Peled Migraine Surgery Blog

Over the past year or so, I've noticed that many patients are being told by their other treating headache doctors that they shouldn't consider surgery for their problem because their headaches are not bad enough. Patients are often so struck by these remarks that many wonder whether this statement represents actual medical fact and repeat it to me as if it were empirically true. They then ask me if I agree with that concept. My answer is always the same, the only person who can say whether the pain you're having is too much, is YOU.
Pain by definition is a subjective experience. There is no objective way to measure it such as with a blood test or an MRI. This fact represents one of the biggest challenges in treating people with pain. Moreover, what I've gleaned is that it's not only the actual episodes of pain that often constitute the greatest burden to people. Many times it is the constant lifestyle adjustments and manipulations often required to stave off the onset of pain that are the most difficult for people to manage. Patients often have to avoid social situations they'd like to be in, avoid foods they love to eat, and avoid activities they used to love participating in. To add insult to injury, I've also been informed by patients that their other headache doctors told them that they would terminate them as patients if they undergo surgical decompression.
I find such statements quite sad because they often leave patients very conflicted perhaps due to the fact that this other doctor has provided some measure of relief that they are afraid they will lose if they pursue other options. It also goes against my general opinion of how chronic headache pain (and all chronic pain for that matter) should be managed. I believe that a multi-modality approach that yields the best results. Just like in breast cancer treatment during which a patient often has surgery to remove the cancer with a breast surgeon, chemotherapy/hormone therapy with a medical oncologist and radiation treatment with a radiation oncologist. Only when these physicians work together do patients derive the optimal benefit.
Who then is anyone else to say how much any individual person should suffer? I believe that the role of the physician in these cases should be to establish a diagnosis if possible and formulate a treatment plan to address the pathology in question if possible often in combination with other clinicians. The physician should then educate the patient about his/her diagnosis and the possible treatment options. Patients must then decide for themselves based upon an evaluation of the potential risks and benefits of the proposed treatments which treatment options are best for them. The take-home message - don't let anyone else make a value judgment for you. They can't.

Several people have recently commented on the publicity surrounding the new class of drug being touted as a “breakthrough” treatment for migraines.  This drug known now as erenumab, is what’s called a CGRP (calcitonin gene-related peptide) receptor inhibitor and works by blocking the effects of CGRP which is thought to play a role in migraines.  Let me first say, that anyone who has read my blog posts over the past few years knows that I am a firm believer in the multidisciplinary approach to chronic headaches and chronic pain in general.  Therefore, I applaud the hard work and resource commitment that has gone into the development of this drug class.  Any advance is good for our patients and ultimately, like in breast cancer, I believe that if we put several of these treatment modalities (i.e. medication, surgery, injections, PT) together in precise ways for each individual patient, we will we see a monumental improvement in headache care.  All this being said, I think some clarity into what the actually data show with regard to erenumab is warranted so people are properly informed.

There are several trials of erenumab that have been completed and several ongoing so the data presented here are not the only numbers available, but rather what I consider to be a reasonable sample of what is available and what is likely to be seen in the next few months.  As of this post, erenumab is not even FDA approved and is therefore not commercially available although approval is expected as early as this later this month.  Furthermore, we don’t know for which indications erenumab will be approved and therefore for what conditions doctors will be “allowed” to prescribe it.  This point is important because many of the studies published focus on ‘episodic migraines’ which are defined as fewer than 15 headache days/month with or without aura.  Already, there is a difference in the uses for this medication and headache surgery as the majority of patients I see have many more headache days per month, in fact many have pain 24/7.  Secondly, the numbers must be explained with respect to the results.  What I mean by this statement is that as physicians and patients, we must distinguish between statistical significance and clinical significance. Allow me to elaborate. 

In one of the pivotal publications on this topic in the New England Journal of Medicine in late 2017, erenumab was noted to “significantly reduce migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months”.  Sounds awesome, right?  But a look at the actual data tell a slightly less impressive story.  The average number of headache days per month in both the placebo and experimental (i.e. erenumab) groups was 8.  The patients who are candidates for headache surgery often have many more headache days per month and hence can be considered much more debilitated on that parameter alone. Moreover, the average days of use per month of acute-migraine-specific medication in these patients was 3.  In other words, these patients were only using abortive medications 3 days per month on average, so aging, the group of patients in this study weren’t as sick as those I often see in my office. The trial lasted six months with monthly injections of the drug and these same parameters were evaluated over the last three months of the trial. At the highest dose of erenumab (presumably the one with the most efficacy), over the last three months of the trial, the patients receiving the active drug had about 4 fewer headache days/month – almost a 50% reduction in frequency.  Sounds good so far.  But in the same trial, patients who were given the placebo had 2 fewer headache days per month. Let me say that again, if you were given the drug at the highest dose possible in this trial, you would have two fewer headache days/month than if you received saline injections.  Furthermore, only 50% of the patients at the highest dose, got this type of result!  Now if you have 8 headache days a month, maybe 4 fewer headache days/month is great, but what if you have 28 headache days a month – perhaps not as dramatic? If you suffer from 28 headache days/month and if I as your doctor told you that you needed monthly injections for the rest of your life, at an estimated cost of $10,000/year and that if you were lucky you would have 4 fewer headache days/month would that be worth it?  The data show statistically significant improvements in those receiving the drug versus placebo, this statement is true, but clinically – meaning to the patient sitting in front of you in the office – are these actual numbers compelling enough? Would the same percentage improvement (50%) hold true for patients with chronic migraines, meaning those who have more than 15 headache days/month?  We don’t know.  Perhaps in those patients, the drug would be completely ineffective or more effective.  However, based upon these initial studies, I would wager that the FDA will approve erenumab only for episodic migraines, so if you have over 15 headache days/month, you won’t even be eligible to get this drug. While these indications may change over time, there is no telling how long that timeline will be. 

