of the mandible and the suprahyoid muscles attached to it is also referred to as genioplasty, mortised genioplasty, and sliding
genioplasty with GGA.
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Indications andPatient Selection
GGA is most often performed with nasal and palate procedures as a multilevel
approach to tongue-base collapse can be identied with DISE, and it is important to
differentiate physiologic tongue-base collapse from lingual tonsil hypertrophy.
Planning Considerations
Ideally, the genial tubercle is incorporated in the movement with avoidance of the
dental roots and mental nerve on either side. Weakening of the alveolar bone must
be avoided, and some degree of bony overlap must be achieved for proper union.
When GGA involves advancement of the inferior border of the anterior mandible, it
is important to assess the patient’s facial proportions and ensure balance is achieved
with advancement of the chin. Custom osteotomy cutting guides and xation plates
allows precise movements and adjustments to achieve consistent esthetic and physiologic results.
Operative Technique
An incision is made perpendicular to the lip before angling through the mentalis
muscle and toward the inferior border of anterior mandible. This is critical for closure, especially with advancement of the chin. The extent of dissection depends on
the osteotomy design, but it is limited laterally by the mental foramina and inferiorly at the border to preserve the attachments of the suprahyoid muscles and the
blood supply for the advancement graft.
Once exposure has been obtained, the osteotomy cutting guide is placed, and the
saw can be used to mark the planned cut. If a custom plate has been made, the osteotomy guide will also include guides for screw placement. Once xated, the patient’s
soft tissue should be redraped, and chin position should be assessed for adequate
advancement and appropriate introduction of any planned pitch, roll, or yaw movements (Fig. 6.6). Closure requires reapproximation of the mentalis muscle to
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Fig. 6.6 The cutting guide is placed. Note the guides for screw placement. Once the bony cut is
made, it is xated with a custom plate
prevent a witch’s chin deformity and the mucosal edges to safeguard against dehiscence and infection. Interrupted sutures should be used here with the knot tied to the
lip, as opposed to the gingival side.
S. Y.-C. Liu and A. A. Al-Sayed
Complications
Signicant, but uncommon, complications include avulsion of the genioglossus
muscle and mandibular fracture. Genioglossus avulsion is a worrisome complication as it carries signicant airway risk. Mandibular fractures resulting from GGA
can be difcult to repair. If it is on the alveolar side, open reduction with internal
xation is not possible, and hence, maxillomandibular xation is the only option. If
it occurs on the cortical side (inferior to the advancement graft), there is usually
inadequate room for plate placement. This does argue for the genioglossus advancement with genioplasty, in one piece, especially for older adults.
Other complications include loss of tooth vitality, paresthesia of the lower lip and
chin, and persistent wound dehiscence leading to infection.
Outcomes
The literature on GGA outcomes is limited but demonstrates low complication rates
and favorable respiratory and quality-of-life outcomes [33, 34]. Studies have shown
that GGA alone confers a 40–50% decrease in AHI and a surgical success rate of
greater than 60% in patients with severe OSA [32, 35]. Two key factors have been
shown to inuence the likelihood of success with GGA: lower preoperative BMI
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and AHI.Specically, patients with a BMI less than 30kg/m2 experience a surgical
success rate of 64% after GGA, whereas those with a BMI greater than 30kg/m2
experience a 41% success rate. Similarly, patients with a preoperative AHI of less
than 50 events per hour experience a 71% success rate, whereas those with an AHI
greater than 50 events per hour experience a 32% success rate. No difference in
outcomes has been found between GGA with just the genial tubercle versus GGA
including the inferior mandibular border and suprahyoid musculature.
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Maxillomandibular Advancement
MMA is a facial skeletal surgery that provides tension and stability of the upper
airway muscles implicated in OSA.It has a documented success rate using the universal Sher’s criteria OSA of 85–90% [36–39]. The procedure was originally
described for OSA by Riley etal., as a 10-mm advancement of the maxilla and
mandible for patients who had failed phase I surgery [40]. Despite its impressive
impact on the airway, it sometimes resulted in suboptimal esthetic outcomes. The
contemporary Stanford MMA is patient specic, with attention to balancing both
airway improvement and overall facial balance [41]. In the updated Stanford sleep
surgery protocol, there are three main indications to recommend MMA.As with the
old protocol, those who have not responded adequately to phase I surgery may be
recommended MMA.There are two phenotypes to which we recommend MMA
rst, which are (1) patients with dentofacial deformity, presenting with any degree
of OSA, and (2) patients presenting with both complete concentric collapse of the
velum and lateral pharyngeal wall collapse.
Even though VSP is helpful, starting with the correct head position is crucial for
planning. The natural head position in a patient with OSA is not healthy. The neck
tends to extend forward to compensate for a narrow, obstructive, or collapsible airway. A patient with bimaxillary retrusion may appear to have normal class I facial
skeletal position with the forward neck extension. Similarly, a patient with class III
malocclusion may have bimaxillary hypoplasia when the head position is not
extended and with the neck in neutral position.
