Resident education center · Ryan Nord, MD

BRP surgical technique, step by step

Learn the key steps of barbed reposition pharyngoplasty (BRP), the palate operation that releases the palatopharyngeus and repositions it laterally and anteriorly with a knotless barbed suture anchored to the pterygomandibular raphe. Each step includes key learning points, from the basics to more advanced considerations. The complete operation on video and clips from my teaching collection illustrate the technique, and questions help you test your understanding.

9 lessons · the complete operation on video · 11 clips · 7 photographs

First case tomorrow? Start with the release →Watch the whole operation →Pre-case review →
The case, step by step

0 of 9 lessons reviewed

Lesson 01About 8 minBRP

Indications for BRP

Use the DISE, the oral exam, and the patient’s place on the hypoglossal nerve stimulation pathway to answer the question: “Why BRP for this airway?”

The complete operation

The complete operation Ryan Nord, MD · 6:55 · Silent · Written viewing guide

Watch for: The order of the case: both tonsils out with the pillars intact, both palatopharyngeus muscles released before the first barbed pass, and every pass taken around the muscle rather than through mucosa alone. Compare the lateral width and the mirror view behind the palate at the start and at the end.

Chapters

  1. 0:00Uvula trimLesson →
  2. 0:07Tonsillectomy, right then leftLesson →
  3. 1:15Baseline mirror view and injectionLesson →
  4. 1:29Palatopharyngeus release, right then leftLesson →
  5. 2:36Needle-point Bovie windowsLesson →
  6. 3:04Barbed suture to each lateral windowLesson →
  7. 3:26Passes around the right palatopharyngeusLesson →
  8. 4:59Passes around the left palatopharyngeusLesson →
  9. 5:52Closing the top of the repairLesson →
  10. 6:47Final airway and mirror viewLesson →

Silent and condensed from the full case. Surgeon’s view from the head of the bed: the mouth-gag blade is at the top, and the patient’s right is on the right of the image.

Before you enter the room

  1. Review the sleep study and prior treatment. Confirm the presence and severity of OSA on a sleep study before surgery, and note the AHI, oxygenation, positional pattern, and hypopnea definition. Know what the patient has tried, including CPAP, an oral appliance, and hypoglossal nerve stimulation, and why each did not work.
  2. Read the DISE by site and pattern. Describe the velum, oropharyngeal lateral walls, tongue base, and epiglottis, with the degree and configuration at each site. BRP treats collapse at the velum and the oropharyngeal lateral walls; it does not treat the tongue base or the epiglottis.

    In a randomized trial of DISE-based selection for BRP, patients chosen with DISE met Sher criteria for success in 83% of cases, versus 60% of patients chosen by awake examination alone. DISE removed 18 of 60 awake-exam candidates (30%) because of tongue-base, epiglottic, or multilevel collapse, or positional sleep apnea.

    Read that result with its limits. The trial was unblinded, and the 18 patients DISE excluded were dropped rather than analyzed by intention to treat, which favors the DISE arm. A 2024 systematic review across procedures called the evidence that DISE improves surgical outcomes “mixed.”

    Related research: Iannella et al. (2022): BRP with and without preoperative DISE

  3. Match the findings to the indication. Dr. Nord’s typical BRP indications, as he lists them, are palatal complete concentric collapse (CCC); no tongue-base or epiglottic collapse (T0E0); and an AHI above 15 after hypoglossal nerve stimulation with palatal and/or lateral-wall collapse.

    CCC is the velum closing in from all sides in the shape of a funnel. It excludes hypoglossal nerve stimulation under current U.S. criteria, so palate surgery is often the way forward for these patients. Read the pattern carefully: in one series, most patients with anteroposterior palatal collapse plus lateral-wall collapse had first been labeled CCC.

    T0E0 is VOTE shorthand for a tongue score of 0 and an epiglottis score of 0. It means the obstruction is confined to the velum and the oropharynx, which is where BRP works.

    Related research: Van de Perck et al. (2022): concentric versus anteroposterior-laterolateral palatal collapse

  4. Grade tongue position and tonsil size. Grade Friedman tongue position with the tongue resting inside the mouth, not protruded as for the anesthesia Mallampati. Ask the patient to open wide without sticking out the tongue, repeat the exam five times, and assign the most consistent grade.

    Grade I shows the entire uvula and the tonsils or pillars; grade II, the uvula but not the tonsils; grade III, the soft palate but not the uvula; grade IV, the hard palate only. Friedman tonsil size runs from 0 (removed) to 4 (to the midline). Many centers use the Brodsky scale instead, so say which one you are reporting.

    Large tonsils, a smaller tongue: that combination predicts a better palate-surgery result. Friedman stage I is tongue position I or II with tonsil size 3 or 4 and a BMI below 40; stage III is tongue position III or IV with tonsil size 0 to 2, along with any patient whose BMI is above 40. In Friedman’s staging series, UPPP succeeded in 80.6% of stage I, 37.9% of stage II, and 8.1% of stage III patients. Those figures come from UPPP, not BRP, so use them for the principle rather than as BRP success rates. BRP is done less often after a prior tonsillectomy, and the DISE trial excluded those patients.

    Related research: Friedman et al. (2002): the original Friedman staging

  5. Weigh BMI and the skeletal frame. Higher BMI lowers the odds of success after pharyngeal surgery. The BRP evidence comes mostly from patients with a BMI of 35 or less: both the multicenter series and the DISE trial capped enrollment there.

    No BMI cutoff is proven. Friedman called his limit of 40 “somewhat arbitrary,” and the 2023 International Consensus Statement on Obstructive Sleep Apnea calls a BMI of 40 or more a poor predictor of success while advising that, below that, other clinical and anatomic features be weighed before surgery is ruled out.

    Look for findings that place the obstruction elsewhere: pronounced macroglossia, Friedman tongue position III–IV, marked tongue-base hypertrophy, or retrognathia. Expert consensus holds that these patients may not benefit from isolated palate surgery.

  6. Place BRP among the palate operations. Classic UPPP, which removes the uvula and part of the palate, is not the typical technique used today. ESP and BRP share one goal: mobilize the palatopharyngeus to expand the oropharyngeal airway and relocate the palate anteriorly.

    ESP rotates the divided palatopharyngeus superolaterally and fixes it with a single suture. BRP suspends the muscle from the pterygomandibular raphe with a barbed suture passed around it in multiple loops, so the tension is spread along its length.

    On outcomes the two are comparable. A 2021 meta-analysis found no significant difference in AHI change between BRP and ESP, and BRP took about 22 minutes less operating time. It pooled four retrospective cohorts with 208 patients, so it does not show that either operation is better.

    Related research: Neruntarat et al. (2021): BRP versus ESP meta-analysis

  7. Plan the staged pathway with HGNS. BRP and hypoglossal nerve stimulation are often steps in one plan. In palatal CCC, BRP treats the apnea and is often the first stage: repeat the sleep study and DISE after healing, and offer HGNS if apnea persists and the collapse pattern now qualifies.

    In a retrospective eight-center series of barbed pharyngoplasty in CCC (48 patients, most of them BRP; 22 also had tongue-base or epiglottic surgery), AHI fell from 34.9 to 12.7 and 86.7% met Sher criteria. That series did not repeat DISE after surgery. Conversion of CCC to a qualifying pattern has been shown after UPPP with tonsillectomy, ESP, and a tissue-preserving palatopharyngoplasty, but not yet in a BRP-specific study, so do not promise conversion.

    The pathway also runs the other way. A patient who uses the stimulator every night at comfortable settings but keeps an AHI above 15, with palatal and/or lateral-wall collapse, has an anatomic problem, not an adherence problem. BRP treats the palate and the lateral walls, and the stimulator is restarted after recovery.

    Related research: Castillo-Farias et al. (2022): barbed pharyngoplasty in complete concentric collapse

  8. Quote outcomes you can defend. In the benchmark multicenter series (111 patients, 15 centers), mean AHI fell from 33.4 to 13.5 six months after BRP. Seventy-three percent met a success definition that adds an Epworth score below 10 to Sher’s criteria, and 62% met a stricter tier the authors labeled “no more CPAP needed” (AHI below 15).

    Success is not cure. About a quarter of that series did not meet the definition of success, and most BRP studies follow patients for only six to twelve months, so long-term data are limited. In the DISE trial, the 83% Sher success fell to 54% at an AHI below 10 and 21% at an AHI below 5. Say which definition a number uses.

    Related research: Montevecchi et al. (2018): the 15-center BRP series

  9. Counsel before consent. Before the patient signs, state the recovery and the common problems: severe pain for up to two weeks, at least one night in the hospital, early trouble swallowing, a roughly one-in-five chance of suture extrusion, and, for many patients, a repeat sleep study and DISE as part of a staged plan.

    Suture extrusion: in the largest dedicated study (488 patients) it occurred in 18%, more often with V-Loc than with Stratafix, and more than a third of extrusions caused no symptoms. The exposed end is trimmed in clinic, and extrusion did not change the result.

    Swallowing, bleeding, and the first nights: transient dysphagia affected 21% of the multicenter series, and 1.8% needed a return to the operating room for bleeding. Apnea is often transiently worse for the first nights while swelling peaks, so plan for those nights before surgery, including CPAP for patients who use it.

    Related research: Gulotta et al. (2021): barbed suture extrusion in 488 patients

Dr. Nord’s teaching

  • Read the DISE by site, degree, and configuration before choosing the operation. BRP treats the velum and the oropharyngeal lateral walls, not the tongue base or the epiglottis.
  • Grade Friedman tongue position with the tongue resting in the mouth. Large tonsils, a smaller tongue predict a better palate-surgery result.
  • BRP and ESP perform similarly in the head-to-head data. The choice comes down to technique and experience, not a proven outcome gap.
  • After a partial stimulator response with nightly use at comfortable settings, think anatomy, not adherence: BRP treats the palate and lateral walls, and the stimulator is restarted after recovery.
  • In palatal CCC, present BRP as treatment and often as the first stage before hypoglossal nerve stimulation.

