Obstructive sleep apnoea (OSA) is fundamentally a mechanical problem. During sleep, the soft tissues of the upper airway collapse inward, obstructing the passage of air, fragmenting sleep, and depriving the body of oxygen dozens — sometimes hundreds — of times per night. For many of these patients, this obstruction has an anatomical cause: a recessed jaw, a narrow pharynx, hypertrophied soft tissues, or a combination of structural factors that no lifestyle intervention can fully correct.
The vast majority of patients with moderate to severe OSA are offered positive airway pressure (PAP) therapy — most commonly CPAP — as the first-line treatment, and rightly so. When tolerated, it is effective. But for a lot of these patients, long-term use proves difficult or impossible. For this group, and for patients in whom the underlying anatomy is the primary driver of the condition, surgery offers a durable, anatomically targeted solution.
This article explains the surgical pathway for OSA as practised at FACES.pt — from diagnosis and patient selection to maxillomandibular advancement (MMA) surgery, nasal surgery, and multidisciplinary collaboration — and describes who is most likely to benefit.
[IMAGE 1 — upper airway anatomy diagram]
Understanding the Surgical Pathway: Where CPAP Ends and Surgery Begins
Rather than considering surgery as an alternative to CPAP, it should be regarded as the next step for patients in whom CPAP has failed or is not appropriate. The clinical pathway typically follows a structured progression.
First-line management includes lifestyle modifications (weight loss, alcohol avoidance, positional therapy) and positive airway pressure therapy. For patients with mild to moderate OSA, a mandibular advancement device (MAD) — a custom oral appliance that advances the lower jaw during sleep — may be an effective and less invasive option. These appliances can reduce the apnoea-hypopnoea index significantly in well-selected cases, and are also used as diagnostic tools to predict surgical outcomes before proceeding to MMA.
Surgery is considered when:
- CPAP therapy is not tolerated despite adequate acclimatisation support
- The condition is refractory to non-surgical treatment
- There is a significant underlying skeletal anomaly — retrognathia, micrognathia, or a narrow maxilla — that is contributing structurally to airway collapse
- The patient is young, motivated, and seeking a permanent resolution rather than a lifelong device
The decision is never taken lightly. A full sleep medicine evaluation, polysomnography, and careful anatomical assessment are prerequisites. At FACES.pt, this work is done in close collaboration with specialist sleep physicians, ensuring that every surgical candidate has been properly staged and that the indication is sound.
Drug-Induced Sleep Endoscopy (DISE): Seeing the Airway as It Collapses
Before planning any surgical intervention, it is essential to understand precisely where in the airway the obstruction occurs. Snoring and apnoea are symptoms — not a diagnosis of location. The airway can collapse at the level of the nose, the soft palate, the tongue base, the epiglottis, or at multiple levels simultaneously, and the surgical approach must be tailored accordingly.
DISE (Drug-Induced Sleep Endoscopy) is a short procedure in which the patient is sedated with propofol to a level that mimics natural sleep. A flexible endoscope is then passed through the nasal passage to observe the pharynx in real time as the airway collapses. The procedure typically takes 10–15 minutes and provides valuable diagnostic information: a direct, dynamic view of airway obstruction during a simulation of sleep.
[IMAGE 2 — DISE procedure or endoscopic view]
At FACES.pt, DISE is used selectively — primarily in cases where the site of obstruction is uncertain, in patients who have not responded to initial treatment, and in younger patients with primary snoring where surgery is being considered. When another procedure is already planned under anaesthesia — such as nasal surgery — DISE can be performed in the same anaesthetic episode, avoiding an additional procedure for the patient.
The findings from DISE directly inform the surgical plan: which levels require treatment, whether MMA alone will be sufficient, and whether additional nasal or oropharyngeal intervention should be considered.
Maxillomandibular Advancement: The Surgical Treatment of OSA at Its Root
MMA surgery is widely regarded as the most effective surgical treatment for obstructive sleep apnoea. Unlike procedures that remove or reduce soft tissue, MMA addresses the skeletal framework of the airway — permanently enlarging the space through which air must pass during sleep.
The procedure advances both the maxilla (upper jaw) and the mandible (lower jaw) simultaneously, carrying with them the tongue, the soft palate, and the suprahyoid musculature. This forward movement — typically between 8 and 12 millimetres — increases the cross-sectional area of the pharynx at every level of the upper airway: retro-palatal, retrolingual, and hypopharyngeal. The result is a structural expansion of the airway that persists permanently, independent of sleep position, muscle tone, or body weight changes.
[IMAGE 3 — cephalometric tracing or surgical planning image]
Published evidence consistently demonstrates that MMA achieves the highest surgical success rates of any procedure for OSA. For patients with severe OSA who cannot tolerate CPAP, this represents a genuinely transformative option.
Surgical planning at FACES.pt integrates cephalometric analysis, 3D imaging, and digital surgical simulation to determine the optimal degree and direction of advancement for each patient. The goal is not only to resolve the apnoea but also to achieve a stable, functional, and aesthetically harmonious result. In many patients — particularly those with an underlying skeletal discrepancy — the profile improvement is a welcomed additional benefit of the procedure.
Nasal Surgery: Where the Airway Begins
The nose is the primary route for airflow during sleep. A significant degree of nasal obstruction — whether from a deviated nasal septum, hypertrophic inferior turbinates, or both — increases upper airway resistance and worsens the severity of sleep-disordered breathing. In many patients, nasal obstruction also impairs CPAP tolerance, as the device cannot function effectively against a partially blocked nasal passage.
