While there are a variety of surgical procedures to address OSA, a growing body of evidence-based data (including from systematic reviews and meta-analyses) demon­strates that surgical intervention, specically MMA, a well-established orthognathic procedure for OSA with a relatively low rate of major complications (1%) [101], currently appears to be the most effective, long-term solution for OSA.In 1993, Riley etal. put forward their two-phase Stanford Protocol [102] (. Fig.28.1), phase 1 of which consisted of presurgical evaluation up to and including numerous targeted procedures.

Genioglossus advancement, glossectomy, and hyoid suspension were previously considered a phase 1 treat­ment for OSA.However, over time these treatments have failed to yield acceptable rates of success. For example, UPPP has a success rate of 40–50% in the short term [103], and long-term outcomes show an even lower rate of success after 4-year follow-up (35%) [104]. Laser­assisted uvulopalatoplasty (LAUP), an outpatient proce­dure for snoring, requires multiple procedures and may result in signicant postoperative pain [105]. It has been suggested that palatal implants may be needed to improve results following LAUP [106]. A 2003 randomized trial of patients treated with LAUP vs. untreated patients showed that there was no difference between groups in measures of excess daytime and QOL [107]. The authors concluded that their results do not support the use of LAUP for OSA.Partial glossectomy also has a questionable rate of success and is known to be accompanied by several com­plications, such as dysphagia, odynophagia, loss of taste sensation, and reduced tongue mobility [108, 109]. Hyoid suspension also has a success rate as low as 17% [110]. A postoperative polysomnography would ultimately be per­formed after these procedures to evaluate the procedure success. If this step failed to yield success, the patient would move on to phase 2: MMA.