Pitfalls

  • Grading tongue position with the tongue protruded, which gives the anesthesia Mallampati rather than the Friedman grade.
  • Offering BRP alone when DISE shows tongue-base or epiglottic collapse. Palate surgery does not treat those sites.
  • Assuming that mild OSA alone makes a good palate-surgery candidate. Friedman’s group called that a “common misconception”: severity does not tell you who will respond.
  • Quoting Sher success or a pooled meta-analysis rate to a patient as if it meant cure.
  • Telling a patient that BRP is proven better than ESP, or that BRP reliably converts CCC so that stimulation becomes possible.

Before moving on: Explain why BRP fits this airway using the DISE findings, Friedman tongue position and tonsil size, BMI, and the patient’s place on the stimulation pathway, then state the counseling points a patient needs before consent.

Check your reasoning

1. A CPAP-intolerant patient asks about Inspire. DISE shows complete concentric collapse at the velum and complete lateral-wall collapse, with no tongue-base or epiglottic collapse. What do you recommend?
2. A patient with a hypoglossal nerve stimulator uses it every night at comfortable, titrated settings. The AHI remains above 15, and DISE shows palatal and lateral-wall collapse. What is the problem, and what is the next step?
3. You are grading Friedman tongue position in clinic. How should the patient hold the tongue?

Published references for this lesson
Lesson 02About 7 minBRP

Setup, fire safety, and exposure

Run a time-out that states the airway-fire risk, confirm the barbed suture is in the room, and suspend the mouth gag for a view that lasts the whole case. Then have the instrument for each part of the operation ready, and set up the camera if the case is being filmed.

Instruments for the case

Review the setup with the scrub team before the case. Each part of the operation has its own instrument; have these ready.

  • Exposure. A mouth gag with suspension, and a bigger blade on hand in case the view is short.
  • Camera. When the case is filmed: the endoscope camera, focused down the gag from the head of the bed.
  • Uvula and tonsils. A curved Allis for the uvula; in the case shown, a curved Allis-type grasper also holds each tonsil in medial traction. DeBakey forceps: “We’re going to need the DeBakey later,” so keep them on the field.
  • Energy and hemostasis. The BiZact, a bipolar tissue-sealing device, for the palatopharyngeus release. In the case shown, it also trims the uvula and dissects both tonsils. A needle-point Bovie for the mucosal windows the barbed suture uses, and for a relaxing incision if one is opened. Suction, and a suction Bovie available for bleeding the BiZact does not control.
  • Local anesthetic. Bupivacaine (Marcaine) in a syringe with a needle, injected into both fossae once the tonsils are out and before the release.
  • Barbed suture. Two 3-0 V-Loc sutures on V-20 needles (26 mm, 1/2-circle taper), with their loops linked into one bidirectional suture. Either the 18-inch or the 9-inch length works. A straight needle driver for the barbed passes.
  • Closing stitch. Vicryl for the single closing stitch once the barbed part is done.
  • Airway check. A mirror with anti-fog to look behind the palate, and a paper ruler to measure the lateral and anteroposterior airway before and after the repair.

Work through the steps

  1. State the fire risk at the time-out. Name the operation at the time-out and state that the fire risk is high: the cautery works in the oral cavity beside the endotracheal tube. Confirm with anesthesia that the inspired oxygen (FiO2) is down before any cautery starts.

    The time-out also states the expected length of the operation, about an hour, and the expected blood loss.

  2. Confirm the barbed suture. Confirm the barbed suture is in the room before you begin. Dr. Nord uses two 3-0 V-Loc sutures on V-20 needles and links their loops into one bidirectional suture, with a needle at each end.

    Either the 18-inch or the 9-inch length works. Published techniques vary: the original description used a single size 0 bidirectional polydioxanone suture, and later series use 2-0 or 3-0 barbed thread.

    Related research: Vicini et al. Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study

  3. Bring the patient up the bed. Bring the patient up toward the head of the bed, keeping the tube connected as the patient moves, so the head sits where the gag can be suspended.

    The original BRP description placed the patient supine and orally intubated, with an inflatable bag under the shoulders to keep the head extended, and exposed the field with a Boyle–Davis mouth gag and lateral cheek retractors.

    Related research: Vicini et al. Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study

  4. Suspend the gag. Place the mouth gag and suspend it for a view that lasts the whole case. If the view is short, change to a bigger blade rather than working through a limited exposure.

    Keep an eye on the gag position through the case. A systematic review of 769 patients after barbed pharyngoplasty recorded one chipped tooth from mouth-gag displacement.

    One published tips paper recommends changing your visual angle between the tonsillectomy and the BRP, for a better view and easier movements.

    Related research: Cammaroto et al. Barbed repositioning pharyngoplasty: tips and tricks

  5. Set up the camera when the case is filmed. Dr. Nord films some BRP cases for teaching, with an endoscope camera looking down the gag from the head of the bed. When the case is being filmed, position the camera, focus it, and start recording before the first cut.

    He films some cases to teach. In a transoral case the surgeon’s head is in the way of anyone else trying to see, and the operation is much easier to follow on video.

    Every clip in this center uses that view: the gag blade at the top of the frame, the soft palate and uvula at the bottom, and the patient’s right on image right.

  6. Ask for the right instrument at each part. Each part of the operation has its own instrument: a curved Allis for the uvula, the BiZact for the muscle release, the needle-point Bovie for the mucosal windows (and for a relaxing incision, if you make one), and a straight needle driver for the barbed passes. Keep instruments you will need later, such as the DeBakey forceps, on the field.

    Have the mirror, anti-fog, and paper ruler ready before the tonsils come out.

Dr. Nord’s teaching

“You’re trying to look in the mouth while someone else’s head is in there, so it’s one of those things that’s much easier to see kind of on a video than it is to try to put your head in there.”

  • “Let me switch out to the bigger one.” Fix a short view before the first cut; it has to last until the final look behind the palate.
  • The fire risk starts with the first cut: from the uvula trim on, every energy device works beside the tube.
  • “We’re going to need the DeBakey later.” Keep instruments for later steps on the field.

Pitfalls

  • A gag that shifts during the case and goes unnoticed until the view is lost or a tooth is chipped.
  • Finding out after the tonsils are out that the barbed suture is not in the room.
  • Clearing the DeBakey off the field after the tonsils, then waiting for it later in the case.
  • Reading the clips as mirrored: image right is the patient’s right.

Before moving on: Before the first cut, confirm that anesthesia has the inspired oxygen down, the barbed suture is in the room, and the gag is suspended with a view that will last the case.

Check your reasoning

1. At the time-out for a BRP, what should the team establish before any cautery?
2. After suspension, the blade leaves a short view and the lower poles of the tonsils are hard to see. What do you do?
3. Which suture setup matches Dr. Nord’s practice for BRP?

Published references for this lesson
Lesson 03About 8 minBRP

Uvula trim and tonsillectomy

Trim a long uvula without removing it, then take the right tonsil and then the left in the capsular plane. Keep both pillars and the palatopharyngeus intact, because the posterior pillar muscle is what you will release and reposition, and keep each fossa dry as you go.

Work through the steps

  1. Treat the tonsillectomy as exposure. In BRP the tonsillectomy is not a stand-alone procedure. It exposes the palatopharyngeus in the posterior pillar, the muscle you will release and reposition, so every decision in the fossa is made with the next step in mind.

    When the tonsils are already out, the multicenter series exposed the muscle by superficial removal of the mucosa over it; another group uses a vertical incision in the mucosa over the palatopharyngeus.

    Related research: Montevecchi et al. (2018): the tonsillectomy exposes the palatopharyngeus

  2. Trim a long uvula; never remove it. A long uvula may be partially trimmed, but it is never removed completely, and not every patient needs a trim. Hold the tip with a curved Allis, take only the distal uvula, and leave a sealed stump.

    Dr. Nord trims first, before the right tonsil, as the clip in the next step shows. One published technique instead trims after the tonsillectomy but still before the palatal work, so the uvula’s actual size can be judged before surgical edema changes it. Either way, decide on the trim before the palatal work.

  3. Retract medially and stay on the capsule. Start with the right tonsil. Grasp it and pull it medially, toward the midline, then dissect along the capsule so the tonsil comes away from the fossa and leaves the muscle behind.

    The view is from the head of the bed, with the gag blade at the top of the image and the palate at the bottom; the patient’s right is on the right of the image. The clip opens with the uvula trim, then takes the right tonsil and, after it, the left. Watch the medial traction, the dissection along the capsule, and the specimen coming out whole.

    Stay on the capsule rather than in the superior pharyngeal constrictor, which forms the lateral wall of the fossa. Beyond it, the external carotid runs about 1.8 cm and the internal carotid about 2.1 cm (at the C2–3 level) from the lateral pharyngeal wall, and in about 5% of people the internal carotid is aberrantly close to, or even behind, the pharynx.

    Uvula trim and tonsillectomy 1:12 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: The partial uvula trim, then the medial traction on each tonsil while the dissection follows the capsule. Both pillars stay intact, because the posterior pillar muscle is what you will reposition.

    Written video guide
    • 0:00–0:07: The tip of a long uvula is lifted and trimmed. A sealed stump remains; it is a trim, not a removal.
    • 0:07–1:02: Right tonsil. The grasper pulls the tonsil medially while the BiZact works along the capsule. The anterior and posterior pillars stay intact, and the tonsil comes out whole at about 1:00.
    • 1:02–1:12: Left tonsil, with the same technique and the instruments switched to the other hands.

    Source: Ryan Nord, MD. Cut from the complete operation at 0:00–1:12.

    Related research: Olszewska and Woodson (2019): constrictor and carotid distances

  4. Keep both pillars intact. Preserve the mucosa of the anterior and posterior pillars and the muscle beneath them. Do not take a strip of pillar to speed the dissection or to tidy the fossa.

    The original BRP description calls sparing as much pillar mucosa as possible “the most important trick” of the tonsillectomy step, with meticulous sparing of the palatoglossus and palatopharyngeus. The same group later adds that a conservative tonsillectomy, sparing the pillar muscles and mucosa, helps avoid postoperative bleeding and gives optimal healing and scarring, and that the mucosa is an important landmark for passing the barbed suture through the posterior pillar.

    Related research: Vicini et al. (2015): spare the pillar muscles and mucosa

  5. Control bleeding as you go. Keep the fossa dry while you dissect, sealing vessels with bipolar energy (in the case shown, the BiZact) as you meet them. The best result is a fossa in which blood does not reach the end of the suction tube.