And these are some of the best data.  Another trial completed and published in early 2018 (ARISE) used the lower dose of erenumab (70 mg monthly) and showed that only 40% of patients achieved the 50% reduction in headache days/month yet in the placebo group, 30% had the same reduction – only a 10% difference.  In addition, the actual numbers showed that these results translated to one fewer headache day/month compared with a placebo! In the more recently reported LIBERTY trial, which included patients with a more debilitating migraine burden, only 30% of patients receiving erenumab had the 50% reduction in monthly headache days which translated to 1.6 fewer headache days/month compared with placebo. Hardly the breakthrough that some in the press would have you believe. The results with headache surgery in patients who seem to suffer many more monthly headaches demonstrate that 88% of patients experience at least a 50% reduction in frequency, severity or duration of symptoms.

There are other unknowns as well.  For example, patients in the New England Journal study were only followed for six months (in the ARISE and LIBERTY trials for only 3 months). What happens afterward? Does the drug continue to be effective, does it become more effective or does it lose its efficacy with time like so many migraine drugs before it? There are 5-year follow-up data for headache surgery that demonstrate continued good results even that far out from an operation.  I have seen this in quite a few patients whom I’m lucky enough to be in touch with that far out.  Most are too busy getting on with their lives. What about side effects?  So far, I believe there is data on erenumab one year out which shows no significant adverse effects. That’s wonderful, but CGRP acts on the vascular system so there are concerns about the long-term risks of stroke and heart attack.  What if you have hypertension, can you use this drug safely?  What if you are a woman of child-bearing age (the major demographic in those suffering from migraines) – can you get pregnant while being on a drug that affects the vascular system and hence possibly the placenta? This question is valid since you will presumably have to take this drug forever.  In the ARISE trial, women of child-bearing age were only included if they were using contraceptives and hence presumably couldn’t get pregnant.

I certainly don’t mean to be a glass is half-empty type of guy as many of you know I am not.  I think this class of drug has a lot of potential and should certainly be studied further.  Maybe with time, we’ll see better results with higher doses or in patients more precisely selected.  Maybe we’ll see this drug used in combination with patients who also have surgery and see more amazing results than in patients having only one or the other.  Time will tell, but I post this so that people who are anxiously awaiting these developments are realistic about what they can practically offer.  Hopefully, that helps.

Seattle is home to just under 1 million people.  Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 180,000 women and 60,000 men suffer from the headaches.  Where can these people turn to for treatment of migraines?  Seattle Migraine and Headache Surgery is available for you.

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief.  Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you.  You can be back home that night, well on your way to recovery from your migraines.  Dr. Peled has performed hundreds of these procedures.  Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Seattle or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches.  Headache surgery in Los Angeles can be a phone call away.

I was really humbled to see and speak with several of my former and current patients just the other day.  During these discussions, one cannot help but be impressed with the sheer strength of the human spirit and the grit and determination with which these people continue to fight their pain and search for answers.  The journey to relief is more like a marathon than a sprint for sure, but even the longest roads begin with the smallest steps and these courageous people have taken big steps forward. Just as amazing are the spontaneous friendships that I have seen form along the way and the support that each of these incredible people provide to one another.  It continually reminds me that connection is an essential part of the human condition and of the role that hope plays in recovery. I am proud to have been a small part of these experiences. These pictures say a million words (mic drop)…….

Questions and comments continue to be raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each approach. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that can be permanent.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique. Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders. He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds. Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.

San Diego is home to nearly 1.5 million people.  Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 270,000 women and 90,000 men suffer from the headaches.  Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief.  Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you.  You can be back home that night, well on your way to recovery from your migraines.  Dr. Peled has performed hundreds of these procedures.  Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in San Diego, Balboa Park, Hillcrest, North Park, City Heights, College Area, Mission Valley, Marine Corps Air Station Miramar, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches.  Headache surgery in Los Angeles can be a phone call away.

