The “Propeller” incision for transpalatal advancement pharyngoplasty: A new approach to reduce post-operative oronasal fistulae

Objective To present a new soft tissue approach for transpalatal advancement pharyngoplasty (TPA), the propeller incision, and to compare the rates of post-operative oronasal fistula in those undergoing TPA with the traditional “Gothic Arch” incision described by Woodson and those with the propeller incision. Methods A prospectively maintained adult sleep apnoea surgery database was used to identify those patients undergoing TPA, either alone or in combination with other procedures, for obstructive sleep apnoea syndrome (OSAS) between February 2001 and September 2006 in a tertiary referral centre by a single surgeon (RHL). In addition to the incision used during TPA, patient demographic data, previous surgery of the upper airways, smoking history, pre-operative body mass index, respiratory disturbance index, oxygen saturation index and the occurrence of oronasal fistula post-operatively, were recorded. The propeller incision technique is described. Results A total of 89 patients who underwent TPA were identified. A total of 49 patients had a “Gothic Arch” incision and 40 had a “Propeller” incision. The two groups of patients were comparable in age, sex, previous tonsillar and uvulopalatopharyngoplasty surgery, smoking histories and pre-operative disease severity. In the “Gothic Arch” group, eight patients (16%) developed oronasal fistulae in the post-operative period versus only one patient (2.5%) in the “Propeller” group. The difference between the two groups was statistically significant (P = 0.038, Fisherʹs exact test). Of the total cases with post-operative oronasal fistula (n = 9), only one patient (from the Gothic Arch incision group) required operative closure which was performed under local anesthesia and healed without complication. Conclusion The propeller incision provides an anatomically sensible axial-based flap that provides adequate access to perform TPA. It is associated with a lower incidence of oronasal fistula and is recommended by the authors