    Dr. Nord grades bleeding control in four categories. None or minimal: “Blood does not reach the end of the suction tube.” Moderate: “Controlled with the BiZact.” Substantial: “Required the suction Bovie.” Poorly controlled: “Substantial bleeding (arterial, a pumper, or spray onto the gown); required suturing; required the attending to scrub in to control it; or bleeding on wake-up.”

    Teaching in the OR, he points to “a good demonstration of using the bipolar to control bleeding,” and describes the dissection as having “kind of a bloodless feel.” Cammaroto and colleagues also advise managing the vessels of the upper tonsillar pole with careful bipolar or monopolar cautery.

    Related research: Cammaroto et al. (2024): conservative tonsillectomy and the upper pole

  6. Take the left side, then send the tonsils. Repeat the same capsular dissection on the left, with the instruments switching hands. The tonsils go to pathology, sent separately; the trimmed uvula tip does not.

    Before moving on to the injection and the release, look at both fossae: anterior and posterior pillars intact, no active bleeding, and a uvula that has been trimmed, not removed.

Dr. Nord’s teaching

“It’s a little bit more challenging, but looks like we’re in a better plane here.”

  • Trim only the tip of a long uvula, never the whole uvula, and not in every case; the tip is discarded, and only the tonsils go to pathology, sent separately.
  • Right tonsil, then left: medial traction and dissection along the capsule.
  • Preserve the anterior and posterior pillar mucosa and the palatopharyngeus. The posterior pillar muscle is what you will release and reposition, so an injured pillar leaves less to work with.
  • Keep the fossa dry as you go. At best, blood does not reach the end of the suction tube.

Pitfalls

  • Removing the whole uvula, or trimming one that is not long.
  • Tearing or stripping pillar mucosa, which leaves less palatopharyngeus to reposition and loses the landmark for the barbed passes.
  • Dissecting through the capsule into the superior constrictor, toward the carotid branches that lie close to the lateral pharyngeal wall.
  • Moving on to the release with an oozing fossa instead of sealing vessels as you meet them.

Before moving on: Show both empty fossae with the anterior and posterior pillars intact, no active bleeding, and a uvula that has been trimmed, not removed, before the injection and the release.

Check your reasoning

1. Your patient has a long uvula. How does Dr. Nord handle it in BRP?
2. Partway through the right tonsillectomy, taking a strip of posterior pillar mucosa would make the dissection faster. Why preserve it?
3. Bleeding in the right fossa reaches the end of the suction tube, and you stop it with the BiZact alone. The suction Bovie is not needed, and no suture is placed. How does Dr. Nord grade this bleeding control?

Published references for this lesson
Lesson 04About 9 minBRP

Inject, then release the palatopharyngeus

Once both tonsils are out, take a baseline look behind the palate and inject bupivacaine. Then free each palatopharyngeus from the superior constrictor so it can reach the raphe without tension, and finish both sides before the first barbed pass.

Work through the steps

  1. Take the baseline view, then inject. With both tonsils out, pass an anti-fogged mirror behind the soft palate and note how much space there is before anything moves; this is the view you will compare against at the end. Then inject bupivacaine into both fossae, after the tonsillectomy and before the BRP part begins.

    The aim of the injection is less pain in the first days after surgery. One randomized trial used a related long-acting agent: in 50 men undergoing UPPP, preincisional submucosal ropivacaine reduced morphine use through the first 48 hours. Timing varies between groups. Cammaroto and colleagues, from Vicini’s group, recommend a topical spray before starting and a final injection of local anesthetic at the end of the case; here the injection comes once the fossae are open and before the release.

    Baseline mirror view and bupivacaine injection 0:14 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: Note how much space the mirror shows behind the soft palate before any repair; you will compare it with the same view at the end. The injection comes after both tonsils are out and before the release.

    Written video guide
    • 0:00–0:05: Both fossae are empty and the pillars are intact. A mirror passed behind the soft palate shows the baseline space.
    • 0:05–0:14: A fine needle injects the right fossa, then the left at about 0:10, before the release begins.

    Source: Ryan Nord, MD. Cut from the complete operation at 1:15–1:29.

    Related research: Li et al. (2014): preemptive ropivacaine infiltration for UPPP

  2. Identify the palatopharyngeus and its neighbors. The palatopharyngeus is the muscle of the posterior tonsillar pillar. Its dorsal and ventral fasciculi lie medial to the superior pharyngeal constrictor in the oropharynx and combine into the band you see in the pillar. The constrictor lies lateral and deep to it in the fossa, and the pterygomandibular raphe lies further lateral still; the raphe is where the muscle will be anchored.

    Respect what lies beyond the constrictor. Olszewska and Woodson place the glossopharyngeal nerve deep to the superior constrictor, with the landmark for its main trunk where the posterior tonsillar pillar meets the tongue base.

    Grayscale illustration of the pharynx viewed from behind, with the soft palate and uvula hanging above the tongue and epiglottis. On one side the muscles are dissected and labeled: palatal aponeurosis, levator veli palatini, salpingopharyngeus, the superior pharyngeal constrictor as a broad sheet on the outer wall, the transverse fascicle of the palatopharyngeus, the uvular muscle, and the dorsal and ventral fasciculi of the palatopharyngeus running down the lateral wall. The palatine tonsil is labeled on the opposite side.

    The palatopharyngeus and the superior constrictor

    The palatopharyngeus fasciculi run down the lateral pharyngeal wall on the medial side of the superior pharyngeal constrictor. The release opens the plane between them: the palatopharyngeus comes away, and the constrictor stays in place. Reproduced without modification.

    Source: Olszewska E, Woodson BT. Laryngoscope Investig Otolaryngol. 2019;4(1):181-187, Figure 2. Olszewska and Woodson, Palatal anatomy for sleep apnea surgery (open-access article). License: CC BY-NC-ND 4.0. View full-size image

    Related research: Olszewska and Woodson (2019): palatal anatomy for sleep apnea surgery

  3. Test the tension toward the raphe. Grasp the palatopharyngeus and pull it toward the pterygomandibular raphe to see how much it resists. A tight band means the release has to go further for a tension-free closure.

    Repeat the test as you release. Cammaroto and colleagues describe moving the muscle medially and laterally with forceps, laying it over the anterior pillar, to confirm it moves without significant tension.

    Related research: Cammaroto et al. (2024): BRP tips and tricks

  4. Release the right palatopharyngeus. Pull the right palatopharyngeus medially with forceps and use the BiZact to free it from the superior constrictor on its lateral side, then divide its inferior part, so the muscle can move to the raphe without tension. The constrictor itself is not cut.

    In the clip, the forceps hold the posterior pillar medially while the BiZact divides its lateral attachment. Near the end, red constrictor fibers remain deep in the fossa.

    The release is what lets the palate move. Vicini’s original description planned the inferior release for an easier, more stable repositioning of the posterior pillar laterally and anteriorly without significant tension. It treats the anterior pillar, posterior pillar and soft palate as a tripod: releasing the posterior leg shifts the whole soft palate forward.

    Release the right palatopharyngeus 0:39 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: The posterior pillar muscle pulled medially as a band while its lateral attachment is divided. The pillar mucosa stays on the muscle, and the constrictor in the fossa bed is not cut.

    Written video guide
    • 0:00–0:21: Forceps pull the right palatopharyngeus medially while the BiZact divides its lateral attachment.
    • 0:21–0:39: After a short edit, the division continues deep in the fossa. The pillar mucosa stays on the muscle, and the muscle is now mobile.

    Source: Ryan Nord, MD. Cut from the complete operation at 1:29–2:13, with a brief camera movement removed.

    Related research: Vicini et al. (2015): the original BRP description

  5. Spare the constrictor and the pillar mucosa. Keep the release in the plane between the palatopharyngeus and the constrictor, and leave the posterior pillar mucosa on the muscle. In Vicini’s original description, the pillar mucosa is not dissected free but follows the muscle as it is repositioned, giving immediate mucosal closure.

    Cahali’s lateral pharyngoplasty, which he described as the first technique to manipulate the superior constrictor directly, cut part of that muscle, and swallowing difficulty was its most troublesome effect. BRP repositions the palatopharyngeus instead; in the original BRP series, no constrictor section was necessary.

    Related research: Cahali (2003): lateral pharyngoplasty

  6. Release the left side the same way. Repeat the tension test and the release on the left. The device and forceps switch sides; the plane and the end point are the same.
    Release the left palatopharyngeus 0:21 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: The same release on the left, with the instruments switched. The clip ends on an overview: both sides are released before any suture is placed.

    Written video guide
    • 0:00–0:19: The left palatopharyngeus is pulled medially and freed laterally, mirroring the right side.
    • 0:19–0:21: Overview: both tonsils out and both muscles released, before the first barbed pass.

    Source: Ryan Nord, MD. Cut from the complete operation at 2:15–2:36.

  7. Finish both sides before the first barbed pass. Complete the release on both sides before any suture goes in. Muscle left tethered to the constrictor makes the barbed suture hold the closure under tension instead of repositioning the muscle.

    The needle-point Bovie openings the suture uses, and the order in which they can be made, are covered in the next lesson.

    Endoscopic surgeon’s view with the mouth-gag blade and tongue at the top, molars in the upper corners, and the oral surface of the soft palate across the lower half, with the trimmed uvula at the center of its free edge. Two open, bloody tonsillar fossae lie on either side of the posterior pharyngeal wall, bordered by intact pillar mucosa.

    Both sides released, before the first suture

    Both tonsils are out and both palatopharyngeus muscles have been released; no suture has been placed. This is the field the barbed suture starts from. Compare the open fossae here with the closed, lateralized pillars at the end of the case.

    Source: Ryan Nord, MD. View full-size image

Dr. Nord’s teaching

“Check muscle tension by pulling the PP towards the raphe. Release the PP from the constrictor laterally to ensure tension-free closure.”

  • Consider using a BiZact for the release.
  • Let the forceps open the plane: pull the posterior pillar toward the midline so the palatopharyngeus comes away from the constrictor, then release it laterally with the BiZact.
  • Inject bupivacaine after the tonsillectomy, before the BRP part. Your PACU nurses will thank you.
  • Release the right side, then the left, and finish both before the first barbed pass.