Chronic headaches represent an enormous medical problem both worldwide and in the US.  Migraines alone represent the most common primary headache disorder for which people seek treatment. It is estimated that over 36 million people suffer from migraines in America¹, representing about 11.5% of the population or more than one in 10 people. Chronic migraines are thought to affect 2% of the population or over 7 million people in the US².  If you factor in both direct and indirect (e.g. days of bedrest) costs to the healthcare system, you are looking at between $10-$30 billion dollars in annual expenditure^3,4.  Moreover and specific to migraines, it has been shown that the health-related quality of life of people suffering from this type of debilitating headache approximates that of patients suffering from congestive heart failure, high blood pressure or diabetes⁵.  Interestingly migraines are primarily defined and diagnoses made by their clinical characteristics.  In other words, headache patients are usually diagnosed as suffering from migraines if they have recurrent attacks, a pro-drome (e.g. warning signal), an aura, a headache and a post-drome (e.g. after effects).  While many patients can relate to these symptoms, not every patient is the same. Specifically, while other types of headaches have slightly different characteristics, there are similarities in symptoms with migraines and sometimes, patients can have symptoms characteristic of more than one type of headache.  In those cases, how should we diagnose the patient? 

In my view, a different way to think about headaches and perhaps to classify them is by what the underlying etiology (i.e. cause) is thought to be.  I am a firm believer in doing the most conservative thing possible that would give you the best result and along those lines, an evaluation by a neurologist and/or headache specialist with a careful work up is a critical first step.  Appropriate imaging (e.g. MRI of the brain, cervical spine, etc.) as necessary and trials of medications are often the first lines of evaluation and treatment, usually with non-operative interventions as adjunctive measures.  Examples of such adjunctive modalities are physical therapy, therapeutic massage, acupuncture, biofeedback, etc.  However, as we note above, there are so many people that suffer from debilitating, chronic headaches that even if only 10% of people fail such measures (the number is likely much higher), then we have millions of people who continue to suffer greatly.  In these instances, we often have to “think outside the box”.  There continues to be a growing body of literature which suggests that some people suffer headaches as a result of peripheral nerve compression in the head and neck region and who find relief from nerve decompression or even neurectomy (i.e. transection of the nerve) with muscle implantation. 

Given that many people who fail traditional treatment as outlined above have been given the diagnosis of migraines (or migraine variants), perhaps it is our diagnoses that are incorrect.  Many of those same people are successfully treated with surgical decompression. Perhaps, many people who have been diagnosed with “migraines” actually have neuralgia.  This word comes from a combination of neur - meaning nerve and algia - meaning pain and hence the word itself literally means nerve pain.  The question is which nerve is causing the pain and what can you do about it?  Fortunately, there are good answers to these questions, but the diagnosis of neuralgia must be on the radar screen of the evaluating physician.  Hence, if traditional modalities have been unsuccessful or only partially successful, don’t lose hope!

1. Lipton, R. B., Bigal, M. E., Diamond, M., et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343-349.
2. Schwedt TJ, Chromic Migraine. BMJ 2014; 348: 1416-1427.
3. Goldberg, L. D. The cost of migraine and its treatment. The American Journal of Managed Care 2005;11:S62-67.
4. Hu, X. H., Markson, L. E., Lipton, R. B., Stewart, W. F., Berger, M. L. Burden of migraine in the United States: disability and economic costs. Archives of Internal Medicine 1999;159:813-818.
5. Turner-Bowker, D. M., Bayliss, M. S., Ware, J. E., Jr., Kosinski, M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation 2003;12:1003-1012.

We are asked quite a bit whether we only deal with local San Francisco patients, or if we’ll see out-of-town patients as well. Of course we do!  Anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

I have performed hundreds of decompression procedures on nerves for chronic headaches with high success rates. Many of these people had been living with their headaches for decades and had resigned themselves to a life of chronic pain despite medication. Happily, we proved that was not the case. Furthermore, because we see so many foreign and out of town patients, we have developed a system to help make your overall experience as seamless as possible. We can assist with travel planning, lodging, transportation to and from the operating room and even post-operative nursing care if required.

In addition, Dr. Peled is available for initial record review and evaluations via Skype or Google+ to help determine if a trip from home is a worthwhile endeavor. Finally, because post-operative follow-up is an extremely important part of the surgical experience and critical to achieving optimal outcomes, we use these same modalities to keep tabs on our patients after they have gone home and remain available to discuss issues with your local treating physicians if needed. This important time can be hard for patients as well as doctors that can't see their patients directly, but our practice has refined this process to ask the right questions and determine if any further action is needed.

So if you suffer from chronic headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 or 925-933-5700 to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

This post was sent to us by a patient that had experienced migraines for years and was seen by Dr. Peled 3 months ago.  We are happy to share his story and so pleased with his recovery.

Exactly 3 months after migraine surgery with Dr. Ziv Peled my headaches are 85% cured. It's a miracle.

Warning: Post contains graphic images.

Before Surgery

From 2005-2017 I experienced severe migraine headaches characterized by overwhelming pain in the back of my neck, eyes and temples, and severe nausea and vomiting.

From 2014-2017, the frequency and severity of these headaches intensified. They became debilitating. I had to change every aspect of my lifestyle in order to manage them.

When I wasn't having a headache, I was afraid of getting one. No matter how perfect I was with food, posture, exercise, sleep, stress, workload–everything!–I was still waking up with headache pain several times per week.

I had a migraine and was feeling miserable when I snapped this selfie while hiking in Florida in 2014

I was sure that I was on course to being handicapped by these headaches for the rest of my life. I had resigned myself to the fact that being sick was my fate. There are tens of millions of disabled people on this planet. I never imagined I would be one of them.

