Inspire surgery: what happens, step by step, and how recovery goes

This page walks through Inspire implant surgery the way I walk my own patients through it: what to arrange beforehand, what happens in the operating room, and what the weeks afterward look like.

What happens before Inspire surgery?

By the time Inspire surgery is on the calendar, the evaluation is already done: a sleep study showing moderate to severe obstructive sleep apnea, a trial of CPAP that did not work for you, a drug-induced sleep endoscopy (DISE) showing an airway pattern the implant can treat, and approval from your insurer. What remains is preparation: your skin, your medications, and a plan for about two quiet weeks at home.

What to arrange in the week or two before

• Skin preparation. In my practice, every patient follows a staph decolonization routine for the five days before surgery: a chlorhexidine soap on the neck and chest, a mouthwash and a nasal ointment. Ask what your surgeon recommends.
• Blood thinners. If you take aspirin, clopidogrel (Plavix), apixaban (Eliquis), warfarin (Coumadin) or a similar medicine, your surgeon and the doctor who prescribes it will decide together whether and when to hold it. Never stop one on your own.
• Time off. Plan on about two weeks away from work.
• A ride home. Do not drive immediately after surgery as the effects of anesthesia could present a safety hazard. Continue to abstain from driving while taking any prescription pain medication such as oxycodone.
• Ice packs ready in the freezer for your neck.
• The Inspire Sleep App. Download it ahead of time. You will use it with your remote once the device is turned on.

The Inspire procedure, step by step

The Inspire procedure is done under general anesthesia, so you are fully asleep. The surgeon wraps a small cuff around the branches of the tongue nerve that push the tongue forward, places the generator under the skin of the upper chest, and connects the two with a thin lead. The system is tested before you wake up, then left off while you heal.

1. Anesthesia and setup. Antibiotics go into your IV before the first incision. In my practice the breathing tube usually goes through the nose, which keeps the tongue in view during nerve testing and is why the nose and throat can be sore afterward. Small recording electrodes in the tongue connect to a nerve monitor.
2. The neck incision. A short incision about a finger’s width below the jawline, roughly 3 centimeters (just over an inch), leads to the hypoglossal nerve, the nerve that moves your tongue. The salivary gland under the jaw is moved aside on the way, which is why that area stays swollen and firm for a few weeks.
3. Choosing the right nerve branches. Some branches of this nerve push the tongue forward; others pull it back. Guided by the anatomy and the nerve monitor, the surgeon wraps the cuff around the forward-pushing branches only.
4. The chest pocket. Through an incision just below the collarbone, the surgeon makes a pocket on top of the chest muscle for the generator.
5. Connecting the parts. The lead from the neck runs under the skin to the chest and plugs into the generator, with a little slack left in the wire.
6. Testing before you wake up. The surgeon confirms that the generator picks up your breathing and that brief stimulation moves the tongue forward. If it does not, the cuff is rechecked while you are still asleep.
7. Closing. In my practice the wounds are rinsed with antibiotic saline before they are closed. Each incision gets Steri-Strips and a pressure dressing, and the device is left off.

If you would like to see it, I have posted operative footage of the neck incision and cuff placement. It is actual surgery, so skip it if you would rather not watch.

How long does Inspire surgery take?

In my practice, Inspire surgery takes about an hour of actual operating. Add the time to go to sleep and wake up, and you are in the operating room for about two hours, then in the recovery area before you go home the same day. Published times vary because some count only the operating and others the whole time in the operating room, which differ by roughly an hour; the setting and the surgeon’s experience also matter.

Going home

You go home the same day; someone else drives (see the driving rule above). You leave with:

• The Inspire remote. Keep it safe and bring it to your activation visit about four weeks later. You do not need it at the one-week visit.
• A small prescription for pain medicine. You can add acetaminophen (Tylenol) and ibuprofen if your health allows them.
• A few days of antibiotic pills, part of my routine for preventing infection.
• Pressure dressings over both incisions, which stay on for 48 hours.

Where are the Inspire surgery incisions?

The current device, Inspire V, needs two incisions, usually on the right side: a short one in the upper neck below the jawline and one on the upper chest just below the collarbone. Earlier Inspire models had a third part, a breathing-sensor wire placed between two ribs, which for years meant a third incision lower on the chest. Inspire V builds the breathing sensor into the generator, so nothing is placed between the ribs.^[3]

Through Inspire IV, that sensing wire was part of every implant, placed first through a separate incision low on the chest and later through the generator incision.^[2] That is why some people with older devices have three scars, and why older patient stories mention a collapsed lung, a risk that came from the wire between the ribs. Inspire V keeps the chest incision and the generator pocket, so bleeding, infection and the eventual battery change still apply. How these incisions heal, including for people prone to thick scars or keloids, is covered under Inspire scars on my risks page.