Pitfalls

  • Cutting into the superior constrictor. It is the plane you release from, not a structure you divide, and the glossopharyngeal nerve lies deep to it.
  • Stripping the posterior pillar mucosa off the muscle. The mucosa should move with the palatopharyngeus and close over the fossa.
  • Judging the release by eye instead of pulling the muscle toward the raphe.
  • Starting the barbed suture while either palatopharyngeus is still tethered to the constrictor.
  • Injecting into a vessel. Li and colleagues warn that in head and neck surgery, inadvertent intravascular injection of a long-acting local anesthetic, or injection into highly vascular tissue, carries a risk of central nervous system and cardiac toxicity.

Before moving on: Before the first barbed pass, show that each palatopharyngeus reaches the raphe without tension, with the superior constrictor and the posterior pillar mucosa intact.

Check your reasoning

1. You have released the right palatopharyngeus. When you pull it toward the raphe, it still springs back as a tight band. What do you do next?
2. In the sequence taught here, when is bupivacaine injected?
3. As you release the palatopharyngeus, which structure do you separate it from, leaving that structure in place deep in the fossa?

Published references for this lesson
Lesson 05About 8 minBRP

Open the suture windows and anchor at the raphe

Link two barbed sutures into one bidirectional suture, open a midline window and a lateral window on each side with the needle-point Bovie, and carry each arm out to its lateral window. Every lateral pass anchors in the raphe and goes back in through the same hole.

Work through the steps

  1. Link the two barbed sutures. Use two 3-0 V-Loc V-20 sutures and link their loops into one bidirectional suture, with a needle at each end, one for each side of the palate. Pass one needle through the loop of the opposite suture, then take the same needle back through its own loop, and pull: the link draws down into a knot.

    Pull it down and, in Dr. Nord’s words, “it should just come into a knot there.”

  2. Find the raphe. The pterygomandibular raphe is the lateral anchor for the whole repair: a fibrous band running from the pterygoid hamulus to the mandible, anterior and lateral to the posterior pillar. In the original description, the raphe is located on both sides by digital palpation and marked before the first pass.

    Its position sets the pull vector. Anchored there, the palatopharyngeus widens the oropharyngeal inlet transversely and brings the lateral palate forward, which enlarges the retropalatal space. It is the same point you pulled the palatopharyngeus toward when you checked its tension before the release.

    The raphe is fibrous and stable, which is why BRP anchors there rather than in the weaker palatoglossus. The original description calls it easy to locate, best by palpation. Cammaroto et al. report that in many cases the raphe is not clearly identifiable; they then anchor in the pterygomandibular fold, a steadier landmark, or the periosteum of the maxillary tuberosity.

    Related research: Vicini et al. (2015): the original BRP description and the case for the raphe anchor

  3. Keep clear of the duct and the lingual nerve. Before any lateral bite, find the parotid duct papilla on the buccal mucosa and keep the suture away from it. Keep low bites on the raphe away from the mandible, where the lingual nerve is at risk.

    One published limit is not to run the needle down the raphe below the level of the cusp of the lower third molar. These cautions come from the literature. The raphe itself lies away from major nerves and vessels, which is part of why it works as an anchor.

  4. Open the windows with the needle-point Bovie. With the needle-point Bovie, open a small window through the mucosa in the midline of the oral soft palate, then one at the superolateral corner of each tonsillar fossa, over the lateral soft palate. The midline window is the start point for both arms; each lateral window is where that arm comes out on the lateral soft palate.

    In the case shown, the windows came after both releases; in another of Dr. Nord’s cases, the needle-point Bovie came before the release. Whatever the order, the barbed suture does not go in until both sides are released.

    Cammaroto et al. describe a small central incision slightly behind the posterior nasal spine to hold the knot when two unidirectional sutures are joined; the video does not show where Dr. Nord’s link sits.

    Open the suture windows with the needle-point Bovie 0:29 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: Where the three small openings go: one in the midline of the oral soft palate, where the barbed suture starts, and one at the superolateral corner of each fossa.

    Written video guide
    • 0:00–0:10: The needle-point Bovie opens a small midline window on the oral surface of the soft palate.
    • 0:10–0:18: A second window at the superolateral corner of the right fossa.
    • 0:18–0:28: The same window on the left.

    Source: Ryan Nord, MD. Cut from the complete operation at 2:36–3:04.

  5. Carry each arm to its lateral window. Start at the midline window and run one needle laterally within the soft palate to the right lateral window, then start the other arm toward the left. Cammaroto et al. keep this pass within the muscle layer of the palate, away from both the oral and the nasal mucosa. In the case shown, the left arm is carried out to its lateral window after the right side is repositioned.

    The original description runs this first pass from the center point laterally within the palate and around the raphe, exits at the top of the raphe, and pulls until the middle of the suture sits at the center. With linked sutures, that middle is the link.

    Cammaroto et al. also lift the submucosa gently as the needle enters to check the depth.

    Carry each barbed arm to its lateral window 0:14 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: Each needle of the bidirectional suture leaves the midline window and travels under the mucosa to its own lateral window. The barbs are visible on the suture.

    Written video guide
    • 0:00–0:09: From the midline window, the right arm is carried out to the right lateral window.
    • 0:09–0:14: The left arm is carried toward the left lateral window.

    Source: Ryan Nord, MD. Cut from the complete operation at 3:04–3:18.

  6. Anchor in the raphe, through the same hole. Every lateral pass anchors in the pterygomandibular raphe. Each time the needle comes back to the raphe, go back in through the same place it came out, so the suture stays buried instead of exiting through new holes in the mucosa.

    In Dr. Nord’s words: “Gonna go through the same place I did through the raphe here.”

    Cammaroto et al. call same-hole re-entry mandatory to prevent extrusion and exposure of the barbed thread. In one modified technique that removes fat through incisions in the sides of the palate, every extrusion was at those incisions, where the suture runs most superficially, and none was in the tonsillar fossa.

    Suture type changes how often the thread shows, not the result. In a series of 488 patients, extrusion or exposure differed significantly between Stratafix and V-Loc, the suture Dr. Nord uses, and the change in AHI did not differ between patients with and without extrusion. Where it occurs and how it is managed are covered in “Recovery, complications, and follow-up.”

    Related research: Cammaroto et al. (2024): tips and tricks, including the same-hole rule

Dr. Nord’s teaching

“Through the opposite loop, and then through its own loop.”

  • Use two 3-0 V-Loc V-20 sutures and link the loops to create one bidirectional suture: through the opposite loop, then through its own loop.
  • Every lateral pass anchors in the pterygomandibular raphe, and every pass goes back in through the same place.
  • The raphe is where the muscle is going: it is the same point you pulled the palatopharyngeus toward when you checked its tension.

Pitfalls

  • Re-entering through new holes, which leaves barbed thread exposed on the mucosa and invites extrusion.
  • Running the palatal pass so superficially that the barbs sit just under the oral mucosa, where they can work out.
  • Anchoring in the palatoglossus or loose submucosa instead of the raphe (or, where the raphe is not distinct, the fold or tuberosity periosteum described in the literature).
  • Carrying low bites down the raphe toward the mandible, where the lingual nerve runs.
  • Placing lateral bites without first locating the parotid duct papilla.

Before moving on: Show the linked bidirectional suture, the midline and both lateral windows, and the raphe on each side, and explain why every pass goes back in through the same hole.

Check your reasoning

1. The right arm has just come out at the raphe on the right, and you are ready for the next pass. Where should the needle go back in?
2. You palpate for the right pterygomandibular raphe and cannot feel a distinct fibrous band. Which anchor does the literature describe instead?
3. How do you turn two looped V-Loc sutures into one bidirectional suture?

Published references for this lesson
Lesson 06About 10 minBRP

Reposition the palatopharyngeus

Carry each arm of the barbed suture from the pterygomandibular raphe all the way around the released palatopharyngeus, deep to the muscle, and draw it laterally until the tonsillar fossa is covered without pulling on the mucosa. Finish each side with a lateral-to-medial pass.

Work through the steps

  1. Keep every pass anchored in the raphe. Both arms of the bidirectional suture have been carried from the midline window toward their lateral windows, anchored in the raphe. Every lateral pass anchors in the pterygomandibular raphe, and each new pass goes back in through the same place so the suture stays buried.

    The reason for same-hole re-entry, and the published fallback anchors when the raphe is not distinct, are in “Open the suture windows and anchor at the raphe.”

  2. Come down anteriorly and take a full bite. From the raphe, come down anteriorly into the tonsillar fossa and take a full bite of the palatopharyngeus: “grab everything.” Exit at the junction of the muscle and the posterior pillar mucosa, not through the mucosa.

    If the bite looks thin, take more.

    The published descriptions put the exit in the same place: near the posterior pillar mucosa but not through it (Vicini), at the border between the muscle and the preserved posterior pillar mucosa (Cammaroto). This is why the pillar mucosa was kept on the muscle during the tonsillectomy and the release.

    Related research: Vicini et al. (2015): exit near, not through, the pillar mucosa

  3. Go all the way around, deep to the muscle. Each pass encircles the palatopharyngeus, passing deep to the muscle, so the suture holds muscle and not just mucosa. Dr. Nord: “I’m going all the way around, deep to that muscle, which you can see right there. Totally around it.”

    In the clip, the released right palatopharyngeus is lifted with forceps as a discrete band while the needle passes behind it. Later bites follow it around, and by the end of the clip the barbed suture encircles the muscle.

    Work along the muscle rather than taking a single bite. In the original description, the first bite enters the posterior pillar at the junction of its upper third and lower two-thirds, and the raphe-to-muscle stitch is repeated at least three times until the lower pole of the muscle is reached.

    Published descriptions vary on the number of loops. Cammaroto and colleagues describe either a double or triple loop around the muscle bundle or an average of three separate loops from the pterygomandibular fold to the muscle. In that double- or triple-loop style, each bite passes through the muscle lateral to medial with the needle kept in its middle part. They note that the literature shows no outcome difference between the two approaches.

    Pass around the right palatopharyngeus 1:03 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: The released muscle lifted as a band while the needle goes all the way around it, deep to the muscle, not just through mucosa. Several bites follow before the suture encircles the muscle.