But there I was, bent over the toilet vomiting day after day, week after week, year after year. I couldn't do the things normal people do because I was in constant fear of awakening in the morning with that feeling that tens of millions of migraineurs know so well–"oh no, I have a headache today."

By late 2017 after an unending streak of failed treatment, I was close to making peace with my illness.

One night in October 2017 I was 18 hours into a migraine. I had woken up with a headache and it worsened throughout the day. It was now midnight and the pain was peaking. I consumed no food and hardly any water all day, but still, the nausea was so severe that I was bent over the toilet vomiting bile for the 4th or 5th time.

I rinsed my mouth, splashed my face with cold water and exited the bathroom into the complete darkness of the hallway. I leaned against the wall into my forearm and was overcome with tears. I sobbed for 15 minutes straight. "This is my life now," I thought. "It's okay. Stop fighting it."

Less than two months later I had migraine surgery with Dr. Ziv Peled and when I emerged from the operating table the headaches were gone.

The 3 Month Marker

It was just 4 days after migraine surgery and I was at my first follow-up with Dr. Ziv Peled. My recovery was just beginning but already I was convinced that the procedure was a slam dunk and that I had been fixed. 

On my way out of his office, I shook Dr. Peled's hand and said, "Thank you, you gave me a new life." 

"Let's not claim victory just yet," he replied.  

What he meant is that it is irresponsible to pass judgment on the effectiveness of migraine surgery for at least 3 months following the procedure. This is because surgery is invasive and makes a big mess of things.

Migraine surgery involves cutting and laser-burning scar tissue, muscle and other structures that are compressing the target nerves. Therefore any headache pain felt for several months after surgery might be related to the invasiveness of the surgery itself. It takes a while after the operation for things to settle down. 

Well, it's been three months and the dust has settled and I am finally ready to pass judgment on the effectiveness of my December 2nd migraine surgery.

The Moment I Knew I Was Fixed

The truth is that I really did know immediately after surgery that the procedure was a home run and that I had been almost completely cured. But I wanted to follow migraine surgery protocol and wait at least 3 months before publicly declaring victory.

Tasting victory the moment I woke up from migraine surgery!

How did I know? From 2013-2016 I spent over 16 months living at two Buddhist monasteries where I received formal meditation training. While living at these monasteries I spent 2-8 hours per day performing seated breath meditation which resulted in me becoming hyperaware of the sensations occurring inside my body.

During this same three year period of monastery-living, my migraine episodes became much worse. There were certain awful stretches at the monastery where every other day I would have 10/10 headache episodes with nausea and vomiting.

As a result, my headache pain became a main focus of my meditation. I would use my breathing to explore the pain and bring myself relief. During this time I came to know the topography of my headache pain like the back of my hand.

On the surface, a migraine headache might seem to be composed of one monolithic blob of pain that descends from thin air onto the head like a black rain cloud.

But with my meditation, I realized that actually there were certain spots in the back of my neck, eyes, and temples that were like little cel-towers that radiated pain outward.

I came to think of these spots as trigger points. Pressing on them with my fingers at any time would create zingy migraine pain that would radiate across my scalp and even into my gut.

There was one trigger point, in particular, that was especially bad. It was on the back of my neck in the vicinity of my right lesser occipital nerve and it almost constantly radiated headache pain.

During surgery, Dr. Peled discovered that the source of this trigger point was my genetically abnormal right lesser occipital nerve which had 3 branches instead of 1 (the normal amount), all of which were severely compressed.

My left lesser occipital nerve was even worse–it had 4 branches, all compressed.

Compressed lesser occipital nerves were the cause of headache trigger points I had felt for years.

Surgery would also reveal that I had severe compression to my greater and third occipital nerves which corresponded to the other trigger points I had felt for years.

The nerve compression seen above corresponds to one of my pre-surgery trigger points.

Compare my decompressed left greater occipital nerve in this photo to the photo above to see how compressed this nerve really was.

I remember the moment I realized that migraine surgery worked. I was in the car on the way home from the procedure, still hazy from the anesthesia but alert enough to do a bit of exploring.

I pressed my finger into my worst trigger point on the right side of the back of my neck: the area was numb and I felt no zing. Totally pain-free. I tried my left side. Same thing–painless. Next, I tried a few other hotspots in the back of my neck and they were all the same: numb and neutral.

I could not remember any time prior to these moments that I had pressed into these spots without invoking headache symptoms. This was a miracle. I knew right then and there that Dr. Peled had eradicated whatever it was in my neck that was transmitting all that pain.

I'm 85% Better. It's a Miracle

Dr. Peled decompressed my greater, lesser and third occipital nerves. All of these nerves are located in the back of the neck and back of the scalp. Since surgery, I have had almost no headache pain at all in this region and I feel 85% better than before.

This means that all along my occipital nerves accounted for 85% of my migraine pain.

I continue to have relatively mild, relatively infrequent headache pain in my eyes and temples. Whatever headache pain I'm still having–that last 15%–is entirely up front where Dr. Peled did not operate.

In the temple is the zygomaticotemporal nerve, near the side of the eye socket. And in the eyebrow and lower forehead are the supraorbital and supratrochlear nerve. Like the occipital nerves, these three nerves are common migraine-triggering culprits.