Septoplasty (correction of the deviated septum) and turbinoplasty (reduction of enlarged inferior turbinates, including by radiofrequency ablation) may be included in the surgical plan for OSA patients with documented nasal obstruction. These procedures are performed as part of a coordinated airway approach — not as standalone interventions, but as one component of a comprehensive treatment plan.
It is important to note that nasal surgery alone rarely cures OSA. Its role is to optimise nasal airflow, improve CPAP tolerance where relevant, and reduce overall upper airway resistance as part of a multi-level strategy.
Soft Palate and Oropharyngeal Surgery: A Multidisciplinary Decision
Palatal and oropharyngeal obstruction — collapse at the level of the soft palate, tonsillar pillars, or tongue base — is a common finding on DISE. In selected patients, addressing this level surgically can meaningfully improve outcomes, either as a complement to MMA or, in milder cases, as a primary intervention.
Not all palatal procedures are equivalent. The classical UPPP (uvulopalatopharyngoplasty), which removes uvular and palatal tissue, has a modest and unpredictable effect on AHI and is no longer considered the standard of care for OSA in most centres. Suspension techniques — pharyngoplasties that reposition and tension the lateral pharyngeal walls rather than simply reducing tissue volume — offer more consistent results at the palatal level and are the preferred approach where oropharyngeal surgery is indicated.
At FACES.pt, oropharyngeal and tonsillar surgery is approached as a genuinely collaborative endeavour. Cases with significant pharyngeal obstruction are discussed with ENT colleagues, who participate in or lead the surgical management of these components. This model reflects both the complexity of the airway and the importance of bringing together different areas of surgical expertise.
The Multidisciplinary Team
Sleep apnoea is not a condition that any single specialty owns. Its effective management requires close coordination between sleep physicians, maxillofacial surgeons, ENT surgeons, and — where relevant — orthodontists, dentists prescribing oral appliances, and physiotherapists.
At FACES.pt, surgical candidates are evaluated within a multidisciplinary framework. Polysomnography and clinical sleep medicine assessments are performed by specialist sleep physicians prior to any surgical planning. Surgical decisions are made in full possession of objective sleep study data, and post-operative follow-up includes repeat sleep studies to confirm treatment outcomes.
Referrals come from a range of sources — pulmonologists, sleep clinics, dentists, physiotherapists, and directly from patients who have researched their options or been recommended by friends and family members who underwent similar treatment. This diversity of referral pathways reflects the breadth of the condition and the range of patients who may benefit from a surgical evaluation.
[IMAGE 4 — lateral profile photograph, clinical case with consent]
Who Is a Candidate for MMA Surgery?
MMA surgery is not appropriate for every patient with OSA, and careful patient selection is essential to achieving good outcomes. The ideal candidate typically presents with one or more of the following:
- CPAP intolerance — documented failure or persistent non-adherence despite adequate support, with moderate to severe OSA confirmed on polysomnography
- Skeletal anomaly — retrognathia or micrognathia, in which the jaw position is a direct anatomical contributor to pharyngeal narrowing
- Younger patients seeking a permanent resolution, who wish to avoid lifelong dependence on a device
- Refractory OSA — persistent significant disease despite other treatments
Patients with significant excess weight are strongly advised to lose weight before surgery — in many cases this is a near-mandatory prerequisite, as obesity independently worsens OSA and reduces the outcomes of surgical treatment. Age, systemic health, anaesthetic fitness, and patient expectations are all factored into the decision.
A thorough assessment — including clinical examination, cephalometric imaging, sleep study results, and often DISE — is the basis for any surgical recommendation. No two cases are identical, and the plan is always built around the individual.
Recovery After MMA Surgery
MMA surgery is a major procedure performed under general anaesthesia, and recovery requires planning and realistic expectations. Patients typically remain in hospital for one to two nights following surgery. Swelling tends to reduce significantly after the first two weeks, though three to six months are needed to appreciate the final aesthetic result.
Diet begins with liquids for the first two days, progressing to a soft consistency — including well-cooked rice and pasta, finely minced meat, and fruit purée — for four to six weeks while the bone consolidates. Most patients return to desk-based work within two to three weeks, though physical exertion should be avoided for six to eight weeks. Temporary numbness of the lips, chin, and teeth is common and usually resolves progressively over weeks to months as nerve function recovers.
Post-operative sleep studies are performed at three to six months to objectively document the change in AHI and confirm the treatment outcome. Most patients report a dramatic improvement in sleep quality, daytime energy, and overall well-being — often noting that the change becomes apparent even before the formal sleep study.
Each case is unique and must be individually assessed in a medical consultation, with realistic expectations discussed in detail before any commitment to surgery.
Considering surgery for sleep apnoea?
If you have been diagnosed with obstructive sleep apnoea and CPAP has not worked, if you are looking for a solution that does not involve sleeping with a machine, or if you suspect that the shape of your face may be contributing to your breathing difficulties — a surgical evaluation at FACES.pt may be the right next step.
Each case is unique and must be assessed in person by a doctor, considering clinical examination, imaging, and individual history. The information presented here is strictly educational and does not substitute for an individual medical consultation.
Article reviewed by Dr. Miguel Lopes Oliveira, MD, DDS, Maxillofacial Surgeon, Faces Facial Surgery, Lisbon and Évora.