    Written video guide
    • 0:00–0:20: Forceps hold the right posterior pillar near the floor of the fossa while the needle takes a full bite.
    • 0:20–0:32: The released muscle is lifted as a band, and the needle passes deep to it.
    • 0:32–1:03: Further bites around the muscle, directed toward the lateral side; by about 0:51 the suture encircles the muscle.

    Source: Ryan Nord, MD. Cut from the complete operation at 3:41–4:43.

    Related research: Cammaroto et al. (2024): loop styles and depth

  4. Tighten gradually, without cinching. Draw the muscle laterally toward the raphe a little at a time, and stop before the suture pulls on the mucosa between the raphe and the tonsillar fossa. Dr. Nord: “You don’t want it to pull on the mucosa … because there’s not a lot of space back there.”

    In the clip, the right palatopharyngeus moves laterally toward the raphe and the fossa is largely covered by the repositioned muscle.

    Barbed suture holds without knots, so tension comes from traction on the thread alone. Vicini’s group applied “a gentle traction” on the thread with no knots, and Cammaroto and colleagues advise against excessive tension to avoid tearing the muscle.

    Tighten: the right muscle moves laterally 0:16 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: As the suture is tightened, the muscle is drawn laterally toward the raphe and covers the fossa. Tighten gradually; the mucosa should not bunch up.

    Written video guide
    • 0:00–0:08: The suture is tightened and the right palatopharyngeus moves laterally.
    • 0:08–0:16: The right fossa is now largely covered by the repositioned muscle.

    Source: Ryan Nord, MD. Cut from the complete operation at 4:43–4:59.

  5. Finish lateral to medial. Once the muscle is encircled, go back one more time the opposite way, lateral to medial: the reverse of the bites you have just taken. Dr. Nord: “I think it hides the tonsillar fossa better because it pulls from here.” And: “It closes it a little bit better.”

    He describes this final pass as a refinement he has added to his technique.

    Cammaroto and colleagues take a different approach to the lower fossa: when they add conventional sutures through the pillars at the end of the case, they leave the inferior part of the tonsillectomy bed open so bleeding can be controlled if it occurs.

    One or two further passes then close the top of the repair; that step is covered in the next lesson.

  6. Repeat on the left. Carry the left arm to the left lateral window and repeat the sequence: anchor in the raphe, re-enter through the same place, go all the way around and deep to the palatopharyngeus, tighten gradually, and finish lateral to medial.

    Watch the end of the clip: the left tonsillar fossa is closed and hidden by the repositioned muscle, with the suture tail exiting at the left lateral palate.

    Reposition the left palatopharyngeus 0:48 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: The same encircling passes on the left. The clip ends with the left fossa closed and hidden by the repositioned muscle.

    Written video guide
    • 0:00–0:08: The left arm is carried to the left lateral window.
    • 0:08–0:41: Passes around the left palatopharyngeus, deep to it, then tightening.
    • 0:41–0:48: The left fossa is closed and hidden by the repositioned muscle.

    Source: Ryan Nord, MD. Cut from the complete operation at 4:59–5:47.

Dr. Nord’s teaching

“I’m going to come down anteriorly here. Grab everything. Come out right at the edge of the muscle and mucosa.”

  • If a bite looks thin, take more muscle. In his words: “I think I can grab a little bit more than that.”
  • Go all the way around the palatopharyngeus, deep to it. If the suture catches only mucosa, the muscle has not been repositioned.
  • Don’t cinch it hard between the raphe and the tonsillar fossa. There is not a lot of space back there, and too much tension pulls on the mucosa and bunches it up.
  • Finish each side with a pass lateral to medial. It hides and closes the tonsillar fossa better.

Pitfalls

  • Taking a superficial bite of mucosa and submucosa that never goes around the muscle.
  • Exiting through the posterior pillar mucosa instead of at the edge of the muscle and mucosa.
  • Stopping the loops high on the pillar. The original description works down the muscle until its lower pole is reached.
  • Cinching the suture between the raphe and the fossa until the mucosa bunches, or pulling hard enough to tear the muscle.
  • Starting the passes while part of the palatopharyngeus is still tethered to the constrictor, so the suture holds tension instead of moving the muscle.

Before moving on: Show a pass anchored in the raphe that goes all the way around the palatopharyngeus deep to the muscle, exits at the muscle–mucosa edge, and goes back in through the same raphe hole, then tension it until the fossa is covered without pulling on the mucosa.

Check your reasoning

1. You have come down anteriorly from the raphe and taken the right palatopharyngeus in the bite. Where should the needle exit?
2. As you tighten the right side, the mucosa between the raphe and the tonsillar fossa starts to bunch. What does that tell you?
3. Why does Dr. Nord finish each side with one more pass, lateral to medial?

Published references for this lesson
Lesson 07About 7 minBRP

Close the top, decide on the palate run, and finish

Finish the barbed repair: close the top on each side, run the suture across the palate in a W only when the palate is loose and floppy, trim the tails flush, and close with a single Vicryl stitch.

Work through the steps

  1. Close the top on each side. After the lateral-to-medial pass, take one or two more passes on each side to close the superior part of the repair, between the lateral palate and the superior pillar at the free edge of the palate. Stop when there is nothing left to throw the suture through.

    At this point in a case, Dr. Nord says: “One or two more passes to close the top part …” A moment later: “Might even be enough with that one. Not much else to throw it through.”

    The clip opens with the barbed suture lying across the palate. The right side is closed first: the barbed needle passes through the superior right pillar at the palatal edge and exits laterally. On the left, the needle goes from the lateral palate into the superior left pillar.

    As with every lateral pass, re-enter through the same hole so the suture stays buried.

    Close the top of the repair 0:36 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: After both sides are repositioned, extra passes go through the superior pillar and the edge of the palate on each side to close the top of the repair.

    Written video guide
    • 0:00–0:09: Both sides repositioned; the suture is brought across the palate.
    • 0:09–0:18: Right side: a pass through the superior pillar and palate edge, exiting laterally.
    • 0:18–0:36: Left side: from the lateral palate into the superior left pillar, then the suture is handled at the left lateral palate.

    Source: Ryan Nord, MD. Cut from the complete operation at 5:52–6:28.

  2. Judge the palate’s laxity. With both sides closed, assess the soft palate before you decide on a palate run. Running the barbed suture across the palate is for a loose, floppy palate. When the palate is already tight and under tension after the lateral passes, skip it.

    In one of his cases the palate was already under tension, so he did not run it: “I don’t really see the value in doing that necessarily.”

    The literature has not settled whether extra palatal passes add anything. In a small retrospective series of 42 consecutive patients, barbed suspension pharyngoplasty, which adds passes through the base of the uvula to the opposite raphe, gave outcomes the authors described as comparable to BRP (p = 0.10). They suggested the extra passes for a highly collapsible soft palate.

    Related research: Barbieri et al. (2019): barbed suspension pharyngoplasty compared with BRP

  3. Run a W from raphe to raphe. When the palate is loose, run the barbed suture in a W: back and forth across the soft palate, all the way to the opposite raphe, with the passes crossing each other completely.

    In his words: “I would do like a W, kind of like from here to here to here, back and forth, all the way to the other raphe.”

    In the literature, these passes stay inside the muscle layer of the palate, away from both the oral and the nasal mucosa. Cammaroto and colleagues suggest lifting the submucosa gently as the needle goes in to check the depth. Thread that runs superficially is more likely to extrude.

    Related research: Cammaroto et al. (2024): barbed repositioning pharyngoplasty tips and tricks

  4. Consider releasing a tight mucosal band. A horizontal band of tight mucosa can stand out across the oral soft palate. Dr. Nord has released such a band with the needle-point Bovie, a relaxing incision. It is an option, not a fixed step, and he has given no rule for when to make it, so decide it with your attending.
    Transoral view with the mouth-gag blade at the top. A needle-point cautery with a teal insulated tip touches a taut, glistening horizontal ridge of mucosa in the center of the field. A raw, trimmed stump of tissue sits at the bottom center, a metal instrument enters from the left, a gloved finger fills the right side, and the lower field is overexposed.

    A tight mucosal band on the oral soft palate

    The needle-point Bovie is set against a horizontal band of tight mucosa on the oral soft palate, before the band is incised.

    Source: Ryan Nord, MD. View full-size image

  5. Trim the tails flush. In the published technique, no knot is tied at the ends of the barbed suture; apart from the midline link, the barbs hold the tension. Cut each tail close to the surface, pulling the scissors down and the thread up, so the cut end is covered by intact mucosa.

    Cammaroto and colleagues cut “pulling the scissor down and the thread up.” In the original description, each thread exits at the raphe on its own side, a superficial stitch is taken back in the opposite direction to lock it, and the thread is then cut under traction. The goal is that no thread is left exposed on the oral mucosa at the end of the case.

    Related research: Vicini et al. (2015): the original BRP description

  6. Finish with one Vicryl stitch. Once the barbed suturing is done, a single Vicryl stitch finishes the closure. Then suction and irrigate.

    His words at the end of one case: “One stitch. If it even holds anything, we’re just about done.” Ask your attending where they want the stitch and how they tie it.

    Suction and irrigation end the operative part. The airway check and the nasopharynx check come next, before the tube is pulled.

Dr. Nord’s teaching

“It’s pretty tight at this point, so I’m not gonna run it all the way across.”

  • Closing the top is finished when there is nothing left to throw the suture through, not after a set number of passes.
  • Feel the palate before you decide. The palate run is chosen in each case from its laxity, not a fixed part of every BRP.
  • The barbed repair is finished before the Vicryl stitch; the Vicryl stitch is a separate closing step.

Pitfalls

  • Cutting the barbed tail before you have decided on the palate run; once it is cut, there is no thread left to run across the palate.
  • Taking the palatal passes superficially, close to the oral or nasal mucosa, where the thread is more likely to extrude.
  • Pulling the barbed suture with so much tension that it tears the muscle.
  • Leaving a tail on the mucosal surface instead of cutting it close to the surface, where intact mucosa covers the end.

Before moving on: Explain when you would and would not run the suture across the palate, and show where the top passes go on each side.