The inflammation of these nerves can be a side effect of the inflammation of the occipital nerves. The eye/temple nerves and occipital nerves do not actually touch each other in the scalp. But as they approach the spinal column, they lie beside each other.

So when the occipital nerves become chronically inflamed, the adjacent frontotemporal nerves can become inflamed as well. This phenomenon is known as referred pain.

And because headache pain in the eyes and temples is often just referred pain coming from compression in the neck, fixing the neck nerves sometimes eliminates eye/temple headaches too. This is why in my case Dr. Peled suggested decompressing the neck nerves and waiting 3-6 months to see if the nerves in my eyes and temples would calm down as a result. 

Well it's been 3 months now and I continue to have frequent but relatively mild pain in my eyes and temples. Just like before, I wake up with this pain. This pain is occurring 2-3 times per week with an average level of 3/10 and an average duration of about 4 hours.

And this pain is very responsive to triptans. I have used Zomig nasal spray exactly 6 times since surgery on December 2nd with a 100% rate of reducing the headache to a 0/10 within 2 hours.

I will most likely have a follow-up migraine surgery with Dr. Peled in April to decompress my zygomaticotemporal, supraorbital and supratrochlear nerves. I'm hoping that after this second procedure my headaches will be 100% cured.

The Key to Migraine Surgery Recovery

Recovering from migraine surgery has been smooth sailing for me. Before surgery, I had read a lot of fear-talk about the recovery process. I found none of it to be true.

My neck's range of motion was limited for the first month. I had a hard time driving my car in reverse or quickly checking my blind spots, that sort of thing. That is about the extent of my disability in the wake of migraine surgery.

Since about day 35, I've been between 80-100% and engaging in all of my normal work and other activities.

I believe that the key to my speedy and painless recovery has been my habit of massaging the surgical site twice a day since week 3. This is not something Dr. Peled advised me to do. Actually, I haven't mentioned it to him. But I have found it very helpful.

Presently I'm convinced that the main reason so many people struggle with migraine surgery recovery is because they allow their neck and scalp to become stale, stagnant and painful through non-use and non-touch in the wake of surgery.

It is easy for this to happen. With all the incisions and numbness it is natural to want to keep as much distance as possible from the site of surgery.

I have found it very beneficial not to fall into this trap.

Massaging the neck and scalp keeps these areas online. Pressing into them with your fingertips promotes blood flow which leads to healing. And just as importantly, massaging through the pain and stiffness teaches you that your post-op neck is a lot stronger and more durable than you think.

I started massaging around my incisions on day 15 after taking my bandages off. I used extremely light pressure with just my finger tips–I wasn't sure if my incisions would reopen with too much force.

But I quickly realized that the incisions were more robust than they felt. By day 18 I was running my fingers directly beside the incisions and applying more and more pressure.

It felt like I was breaking up weeks worth of coagulated stiffness. The pleasure was amazing. 

Eventually, I ended up with the following routine which I performed twice a day: first thing in the morning and last thing before bed.

How to Self Massage After Migraine Surgery:

1. Fill a Tupperware with either plain or very lightly salted water. This will serve as massage lubricant.
2. Lean your forehead against a wall in order to allow your head and neck muscles to rest and relax.
3. Dip your fingertips into the water and run them down the entire area of the back of your head and neck using light pressure. Do this two fingers width at a time
4. With massage, press into the area directly around the incisions. Soon you'll realize that it's no big deal to use a fair amount of pressure around and even directly on top of the cuts.
5. Do 30 strokes in the area of each incision.
6. Massage your eyes, temples, and the rest of your scalp for good measure. You want to do everything you can to promote blood flow and awaken and nerves that have gone numb with surgery.
7. Experiment with other massage strokes and pressures that feel good.
8. Perform this massage last thing before bed and first thing in the morning. Each session should last between 5-15 minutes.
9. Do this for at least 3 months after migraine surgery.

This massage routine has kept my neck loose and limber following surgery. If I skip even one night of massage I feel a significant increase in neck stiffness the following morning.

Stay in touch with your neck. Keep it online. Touch it often after migraine surgery.

Here's to Dr. Ziv Peled

I cannot overstate how tremendous my experience with Dr. Peled has been. I am not exaggerating when I say that he is the most impressive physician I have ever met.

I think he is outdone only by his wife, Dr. Anne Peled, who is a highly respected, life-saving breast cancer surgeon.

Dr. Peled site-marking before surgery. These were some of my final moments as a migraineur.

My A+ experience with Dr. Peled began with my first phone call to his office when I spoke with practice manager Cary-Anne Alvord. She was kind, attentive and seemed genuinely concerned about my dire headache situation.

Since the very beginning, Cary-Anne has been patient and available and has made arranging the ins and outs of meeting with Dr. Peled a piece of cake. A practice manager can make or break a medical experience and Cary-Anne is fantastic.

Before ever meeting Dr. Peled I had read many of his blog articles and seen online interviews and lectures. I knew that he was brilliant and clearly one of the world's leading experts in peripheral nerve headache surgery.