Since esthetic results of the midface largely depend on the degree of distortion of
the nose and having adequate incisal show (and preferably with a nice smile arc),
placement of the maxilla cannot be planned based on bony position alone. A way to
allow exibility while maintaining efciency of the procedure may be to approach
surgery with two plans. One would have more rotation and less advancement, and
the other may be less rotation but more advancement. Ultimately, since the surgeon
controls the pitch, the two intermediate splints that are designed for these movements allow for optimization of maxillary placement on the table. This combines
the best of VSP with concepts borrowed from esthetic orthognathic surgery using
the single splint technique [42].
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S. Y.-C. Liu and A. A. Al-Sayed
Preoperative Planning
The earliest indications for MMA included severe OSA, morbid obesity, severe
mandibular deciency, and failure of other forms of therapy. Today, appropriate
patient selection begins with a thorough history, subjective questionnaires (Epworth
Sleepiness Scale and Nasal Obstructive Symptom Evaluation), head and neck physical examination, polysomnography interpretation, and beroptic nasopharyngoscopy observation. Moreover, selection criteria for MMA include the use of dynamic
examinations, such as drug-induced sleep endoscopy (DISE). MMA is particularly
effective when DISE shows lateral pharyngeal wall or concentric velum collapse
[43]. Because concentric collapse of the velum is a contraindication for hypoglossal
nerve stimulation and lateral pharyngeal wall collapse is difcult to address with
soft tissue pharyngeal procedures, MMA can be a rst-line recommendation in
OSA patients exhibiting these airway collapse patterns (Fig.6.7) [44].
Maxillomandibular advancement is also performed in OSA patients with dentofacial deformity. However, in patients with Class 1 occlusion, MMA with airwayspecic counterclockwise (CCW) rotation can be expeditiously performed with
minimal orthodontic decompensation.
The most unique aspect of today’s Stanford MMA in preoperative planning is the
center of rotation for the maxillomandibular complex (MMC). When counterclockwise rotation is appropriate, the center of rotation is at the maxillary buttress to
maximize both airway stability and facial aesthetics (Fig.6.8). Additionally, the
main reference points and movements for planning are (1) advancement from a
point at the piriform rim just below level of the inferior turbinate, (2) degree of
occlusal plane change dictated by the maxilla, and (3) postoperative position of the
pogonion. If patients also exhibit dentofacial deformity, this is certainly addressed,
but the general principle of movement, as described here, remains consistent.
ab
Fig. 6.7 (a) Lateral pharyngeal collapse on drug induces sleep endoscopy pre-MMA. (b) Stable
lateral pharyngeal walls on drug-induced sleep endoscopy post-MMA
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Fig. 6.8 The red dot represents the center of counterclockwise rotation (maxillary buttress). Note
the degree of chin advancement
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Virtual Surgical Planning
Prior to virtual surgical planning (VSP), Riley and Powell performed what is commonly described in the orthognathic literature as a single-splint technique [42]. This
requires extensive experience to control the pitch, roll, and yaw of the MMC and is
difcult to reproduce consistently. With VSP, surgical movements are planned, and
two intermediate splints are usually produced to provide a clinical outcome that balances bite, beauty, and breathing. Regarding the movement, a differential anterior
impaction is performed with the rotation center in line with the buttress. CCW rotation has been described with centers at the anterior nasal spine (ANS) or posterior
nasal spine (PNS). The buttress may seem like a peculiar landmark. The rationale is
that when the maxilla is rotated in line with the buttress and the level of the rst
molar is maintained, the CCW rotation brings the entire maxilla posterior to the
original piriform rim (Fig. 6.8). From here, an advancement of approximately
3–5 mm anterior to the piriform translates to a nal pogonion position approximately 12–18mm anterior and 2–4mm superior to its original position. Concurrent
orthognathic problems, if present, are corrected during the planning session.
Preparation andPatient Positioning
There are two important nuances to the positioning of the MMA patient compared
with the orthognathic patient. Classically, nasal Ring, Adair, and Elwyn (RAE)
tubes are used for orthognathic cases. However, OSA patients tend to have longer
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airways, requiring longer RAE tubes, which are bulkier, distorting nasal anatomy
and limiting access to the nasal septum and prohibiting accuracy in performing the
piriformplasty. Instead, the authors use the microlaryngoscopy tube (MLT), where
there is adequate length and thinner diameters (usually 5mm). The authors trim
back the tube toward the nares and place a 120° reverse metallic attachment, followed in-line with an accordion extension. Another important positioning element
is that patients are not placed on a shoulder roll because this overextends the neck.
Recall that OSA patients tend to have extended neck position already to compensate
for compromised upper airway. A neutral head position is important for control of
the occlusal plane change.
S. Y.-C. Liu and A. A. Al-Sayed
Anesthetic Considerations
Total intravenous anesthesia with agents such as propofol and remifentanil is used.
Although controlled hypotension with a target mean arterial pressure of 60mmHg
is recommended for orthognathic procedures, many OSA patients undergoing
MMA have cardiovascular comorbidities. Keeping the mean arterial pressure this
low is both difcult for the anesthesiologist and sometimes contraindicated. The
authors still aim for a brief period of controlled hypotension during maxillary downfracture but most often are doing this at a mean arterial pressure of approximately
80mmHg. Total blood loss is approximately 250–350mL for the procedure. Mean
operative time is approximately 3h without GGA and 3.5h with GGA.