How long is the recovery from Inspire surgery?

Most people go home the same day, and the soreness is usually gone within one to two weeks. Plan on two weeks off work with no lifting over 15 pounds, then two more weeks without weight training or quick, forceful sports such as golf and tennis. The implant stays off while you heal. It is turned on at about four weeks, and a sleep study at three to four months confirms that it is working.

This timeline follows my post-op instructions.

Your own surgeon’s instructions come first. Wound care, icing, scar care and the full activity list are in my printable post-op instructions.

What should I expect in the first two weeks after Inspire surgery?

Expect soreness, swelling and some bruising that ease over 7 to 14 days. Ice the neck for the first day or two, keep the pressure dressings on for 48 hours, and shower once they are off. Walking and light activity are fine; heavy lifting, strenuous exercise and shaving over the neck incision have to wait. Start neck rolls right away. The device is off, so you will not feel any stimulation yet.

Pain and swelling

The first three days are the sorest. Soreness can also turn up in the nose and throat from the breathing tube, and in the jaw, ear or tongue. Swelling under the jaw that looks like a double chin is normal and settles over two to four weeks, though the area can stay firm a while longer.

Neck rolls

Slowly roll your head in a full circle ten times, then ten times the other way, at least three times a day for the first four weeks. The wire from the neck to the chest can scar in place as it heals and cause a tight band when you look up; keeping the neck moving helps prevent that. I developed this routine for my own patients, and surgeons elsewhere have since adopted it.

Activity, work and eating

The activity limits are in the table above. You can eat normally right away. Most people are back at work after about two weeks; some with desk jobs start light duty within a few days.

When is Inspire turned on after surgery?

Inspire is turned on at an office visit about four weeks after surgery, once the incisions have healed. It starts at a low strength, and you learn to use the remote. Over the following weeks you raise the strength yourself, about once a week as you tolerate it. At about ten weeks your surgeon checks the tongue movement and the breathing signal, adjusts the program, and confirms the date of your sleep study.

At bedtime you press the remote. The device pulses once to show it is on, then waits about thirty minutes before stimulation starts; if you wake during the night, the pause button delays it for about 15 minutes. Use it every time you sleep, naps included. While you are awake the pulses do not line up with your breathing; they fall into rhythm once you are asleep. Most people should be on their way to better sleep within the first three months. If you use CPAP, ask your surgeon when to stop; my post-op instructions say two weeks before the activation visit.

The follow-up sleep study: how you know Inspire is working

About three to four months after surgery, a sleep study measures how well the implant controls your apnea on your own setting. In my practice that is usually an all-night home sleep test; some patients have an in-lab study. We review the results together and adjust the settings if needed. Up to 30% of patients need further adjustment after that first study, often guided by a short awake endoscopy in the office and followed by a repeat sleep study.

The type of sleep study can swing the measured success rate by 30 points or more in the same patients;^[5] my Inspire success rate page explains which numbers to judge the operation by. Those outcome studies used earlier Inspire hardware. Inspire V uses the same stimulation lead and moves the tongue the same way; its own outcome studies have not been published yet.

What is normal while you heal from Inspire surgery, and what is not?

Soreness, swelling, bruising, a firm area under the chin and some tightness in the neck are expected in the first weeks and fade with time. Less common problems include a collection of blood at the chest incision, infection, and temporary weakness of the tongue or lower lip. Serious problems are uncommon: fewer than 2% of patients had a serious procedure-related event in the first year of the pivotal trial.^[1]

• Bleeding. In my experience a collection of blood under the skin (a hematoma) happens in about 1% of patients, almost always at the chest incision. Blood thinners and resuming activity too soon make it more likely.
• Infection. Uncommon but serious: in my center’s published series, 3 of 215 patients (1.4%) developed one, and all three needed the device removed.^[4] That is why my routine includes the skin preparation, IV antibiotics, an antibiotic wound rinse and a few days of antibiotic pills afterward.
• Tongue or lip weakness. The tongue may drift slightly to the right, speech may be a little slurred at first, and the right side of the lower lip may not pull down fully in a big smile. These are usually temporary. If you notice one, mention it to your surgeon’s office so they can check it.

Every risk, with its published numbers, is on my page on Inspire side effects and risks.

When should I call my surgeon after Inspire surgery?

Technical questions about the remote or the device itself go to Inspire’s patient support line, which is printed in the post-op instructions. Everything else goes to your implanting surgeon’s office.