I was most impressed by his groundbreaking article on the compression topography of the lesser occipital nerve. Other migraine surgeons automatically perform a neurectomy on the lesser occipital nerve. But Dr. Peled has pioneering, expert knowledge in the handful of areas where this nerve regularly becomes compressed.

As a result he is able to offer an individualized approach to dealing with the lesser occipital nerve during surgery. Unlike other migraine surgeons who always remove this nerve, no questions asked, Dr. Peled decides whether or not to perform a neurectomy on a case-by-case basis.

If the nerve can be fixed he will do so and leave it intact. The advantage of decompressing rather than severing the nerve is that sensation to the innervated area is preserved. The patient keeps sensation in that part of their head or neck.

My first meeting with Dr. Peled was a Skype consultation. He spent 45 minutes conversing with my father and I about every last detail of my patient history and everything we needed to know about migraine surgery.

I was surprised that such a high profile surgeon offered us so much time and attention. We ended that first Skype call feeling great about Dr. Peled and about my candidacy for migraine surgery and would book an operation date 24 hours later.

When my parents and I arrived in San Francisco and met Dr. Peled we were again blown away by his expertise and availability. I showed up to my in-person consultation with a throbbing 10/10 headache and he spent close to two hours performing the nerve block diagnostic on me.

The only other time I had spent 2 hours or more in a doctor's office, it was in the waiting room. 

Throughout this long appointment, he was happy to answer any and all questions my parents and I had. His responses were all very thorough and very brilliant.

Dr. Peled talks us through the photos he took during surgery.

Dr. Peled's enthusiasm and passion while discussing headaches left no doubt that he was put on this earth to advance humanity's understanding of peripheral nerve headaches and to surgically heal them whenever he could.

As for his surgical skill: what more can be said? The man cured me. He did the impossible. He made over ten years of chronic headaches disappear in a matter of 3 hours. 

I had almost no postoperative pain. My incisions have healed well without complication since the beginning. Now they are almost completely painless and hardly visible at all.

After all Dr. Peled is a plastic surgeon. Finish work is his forte. 

Here's what my scars look like exactly 3 months after surgery. The following photos were taken on March 2, 2018.

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Three months ago at my first post-op Dr. Peled would not let me thank him for giving me a new life. It was too soon then, but it isn't now. Dr. Peled–thank you. 

Under his knife I've been cured from of a chronic headache condition that I was certain would handicap me as long as I lived.

He is my hero and I hope that this post will lead other migraineurs into his healing hands.

Digging Deeper

Dr. Peled relieved my headaches by decompressing my occipital nerves. But to understand the root cause of my headaches we must ask: what caused the nerves to be compressed in the first place?

Just to clarify: the following ideas are my own, not Dr. Peled's.

I believe that in my case my occipital nerves became compressed as a result of a lifetime of poor neck posture.

To go one step further down the rabbit hole, I'm actually convinced that my poor neck posture was itself just a byproduct of the true root cause of my headaches: abnormal facial growth that began in my infancy.

It works like this:

atypical facial growth→ compressed neck posture → nerve compression in the neck → chronic migraines

This is why in addition to migraine surgery I am growing my palate forward with the Anterior Growth Guidance Appliance and leveraging the increased space in my mouth to develop proper tongue and neck posture.

By developing proper tongue and neck posture, I am ensuring that my neck will never bear excessive stress and strain again.

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that can be permanent.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique. Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders. He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds. Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment for your Beverly Hills Headache and Migraine Surgery today.

Patients are often asking me why nerves become compressed and what causes the compression. Many different structures can cause nerve compression and there are any number of biologic processes that can also result in nerve pressure on a nerve. However, after distilling it down to its basic essence, there are, in my humble opinion, three reasons why nerves can become compressed and I will list those below.   The key thing to remember is that all peripheral nerves travel some distance going from the spinal cord to the structure(s) they innervate.  Along the course of their travels, they pass along many other structures and through many little spaces.  The most common example is the carpal tunnel.  Most people have heard the term ‘carpal tunnel syndrome’ and this clinical entity occurs when the median nerve experiences undue pressure as it passes through a normal anatomic canal known as the carpal tunnel in going from the wrist to the hand. 

Using the carpal tunnel example, the first basic thing that can cause pressure on a nerve is if the nerve swells within a fixed space.  The carpal tunnel is bounded, by bone and ligaments and like the skull, will not expand.  Hence when the median nerve is swollen passing through that fixed space, there is pressure on that nerve that didn’t exist when the nerve was not swollen. As the wrist flexes back and forth, that nerve is asked to glide back and forth as well and because it no longer glides as easily, there can be trauma to that nerve that may further exacerbate the damage caused directly by the pressure. 

Another basic factor that can cause nerve compression is if the nerve is passing through a fixed space, but that space becomes narrowed.  A prime example of this phenomenon would be arthritis.  Recall that any ’itis is an inflammation of something.  Mastitis is inflammation of the breast, colitis an inflammation of the colon and so forth.  Arthritis is an inflammation of the joints and the wrist joint is one prime example.  Therefore if a normal sized median nerve is trying to pass through an inflamed wrist joint, there is less room to allow passage and once again the nerve becomes compressed.  Similarly as in the above example, as the wrist moves back and forth, the nerve is unable to glide as easily and the same pathologic processes noted above likely occur.