Check your reasoning

1. Both sides are repositioned and the top is closed. The soft palate now feels tight and under tension. What do you do about the palate run?
2. The palate is loose and floppy, so you will run the suture across it. How should it go?
3. The barbed suturing is done. How does the published technique handle the tails?

Published references for this lesson
Lesson 08About 6 minBRP

Judge the result before extubation

Compare the finished repair with the baseline view in two dimensions, the lateral width at the tonsillar fossae and the anteroposterior (AP) space behind the soft palate, then clear the nasopharynx before the tube comes out.

Work through the steps

  1. Take the baseline view first. Once both tonsils are out, and before you inject or release anything, look at the inlet and pass a mirror behind the soft palate. This view is the reference you will compare against at the end: “So that’s kind of the amount of space we have right now.”

    Dab anti-fog on the mirror before it goes in. If it fogs, have it wiped and re-applied before you judge the view.

    The baseline mirror view appears at the start of the injection clip in “Inject, then release the palatopharyngeus.”

  2. Put numbers on the change. When you want numbers, a paper ruler held with forceps measures the change. Measure side to side across the inlet and front to back behind the palate, once at baseline and again at the end, so you compare the same two dimensions.
    Four endoscopic views through the mouth, labeled Before · lateral, After · lateral, Before · AP, and After · AP. In each, a paper centimeter ruler sits in the oropharynx. In the before views the tonsils are out, raw fossae are visible, and the inlet is narrow. In the After · lateral view the ruler spans a wider inlet above the repositioned palate; in the After · AP view forceps hold the ruler upright behind the palate edge.

    Measuring the airway before and after

    The same two dimensions, measured after the tonsillectomy but before the repair (left) and at the end (right): lateral width across the inlet (top row) and AP depth behind the soft palate (bottom row). Compare each row from left to right.

    Source: Ryan Nord, MD. View full-size image

  3. Judge the lateral width. Look at the inlet from above with the repair finished. The posterior pillars should be drawn laterally toward the raphe, the tonsillar fossae largely hidden behind the repositioned palatopharyngeus, and the lateral walls no longer crowding toward the midline.

    The pterygomandibular raphe lies anterior and lateral to the posterior pillar. Pulling the palatopharyngeus toward it widens the oropharyngeal inlet side to side and moves the palate forward, which is why the result is judged in both dimensions.

    Make this judgment while the gag is still suspended and the field is still exposed.

    Two endoscopic views of the oropharyngeal inlet through the mouth, labeled Before and After. Before: folded mucosa of the lateral walls and pillars crowds toward the uvula at the center, narrowing the inlet. After: a short trimmed uvula sits at the center of a straight palatal edge, the pillars are pulled outward with suture visible at both sides, and a broad view of the posterior pharyngeal wall opens behind the palate.

    The inlet before and after repositioning

    Before (tonsils already out), the posterior pillars and soft palate crowd inward and leave a narrow inlet. After, the pillars have been drawn outward, the uvula is trimmed, and the space behind the palate is visibly wider.

    Source: Ryan Nord, MD. View full-size image

    Related research: Vicini et al. (2015): the original BRP description

  4. Look behind the palate again. Pass the mirror behind the soft palate and compare the AP space with your baseline. As the palate moves forward, the space behind it should be visibly larger. When it has opened well, the view reaches into the nasopharynx: “There’s the septum. Lot of space.”

    The clip opens on the last smooth (non-barbed) stitch from the closure, then shows the final inlet and the mirror behind the palate. Compare it with the baseline mirror view taken before the release.

    Final airway and mirror view 0:14 · Ryan Nord, MD · Silent · Written viewing guide

    Watch for: Compare this with the baseline clip: the width at the tonsillar fossae and the mirror view behind the palate at the end of the case.

    Written video guide
    • 0:00–0:02: A smooth, non-barbed suture on the needle driver.
    • 0:02–0:06: The suture is handled at the left lateral palate.
    • 0:06–0:11: The final oropharyngeal inlet, then a mirror passed behind the soft palate.
    • 0:11–0:14: The final view.

    Source: Ryan Nord, MD. Cut from the complete operation at 6:41–6:55.

  5. Clear the nasopharynx before extubation. After suction and irrigation, make sure nothing, such as a blob of fat, is sitting in the nasopharynx where it could come out as soon as the tube is pulled.

    The early hours carry the airway risk. As Kezirian and colleagues note, airway obstruction after UPPP that leads to respiratory arrest, reintubation, or an emergency tracheotomy is rare, but it most commonly occurs within hours of surgery.

    Related research: Kezirian et al. (2004): serious complications after UPPP

Dr. Nord’s teaching

“When you do this, make sure there’s no blob of fat sitting like in the nasopharynx that comes out as soon as they pull the tube.”

  • Take the baseline look once both tonsils are out, before you inject or release. Without it, there is nothing to compare the end result against.
  • Judge the result in two dimensions: the lateral width at the tonsillar fossae and the AP space behind the soft palate.
  • When the space behind the palate has opened well, the mirror view reaches into the nasopharynx.
  • Clear the nasopharynx after suction and irrigation, before anesthesia pulls the tube.
  • Judge the case by its result as well as its pace. The lateral and AP opening at the end are the outcome; a fast case is not automatically a good one.

Pitfalls

  • Skipping the baseline view, so the end-of-case look has no reference.
  • Judging only the lateral width and never looking behind the palate.
  • Letting the gag come down before the result has been judged in both dimensions.
  • Pulling the tube with debris, such as a blob of fat, still sitting in the nasopharynx.

Before moving on: Compare the baseline and final views, explain the change in lateral width and in AP space behind the palate, and confirm the nasopharynx is clear before extubation.

Check your reasoning

1. At the end of the case, which two dimensions do you judge before the gag comes out?
2. Suction and irrigation are done and anesthesia is ready to extubate. What is your last step?
3. When do you take the baseline view you will compare against at the end of the case?

Published references for this lesson
Lesson 09About 9 minBRP

Recovery, complications, and follow-up

Counsel for a two-week recovery, build analgesia on scheduled acetaminophen and ibuprofen, watch the airway on the first nights, manage bleeding and the common benign problems such as suture extrusion, and re-measure the airway after healing.

Work through the steps

  1. Set expectations before surgery. Tell the patient to plan two full weeks off work, that patients report the pain peaking at 10 out of 10, and that it can stay severe enough to need strong prescription pain medication for up to two weeks.

    Pain may not peak on the first day. A European expert consensus agreed unanimously that pain after palatoplasty may need treatment for two weeks and is most severe on days 5–7. The tonsillectomy adds to it: in one palate-surgery cohort, a concurrent tonsillectomy was associated with about 31 more morphine milligram equivalents in the first 24 hours.

    Warn about the tail as well. Residual twinges with yawning, sneezing, or coughing can last up to a month.

    Related research: Olszewska et al.: European consensus on palatal surgery, complications, and postoperative management (2024)

  2. Watch the airway on the first nights. Plan at least one night in the hospital. The most dangerous airway events after palate surgery, obstruction leading to reintubation or an emergency tracheotomy, most commonly occur within hours of surgery, and the apnea can stay worse for several nights after that.

    In a small prospective cohort of 11 expansion pharyngoplasty patients (not BRP) with nightly home sleep testing through the first week, AHI rose by about 19–25 events per hour over baseline on postoperative nights 1–3, with a peak on night 2. Counsel that apnea is often transiently worse while swelling peaks, and plan CPAP use if the patient tolerates it.

    Keep the head of the bed elevated. If opioids are needed, give them where oximetry can be monitored, and avoid background opioid infusions.

    Related research: Yu et al.: immediate postoperative changes after expansion pharyngoplasty and hypoglossal nerve stimulation (2025)

  3. Lead with acetaminophen and ibuprofen. Schedule nonopioid analgesia instead of leaving it as needed. Dr. Nord’s instructions alternate acetaminophen 1000 mg and ibuprofen 600 mg every 3 hours, so each drug is taken every 6 hours, with a limited supply of opioid for severe pain and an antiemetic if needed.

    The NSAID question is about the agent, not the class. In pooled adult tonsillectomy trials, acetaminophen, NSAIDs, and dexamethasone did not increase post-tonsillectomy hemorrhage. Ketorolac is the outlier: a meta-analysis found about a fivefold hemorrhage risk in adults, although that estimate rests on three adult studies. Celecoxib has no antiplatelet effect, and in a palate-surgery cohort it was opioid-sparing with no increase in hemorrhage (1.6% with celecoxib vs 2.4% without).

    The bupivacaine injected after the tonsillectomy, before the release, is part of this plan; the aim is less pain in the first days. The timing and the trial evidence are in “Inject, then release the palatopharyngeus.”

    Related research: Cramer et al.: nonopioid, multimodal analgesia after otolaryngology operations (2021)

  4. Consider routine postoperative antibiotics. Dr. Nord considers routine postoperative antibiotics after BRP. In a claims cohort of nearly 40,000 UPPPs, patients prescribed antibiotics had half the rate of secondary bleeding (3.13% vs 6.25%), and antibiotics were also associated with fewer infections, pneumonias, and readmissions.

    Know the limits of that evidence. The data are observational, and the authors urge caution. The length of treatment (5, 7, or 10 days) made no difference. The Cochrane tonsillectomy review, which excluded UPPP and was mostly in children, found no bleeding benefit, and a European expert panel split: 75% favored intraoperative prophylaxis, but only 50% favored postoperative antibiotics.

    Related research: Abdelwahab et al.: perioperative antibiotic use in sleep surgery (2022)

  5. Give clear discharge instructions. Send the patient home on a soft diet for two weeks, avoiding spicy, acidic, crunchy, or hard foods, with no strenuous activity or heavy lifting for at least two weeks. In the multicenter BRP series, all patients were allowed to resume oral feeding by the second day after surgery.

    Add warm salt-water rinses after meals and before bed, and have the patient sleep with the head elevated to limit swelling.

    Tell the patient to call for a fever of 100.4°F (38°C) or higher, inability to drink enough to stay hydrated, significant bleeding, pain that persists or worsens despite medication, or increased redness, swelling, or foul discharge.

  6. Know what two weeks of healing looks like. See the patient at 2–3 weeks to check healing. At about two weeks, fibrin still lines the healing tonsillar fossae, the pillars stay lateralized, and the inlet stays wide.
    Transoral photograph of an open mouth with a wooden tongue depressor on the tongue. White-gray fibrin lines both tonsillar fossae on either side of a broad soft palate arch, and a small white spot sits high on the midline palate.

