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Subjective success is based on comparative improvement in snoring level, daytime sleepiness, and overall well-being. Patients who underwent ZPP were compared with patients who had previously undergone UPPP for the treatment of OSAHS. The results achieved were far superior with ZPP, particularly with adjunctive TBRF. Quality-of-life scores improved significantly more often after ZPP than after UPPP [4]. When focusing on objective success, ZPP showed considerable improvement over UPPP. Objective cure rates for stage II patients treated with ZPP and TBRF were close to 70%, compared with about 30% for classic UPPP with TBRF.

Limitations of this technique include a higher risk of temporary VPI, owing to a more aggressive modification of the palatal anatomy even though the resection is limited to the mucosa. While VPI is usually temporary, should permanent VPI ensue, ZPP is probably not reversible. There are also no clear anatomic landmarks to assist in describing the size of the flaps, and ultimately the guidelines outlined in this chapter do not substitute for the surgeon's judgment. The procedure is significantly more difficult technically, and it takes longer to perform. A learning curve, as with any other procedure, leads to progressively better results.

The treatment, like any other, may fail. Failure can be defined as a persistence of symptoms, which demands additional treatment. Failure also occurs when symptoms of snoring and daytime sleepiness are eliminated, but polysomnography scores still indicate persistent disease. Typically, patients who fail will show a pattern of elimination of apneas, with persistent hypopneas. Failure in achieving satisfactory results may in some cases convince the patient to accept CPAP therapy. When CPAP is not accepted by the patient, further evaluation and treatment are essential. The first step should be a thorough investigation in order to identify the site of failure. Sleep endoscopy evaluation may be a valuable test at this point. If the level of obstruction continues to be retropalatal, a transpalatal advancement pharyngoplasty can be considered [10]. If the persistence of obstruction is at the tongue base or hypopharyngeal level, genioglos-sus advancement alone or in combination with thyro-hyoid suspension could be an option [11]. Bimaxillary advancement should be kept in mind as a second-line procedure as well, if the above interventions fail. This procedure will correct failures both at the retropala-tal and the retrolingual levels [12].

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