The final basic factor that can result in nerve compression is a combination of swelling of the nerve and narrowing of the space through which it is trying to pass. In this case, the nerve is often very compressed.  Putting these three basic principles into play, one can also see that there are many structures that can cause these problems.  For example, in the case of the greater occipital nerve, it often passes through a narrow fascial window comprised of the insertion of the trapezius muscle at the base of the skull. At around this level, the GON also passes in close proximity to the occipital artery.  If the artery is enlarged (e.g. aneurysmal secondary to trauma) the space through which the nerve passes is by definition narrowed.  Moreover, the beating of that larger blood vessel against the GON may be one reason why many people report a “pounding” headache.  Alternatively, the supraorbital nerve is theoretically supposed to pass from the back/top of the eye socket to the forehead through a notch in the frontal (i.e. forehead bone) known as the supraorbital notch.  In some patients, however, that notch is actually a bony foramen - in other words the nerve is completely surrounded by bone.  Bone is therefore the culprit here and the treatment is to convert that foramen into a notch.  I have attached two pictures that illustrate this maneuver.  The take home message is that the causes of nerve compression are actually simple in their most basic form, but a thorough knowledge of peripheral nerve anatomy and experience in peripheral nerve surgery are key factors in putting these principles into action and in achieving a good outcome from surgical intervention.

If you’ve been paying attention to the Winter Olympics in South Korea, you might have seen American luger Emily Sweeney crash on her fourth and final run at approximately 68 miles per hour.  It was clear that she was initially stunned, but happily was able to get up and walk away on her own.  Sometime later, she was being interviewed by a reporter from NBC and stated that she was ok adding that she was also very sore and stiff and was about to get an x-ray of her back.  Obviously, we all hope that Ms. Sweeney has no significant, permanent injuries and we all respect her courage and toughness in competing at a difficult sport at such a high level, especially when faced with the prospect of injury.  However, in watching her interview, I couldn’t help, but feel that there was some continued suffering in her affect and voice.

If you watch her actual crash, you can’t help but notice the impact of the speed and ice on her body as you see her hit her head and the contortions that follow.  Sadly, I see people who have had similar injuries from motor vehicle accidents, falls from horses and other types of sports who suffer from chronic headaches.  Many of these people have been diagnosed with “whiplash” which tends to be a basket diagnosis when someone has continued chronic pain, usually headaches, but whose workup including x-rays and MRIs don’t show any pathology and whose etiology remains unclear.  Unfortunately, at this point in time x-rays and MRIs (even magnetic resonance neurograms) are often not sensitive enough to pick up injuries in very tiny nerves that can cause significant pain.  In the case of neck injuries following which people experience chronic headaches, I believe that many of these symptoms are caused by traction (i.e. stretch) injuries of the various occipital nerves resulting in scar impingement around the nerves or actual tears within the nerves themselves.  These tears then heal with scar impacting nerve conduction and resulting in numbness, tingling and/or pain.  As a result, these patients end up seeing many different types of doctors who often prescribe many different types of drugs and give many types of injections in the hopes of treating this pain permanently. 

However, whenever there is a mechanical injury of a nerve, for example, compression secondary to scar tissue formation, a mechanical solution needs to be found.  For these patients, a simple nerve block (i.e. injection of local anesthetic) used in a diagnostic manner, will not only provide temporary relief, but allow the experienced peripheral nerve surgeon to discern which nerve or nerves may be involved in that particular person’s symptoms thereby pointing the way to a potential surgical solution which is often permanent.  Sadly, peripheral nerve pathology as a cause for many cases of whiplash or sports concussions with resulting headaches remains very unrecognized.  However, some physicians including some prominent neurologists are actually coming around to recognizing that structures outside of the brain and spinal cord can cause debilitating headaches.  Happily, they refer these patients to a trained peripheral nerve surgeon for appropriate diagnostic workup and ultimately treatment.  Hopefully Ms. Sweeney will not require surgical intervention of any kind, but if she were to experience chronic headaches with no other identifiable cause, I would hope that her trainers and doctors consider the possibility that a stretch injury to a peripheral nerve may be the underlying etiology which will save her and perhaps many others years of suffering.

To learn more about how migraine surgery can help with migraines caused by peripheral nerve damage from sports injuries or whiplash, visit www.peledmigrainesurgery.com today or call (415) 751-0583 to make an appointment.  Don't live with migraines if you don't have to. 