    About two weeks after BRP

    Office view about two weeks after BRP. Notice the fibrin still lining both tonsillar fossae, the pillars set laterally, and the wide inlet above the tongue depressor.

    Source: Ryan Nord, MD. View full-size image

  7. Treat bleeding as a two-week risk. Most bleeding after palate surgery is delayed. In the claims cohort of nearly 40,000 UPPPs, secondary bleeding made up 91% of bleeding events. In the multicenter BRP series, 5% bled after surgery and 1.8% needed a return to the operating room to control it.

    When a tonsillectomy is part of the operation, patients should stay within reach of a medical facility for at least two weeks. A postoperative bleed is managed with inpatient observation or surgical hemostasis, and a return to the operating room for cauterization is a risk to name at consent.

    Related research: Montevecchi et al.: prospective multicentre study on barbed reposition pharyngoplasty (2018)

  8. Expect suture extrusion and trim it in clinic. Across 488 patients treated with BRP alone or with multilevel TORS, suture extrusion occurred in about 18%, significantly more often with V-Loc, the suture used in these lessons, than with Stratafix. More than a third of extrusions cause no symptoms.

    In that series, about three quarters appeared between the first week and two months after surgery, and only 5.5% appeared after two months. Look at the soft palate and the tonsillar bed: 46.7% of exposures were in the soft palate and 35.5% in the tonsillar bed. Tell patients to expect roughly a one-in-five chance, and that the fix is a trim of the exposed segment with scissors in the office, without anesthesia and without changing the result. Published timing varies: one series trimmed at two weeks, a systematic review suggests waiting at least three weeks so healing is not disturbed, and the originating group removes it according to the patient’s discomfort.

    Prevention happens in the operating room. Keep every pass within the muscle layer and re-enter through the same hole each time. Extrusion is more common early in a surgeon’s experience.

    Related research: Gulotta et al.: barbed suture extrusion and exposure in palatoplasty for OSA (2021)

  9. Separate early swallowing complaints from lasting ones. Early dysphagia is common and usually brief. In the multicenter BRP series, 21% had transient dysphagia, and all recovered within 6 days. A 2022 review reports a long-term questionnaire study of 140 BRP patients (mean follow-up about 26 months) in which 51% reported swallowing problems after surgery and 9% still had some difficulty at interview.

    In that same study, 20% reported a foreign-body sensation, 8% rhinolalia (altered nasal resonance of speech), and 2% nasal regurgitation. A long-term multicenter study of 217 palate-surgery patients, 40 of them BRP, recorded no velopharyngeal incompetence, taste disturbance, or voice change with any technique, counting only symptoms present at least twice a week. In older pooled UPPP data, velopharyngeal insufficiency was reported in 8.1%, and it did not resolve with time.

    Related research: Iannella et al.: barbed reposition pharyngoplasty in OSA treatment, state of the art (2022)

  10. Re-measure the airway after healing. Order the follow-up sleep study after healing, not at the early visit. An international expert consensus put the first study at least 3 months after soft-tissue surgery, on the same device as the preoperative study; a home sleep apnea test is adequate.

    In the staged pathway for complete concentric collapse, the order is DISE, then pharyngoplasty, then a repeat sleep study and repeat DISE after healing, then hypoglossal nerve stimulation if apnea persists. When BRP treats a partial response to an implant that is already in place, the implant is restarted after recovery and the patient is retested on therapy.

    If apnea persists, DISE is a valid test to find the sites of collapse that remain.

    Close transoral view of a healed soft palate forming a smooth, broad arch with a short uvula at its center, a wide opening to the back wall of the throat behind it, and the tongue along the bottom edge.

    Healed result

    A healed palate after BRP at a later visit. Notice the smooth, broad arch, the short uvula, and how much of the posterior pharyngeal wall shows through the inlet.

    Source: Ryan Nord, MD. View full-size image

    Related research: Iannella et al.: international expert consensus statement on surgical failure in OSA (2024)

Dr. Nord’s teaching

“Patients report the pain peaking at 10 out of 10, and it can remain severe — requiring strong prescription pain medication — for up to two weeks.”

  • Schedule alternating acetaminophen and ibuprofen; keep the opioid supply limited and for severe pain only.
  • Suture extrusion has no impact on outcomes. Expect it, warn about it, and trim it in the office.
  • Re-measure after healing. When the patient already has an implant, restart it after recovery.

Pitfalls

  • Treating pain that worsens late in the first week as a complication on its own; expert consensus puts the most severe pain after palatal surgery on days 5–7.
  • Treating all NSAIDs as one class: avoiding ibuprofen reflexively, or reaching for ketorolac in an adult.
  • Giving opioids without oximetry on the first night, or sending the patient home without a plan for CPAP while swelling peaks.
  • Calling suture extrusion a failure, or bringing the patient back to the operating room for it.
  • Ordering the follow-up sleep study before healing is complete.

Before moving on: Counsel a patient through the two-week recovery, state the extrusion rate and how you will manage it, and say when the follow-up sleep study happens and what comes next if apnea persists.

Check your reasoning

1. On day 5 after BRP with tonsillectomy, a patient calls to say the pain is worse than on day 1. She is afebrile, drinking enough, and not bleeding. What is the best response?
2. Three weeks after BRP, a patient feels something sharp in the throat. You see a short end of barbed suture exposed at the lateral palate. The airway looks wide. What do you do?
3. When should the follow-up sleep study after BRP be done?

Published references for this lesson

The teaching collection

Watch the operation, or one part of it

The complete operation from Dr. Nord’s teaching collection, with chapters, then short clips cut from it and labeled photographs. Each clip and photograph also opens within its lesson, beside the step it shows.

Real operative footage, recorded through the endoscope. The video is silent; each clip has a written viewing guide.

The complete operation

The complete operation Ryan Nord, MD · 6:55 · Silent · Written viewing guide

Watch for: The order of the case: both tonsils out with the pillars intact, both palatopharyngeus muscles released before the first barbed pass, and every pass taken around the muscle rather than through mucosa alone. Compare the lateral width and the mirror view behind the palate at the start and at the end.

Chapters

  1. 0:00Uvula trimLesson →
  2. 0:07Tonsillectomy, right then leftLesson →
  3. 1:15Baseline mirror view and injectionLesson →
  4. 1:29Palatopharyngeus release, right then leftLesson →
  5. 2:36Needle-point Bovie windowsLesson →
  6. 3:04Barbed suture to each lateral windowLesson →
  7. 3:26Passes around the right palatopharyngeusLesson →
  8. 4:59Passes around the left palatopharyngeusLesson →
  9. 5:52Closing the top of the repairLesson →
  10. 6:47Final airway and mirror viewLesson →

Silent and condensed from the full case. Surgeon’s view from the head of the bed: the mouth-gag blade is at the top, and the patient’s right is on the right of the image.

18 videos and photographs
Curved grasper from the left of the image pulling the right tonsil medially while the BiZact dissects along its capsule, with the mouth-gag blade at the top of the image

Uvula trim and tonsillectomy

Video · 1:12

The partial uvula trim, then the medial traction on each tonsil while the dissection follows the capsule. Both pillars stay intact, because the posterior pillar muscle is what you will reposition.

Watch in the lesson →
Both tonsillar fossae empty after tonsillectomy, with a round mirror passed behind the soft palate

Baseline mirror view and bupivacaine injection

Video · 0:14

Note how much space the mirror shows behind the soft palate before any repair; you will compare it with the same view at the end. The injection comes after both tonsils are out and before the release.

Watch in the lesson →
Forceps pulling the right posterior tonsillar pillar medially while the BiZact works lateral to it in the fossa

Release the right palatopharyngeus

Video · 0:39

The posterior pillar muscle pulled medially as a band while its lateral attachment is divided. The pillar mucosa stays on the muscle, and the constrictor in the fossa bed is not cut.

Watch in the lesson →
Left posterior tonsillar pillar retracted medially by forceps while the BiZact works in the left fossa

Release the left palatopharyngeus

Video · 0:21

The same release on the left, with the instruments switched. The clip ends on an overview: both sides are released before any suture is placed.

Watch in the lesson →
The palatopharyngeus and the superior constrictor, operative photograph

The palatopharyngeus and the superior constrictor

Photograph

The palatopharyngeus fasciculi run down the lateral pharyngeal wall on the medial side of the superior pharyngeal constrictor.

See it in the lesson →
Both sides released, before the first suture, operative photograph

Both sides released, before the first suture

Photograph

Both tonsils are out and both palatopharyngeus muscles have been released; no suture has been placed.

See it in the lesson →
Needle-point Bovie with a blue handle making a small opening at the corner of the left fossa, with the midline opening already made

Open the suture windows with the needle-point Bovie

Video · 0:29

Where the three small openings go: one in the midline of the oral soft palate, where the barbed suture starts, and one at the superolateral corner of each fossa.

Watch in the lesson →
Both barbed suture arms running out toward each side of the soft palate, with the midline window at the bottom of the image and both tonsillar fossae open

Carry each barbed arm to its lateral window

Video · 0:14

Each needle of the bidirectional suture leaves the midline window and travels under the mucosa to its own lateral window. The barbs are visible on the suture.

Watch in the lesson →
Forceps lifting the released right palatopharyngeus as a band while a needle driver passes a barbed suture deep to it

Pass around the right palatopharyngeus

Video · 1:03

The released muscle lifted as a band while the needle goes all the way around it, deep to the muscle, not just through mucosa. Several bites follow before the suture encircles the muscle.

Watch in the lesson →
Right palatopharyngeus encircled by the barbed suture, with the suture exiting at the right lateral palate

Tighten: the right muscle moves laterally

Video · 0:16

As the suture is tightened, the muscle is drawn laterally toward the raphe and covers the fossa. Tighten gradually; the mucosa should not bunch up.

Watch in the lesson →
Left tonsillar fossa closed by the repositioned left palatopharyngeus, with the barbed suture exiting at the left lateral palate

Reposition the left palatopharyngeus

Video · 0:48

The same encircling passes on the left. The clip ends with the left fossa closed and hidden by the repositioned muscle.