Surgical Technique
Approach to general aspects of MMA surgery is not discussed in detail. However,
critical steps are highlighted.
At the time of LeFort I osteotomy, a wedge can be created that determines the
degree of CCW rotation. An appropriate degree of CCW rotation should not compromise incisor show in the nal maxillary position.
The maxilla is never mobilized aggressively with instruments like the Rowe disimpaction forceps (Sklar Surgical Instruments, West Chester, PA). With a wire
through the anterior nasal spine area to control the maxilla, lateral forces are applied
concurrently to the posterior maxillary wall to mobilize the maxilla.
With large CCW rotations, muscle tension associated with the maxilla and mandible is signicant. For this reason, maxillomandibular xation prior to rigid xation is performed with the aid of suspension wires. The authors use suspension
wires anchored to the alveolus with intermaxillary xation (IMF) screws and
through a hole by the piriform rim above the LeFort osteotomy for the maxilla and
to the arch wire for the mandible. Maxillomandibular xation prior to xation with
the use of 24-gauge wires on dental brackets or the arch bar may debond brackets or
shift the arch bar. Minor discrepancy greatly affects accuracy of the nal xation.
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The authors do not perform sagittal split osteotomy with instruments like Smith
spreaders. Older patients tend to have little bone marrow space. With the need of
longer osteotomy (anterior extent to the second premolar) for xation after large
advancements, the use of Smith spreaders leads to poorly controlled fractures.
Instead, the authors focus on an accurate horizontal osteotomy taking down the
lingula, anterior osteotomy not past the midline of the inferior mandibular border
and wedging open the segments with 3 osteotomes in a sequential sandwiched
fashion.
For xation, the authors use two to three bicortical xation screws, coupled with
a long 2.4-mm plate across the osteotomy site. The rigidity allows the patient a rapid
return to function. Patients are not kept in a splint, and only guiding elastics are used
immediately after surgery. This allows MMA patients to breathe orally in the immediate postoperative period. By the end of the second week postoperatively, patients
progress beyond the liquid diet. Minimal use of narcotic pain medications is
expected.
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Complications
The most serious complication is airway obstruction. The authors do not band the
jaws of post-MMA patients tightly nor place them in a splint. By not using a splint
postoperatively and only using guiding elastics, patients are able to orally breathe
while congested and have additional access to suctioning when needed. If there is a
well-supported ENT ward, patients do not need to for observation in the intensive
care unit.
Based on a review of more than 370 MMA patients from Stanford, approximately 18.7% underwent functional or esthetic nasal surgery approximately
1.5years after surgery. This rate has decreased to less than 5% in the recent 120
patients with judicious midfacial contouring and intraoperative septoplasty and
inferior turbinate reduction with outfracture [45]. Perioperative considerations and
interventions are also critical. In a review comparing OSA patients to dentofacial
deformity patients, the morbidity and mortality rates of MMA are higher. Early,
late, minor, and major complications were present. The patients with OSA were
older, had a higher American Society of Anesthesiologists classication, had a
greater number of medical comorbidities, and had a higher body mass index [46].
Clinical Outcomes
Although there are variations on how MMA is performed around the world, it consistently demonstrates high rates of surgical success and moderate rates for cure.
The systematic review and meta-analysis published by Holty etal. in 2010 with 22
unique patient populations (627 adults with OSA) report mean Apnea/Hypopnea
Index (AHI) decrease from 63.9/h to 9.5/h, with pooled surgical success and cure
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S. Y.-C. Liu and A. A. Al-Sayed
(AHI <5/h) rates of 86% and 43.2% [36]. An update to this meta-analysis was performed by Zaghi and colleagues in 2016, which included 518 patients across 45
studies. They reported success and cure rates of 85.5% and 38%, respectively [39].
When compared with continuous positive airway pressure (CPAP), both Riley and
Powell, of Stanford, and Vicini of Forli, Italy, independently showed MMA to be as
effective based on the AHI and Epworth Sleepiness Scale in evidence level 2 and
level 3 studies [47, 48].
MMA compares favorably to CPAP regarding improvement in sleep quality.
Although the increase in rapid eye movement sleep is comparable between CPAP
and MMA, MMA has shown additional decrease in wakefulness after sleep onset, a
measure for sleep disturbance. A patient treated with MMA can restore sleep architecture comparable to a younger, healthy individual [49]. Therefore, MMA leads to
signicant improvements in neurocognitive performance Moreover, MMA is effective in reducing cardiovascular risk by lowering blood pressure [50].
Conclusions
The updated Stanford sleep surgery protocol aims to provide a roadmap for all practitioners across the continuum of care. At its core, it is about precision in patientselection, phenotype recognition, and surgical application. With the technological
advances described, the principles described can be better adopted and applied in a
universal manner. This would then allow optimization of personalized care across
all ages, gender, and ethnicity.
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