Watch in the lesson →
Barbed suture passing through the superior edge of the left posterior pillar near the soft palate

Close the top of the repair

Video · 0:36

After both sides are repositioned, extra passes go through the superior pillar and the edge of the palate on each side to close the top of the repair.

Watch in the lesson →
A tight mucosal band on the oral soft palate, operative photograph

A tight mucosal band on the oral soft palate

Photograph

The needle-point Bovie is set against a horizontal band of tight mucosa on the oral soft palate, before the band is incised.

See it in the lesson →
Widened oropharyngeal inlet at the end of the case, with the repositioned pillars drawn laterally

Final airway and mirror view

Video · 0:14

Compare this with the baseline clip: the width at the tonsillar fossae and the mirror view behind the palate at the end of the case.

Watch in the lesson →
Measuring the airway before and after, operative photograph

Measuring the airway before and after

Photograph

The same two dimensions, measured after the tonsillectomy but before the repair (left) and at the end (right): lateral width across the inlet (top row) and AP depth behind the soft palate (bottom row).

See it in the lesson →
The inlet before and after repositioning, operative photograph

The inlet before and after repositioning

Photograph

Before (tonsils already out), the posterior pillars and soft palate crowd inward and leave a narrow inlet.

See it in the lesson →

Your preparation sheet

Before you scrub

Use these prompts to rehearse the case aloud. Bring the steps you cannot yet explain to your supervising surgeon.

Before the case

  • Review this lesson →
  • Review this lesson →
  • Review this lesson →
  • Review this lesson →
  • Review this lesson →

Before suspension

  • Review this lesson →
  • Review this lesson →
  • Review this lesson →

Before the barbed suture

Before the closing stitch

  • Review this lesson →
  • Review this lesson →
  • Review this lesson →
  • Review this lesson →

Before extubation

How BRP cases are assessed in Dr. Nord’s program

After a supervised case, two times are measured and the attending records six ratings. BRP is judged on quality as well as time: a fast case does not count as a good one if the release, the passes, or the result fall short.

Time

  • Both times are measured from mouth-gag suspension, because a transoral case has no skin incision.
  • First time point: the uvula and both tonsils are out. The uvula is not timed on its own.
  • Second time point: the barbed suturing is done. The final closing stitch does not count.
  • Your times are compared with the attending’s own times for the same steps.

Quality

  • Palatopharyngeus release: quality and completeness, with both sides released before the first barbed pass.
  • Barbed suture handling: linking the two sutures, handling the needle and suture, and tightening without bunching the mucosa.
  • Suture placement: the raphe anchor and same-hole re-entry, passes around the muscle and deep to it, the lateral-to-medial finish, the top closed, and the palate-run decision.
  • Airway opening, lateral: the width at the tonsillar fossae at the end of the case.
  • Airway opening, AP: the space behind the soft palate at the end of the case.
  • Hemostasis: rated by category, as defined below.

Hemostasis categories

None or minimal
Blood does not reach the end of the suction tube.
Moderate
Controlled with the BiZact.
Substantial
Required the suction Bovie.
Poorly controlled
Substantial bleeding (arterial, a pumper, or spray onto the gown); required suturing; required the attending to scrub in to control it; or bleeding on wake-up.

Hemostasis and the two airway results are outcome ratings, and only the attending judges them. The goal is to approach the attending’s own performance, not a perfect score.

These checks support preparation and discussion. Completion and quiz scores do not establish operative competence or replace supervised surgical training.

Teaching sources

The pathway draws on Dr. Nord’s operative teaching: his step-by-step BRP technique, the complete operation on video with clips cut from it, and surgical pearls from his recorded teaching during BRP cases. Published references are listed beside each lesson and below.

The recommendations present a teaching approach for supervised palate surgery. Technique varies between surgeons and centers. Confirm the plan, the suture, and the instruments with your supervising surgeon before the case.

Published references and related reading
Terms used in the lessons
BRP
Barbed reposition pharyngoplasty, described by Vicini’s group in 2015. The inferior palatopharyngeus is released, and the posterior pillar is repositioned laterally and anteriorly with a knotless bidirectional barbed suture anchored to the pterygomandibular raphe. It widens the oropharyngeal inlet and the retropalatal space.
Palatopharyngeus (PP)
The muscle of the posterior tonsillar pillar. Its longitudinal fibers form a compact bundle in the palatopharyngeal arch and the lateral pharyngeal wall. In these lessons, “the muscle” always means the palatopharyngeus, never the palatoglossus.
Posterior tonsillar pillar
The palatopharyngeal arch behind the tonsil, formed by the palatopharyngeus and its mucosa. In BRP the mucosa is not dissected off the muscle; it moves with it.
Superior pharyngeal constrictor
The muscle lateral and deep to the palatopharyngeus in the tonsillar fossa. The palatopharyngeus is released from it laterally; the constrictor itself is not cut.
Pterygomandibular raphe
The fibrous band joining the pterygoid hamulus to the mandible, lateral to the tonsillar fossa. It is the stable anchor for the lateral passes and is best found by palpation. When it is not clearly identifiable, published technique anchors in the pterygomandibular fold or the maxillary tuberosity periosteum.
Velum
The soft palate. In VOTE notation, V describes collapse at the level of the velum.
Lateral-wall collapse
Collapse of the oropharyngeal lateral walls (the O in VOTE), from tonsil, muscle, or fat. In a multicenter DISE cohort, any lateral-wall obstruction was linked to about half the odds of response to pharyngeal surgery.
CCC
Complete concentric collapse at the velum on DISE: the palate closing in from all sides in the shape of a funnel. It excludes hypoglossal nerve stimulation under current U.S. criteria. Conversion to a qualifying pattern has been reported after some palate operations, but not yet in a BRP-specific study.
DISE
Drug-induced sleep endoscopy: flexible endoscopy under sedation that aims to reproduce sleep-related collapse, to show where and how the airway collapses.
VOTE
The DISE classification by velum, oropharyngeal lateral walls, tongue, and epiglottis, each scored by degree (0 none, 1 partial, 2 complete) and configuration (anteroposterior, lateral, or concentric). T0E0 means no tongue-base and no epiglottic collapse.
Friedman tongue position (FTP)
The palate–tongue relationship graded I to IV with the mouth open wide and the tongue left inside the mouth, not protruded as in the anesthesia Mallampati exam. It was first called Friedman palate position.
Friedman stage
A clinical stage that combines Friedman tongue position, tonsil size, and BMI. In the original 2002 system, stage I (position I or II, tonsils 3 or 4, BMI under 40) had the best UPPP success. The 2004 revision added stage IV (BMI over 40 or a significant craniofacial or skeletal deformity): these patients are not candidates for palatal or tongue-base surgery.
UPPP
Uvulopalatopharyngoplasty, described by Fujita in 1981: tonsillectomy with removal of the uvula, part of the soft palate, and redundant posterior pillar mucosa. Classic UPPP is not the typical technique used today.
ESP
Expansion sphincter pharyngoplasty (Pang and Woodson, 2007). After tonsillectomy, the inferior palatopharyngeus is transected and rotated superolaterally. Like BRP, it mobilizes the palatopharyngeus to expand the oropharyngeal airway and move the palate forward; a 2021 meta-analysis found no significant difference in AHI change between the two.
Barbed suture
A suture with barbs cut into its surface that hold tissue without knots and spread tension along the whole length of the suture.
Bidirectional suture
A barbed suture with a needle at each end and barbs running in opposite directions on either side of a central transition zone, so each arm holds toward its own side. In this technique, two looped barbed sutures are linked into one.
V-Loc
The barbed suture used in this technique: two 3-0 V-Loc sutures on V-20 needles (26 mm, ½-circle taper), with the loops linked into one bidirectional suture. In a 2021 series of 488 patients, extrusion was significantly more frequent with V-Loc than with Stratafix.
BiZact
A bipolar tissue-sealing and dividing device. In this technique it is used to release the palatopharyngeus, and bleeding controlled with it counts as moderate in the hemostasis categories.
Needle-point Bovie
Monopolar cautery with a fine needle tip. It opens the midline and lateral suture windows on the oral soft palate and is also used for a relaxing incision when one is made.
W run (palate run)
Running the barbed suture back and forth across the soft palate in a W, from raphe to raphe, with the passes crossing completely. It is for a loose, floppy palate and is skipped when the palate is already tight.
Relaxing incision
An optional incision through a tight band of mucosa on the oral soft palate, made with the needle-point Bovie. There is no set rule for when to make one.
Suture extrusion
Exposure of part of the barbed suture through the mucosa after surgery. It occurred in about 18% in a large series, more than a third had no symptoms, and it did not affect the result. The exposed segment is trimmed in clinic.
VPI
Velopharyngeal insufficiency: inability to close the nasal cavity off from the mouth, which affects speech, eating, and breathing. It shows as hypernasal speech (rhinolalia) or nasal regurgitation.
Sher criteria
The classic definition of surgical success: AHI reduced by at least 50% and to below 20. A 2024 international expert consensus called for abandoning it in favor of new criteria that also account for symptoms and quality of life.
AP and lateral dimensions
The two directions in which the result is judged: lateral, the width at the tonsillar fossae, and anteroposterior (AP), the space behind the soft palate.
HGNS
Hypoglossal nerve stimulation, such as Inspire or Genio. BRP is used for complete concentric collapse at the velum before HGNS, with a repeat sleep study and DISE after healing, and for residual palatal or lateral-wall collapse after a partial HGNS response.

Educational material for residents and clinicians. Includes real operative footage and photographs. Learning progress is kept only on this device if you choose to remember it. Site privacy notice.

Disclosures

Ryan Nord, MD, consulted for Inspire Medical Systems until 2025 and consults for AvivoMed. He has also consulted for Medtronic, which makes the BiZact and the V-Loc suture named in these lessons; that relationship has ended. He has received research support from Nyxoah, the maker of Genio, and has been a paid member of the clinical events committee for Nyxoah-sponsored trials. This is his personal educational website. The education center adapts his teaching materials for resident education; it is not a manufacturer training credential. See the full disclosures for his industry relationships and how to report a content correction.

Try “success rate”, “BMI”, “Medicare”, “battery”, or “concentric collapse”.