I was recently made aware of a post written by a patient suffering from occipital neuralgia.  This disorder is a terribly debilitating neurological condition often characterized by unremitting pain in the back of the head and neck that, if left untreated, can lead to pain in the temples and face.  The gist of her essay was that at times, the burden of this chronic pain was so overwhelming that there was a desire to just ‘get off the train’ to make it stop.  I read this post with sadness and empathy and had been chewing on its message for the past several days.  I then began to reply with a message of hope which, in the case of ON, I believe is very real and possible.  Over the years, I have seen numerous patients who came to believe there was nothing anyone could do to help them.  These patients felt abandoned by their doctors who either didn’t understand their condition, didn’t care or simply didn’t know what to do despite the best of intentions.  In fact, despite beating the drum about the surgical treatment of ON, I continue to find that many physicians remain skeptical or simply unaware that a good treatment option exists.  Aside from the actual physical, emotional and psychological burden of the actual pain, this perceived state of affairs causes further trauma and often leads to outright despair on the part of the patient.  Yet somehow, through sheer grit and a desire to keep looking for solutions, they arrived at my office.  Happily, in the overwhelming majority of cases we found a path forward together - not always a cure, but a significant improvement in their daily pain that made their lives better and restored their belief that things would eventually be ok.  The fulfillment derived from the ability to give someone their lives back in this way cannot be put into words and is the reason doctors do what they do.  The take-home message was simply to never give up hope, to always look for answers, even if you had to look outside the box and to have the knowledge that a solution is always possible, just sometimes harder to find.

As I began to finalize this post, I heard from the husband of a former patient who, in the prime of her life had just passed away from an accident at home.  I had operated on her for ON almost 4 years to the day and happily, she had done very well.  There were other pain-related issues with which we were also able to help and the road to recovery was far from smooth, but her ability to stay positive and always look towards the future overpowered the years of suffering.  She was a true warrior and recently had essentially weaned off of all of her medication. She looked like a new person when I last saw her with a smile and brightness I hadn’t appreciated on her initial visits.  I can’t help but feel in my soul that what truly sustained and ultimately healed her was the love of her amazing & devoted husband and their children as well as her unending optimism.  After an initial emotional reaction, I called her husband to convey my condolences and provide whatever support I could, given the circumstances. We spoke for some time and he kindly allowed me to dedicate this post to her. 

Charlotte, this one is for you.  My faith teaches me that we don’t know what happens when we pass, but we can live on in the hearts and memories of those who remain with us.  I can think of no one who better epitomizes this message. Your life and example of never-ending optimism taught me so much, made me a better physician, and will continue to serve others whom I treat in the future when the world seems dark.  I’ll end with one of your favorite sayings: “You don’t have to move mountains. Simply fall in love with life.  Be a tornado of happiness, gratitude, and acceptance.  You will change the world just by being a warm, kind-hearted human being.” Charlotte, you have done just that.

Dr. Ziv Peled has been named as a 2018 Top Doctor by Castle Connolly, one of the trusted names in the medical industry.  Dr. Peled earned the honor for his tireless work to make the lives of patients better, in plastic surgery and migraine surgery.  Dr. Ziv Peled's career is marked by hundreds of satisfied patients and multiple awards and articles written.

One of the questions I find myself answering again and again is how I make the decision as to what to do with a nerve once I see it in the operating room. Do I perform a neurectomy and muscle implantation or do I stop at a decompression? There are a lot of factors that go into making that decision so I will elaborate on a few of these in the lines that follow.

To begin, there are certain ultrastructural characteristics that indicate a relatively healthy nerve. One, you should have an intact vasa nervorum – the blood vessels within the nerve. These can be seen under loupe magnification as fine red lines and indicate good blood flow to the nerve itself.   Blood flow is usually a sign of life and this nerve should be considered for decompression and preservation. Another characteristic is the feel of the nerve. A healthy nerve should feel like a soft, wet noodle. If a nerve is firm like a banjo string, it usually means that there is at least scarring of the epineurium (the outermost covering of the nerve) and often the structures contained within. In these cases, an internal neurolysis to separate the healthy from unhealthy fascicles is required and if the scarring affects too many fascicles, a neurectomy with muscle implantation is probably the better part of valor. Third, the fascicular pattern should be visible. Think of nerve fascicles like bundles of wire (e.g. the blue one vs the red one in all of those movies in which the hero is trying to defuse a bomb) within an electrical cord. Stated differently, what you’re looking at when you look at a cord plugged into a wall is a rubber tube - the actual wires are the copper fibers inside that rubber housing. Those copper wires are analogous to the individual neurons (i.e. nerve cells) and in an electrical wire, are often arranged into bundles. In a nerve, those bundles of neurons are called fascicles. However, unlike the cord plugged into the wall, in a healthy nerve, the “rubber housing” should be transparent and the fascicular pattern should be visible. If it isn’t, the nerve isn’t completely healthy and those fascicles may be permanently damaged. Take a look at the attached picture of a recent patient whose supraorbital nerve branches (multiple black lines) and supratrochlear nerve (arrowhead) are visualized. Notice how white the supratrochlear nerve towards the right of the picture is and the lack of any fascicular pattern. In contrast, the supraorbital nerve branches towards the left are pink indicating an intact vasa nervorum and the fascicular pattern is visible if you look very carefully (and likely magnify the picture on your computer). Fortunately for this patient, the vasa nervorum re-constituted and the fascicular pattern became more pronounced once the supratrochlear nerve was decompressed and a few minutes were given for the nerve to declare itself – yet another nuance of technique. Therefore, both nerves were able to be preserved in this particular case.

Yet another factor to consider when deciding what to do with a nerve in the operating room is the actual function of the nerve itself. For example, the greater occipital nerve, as its name suggests, has the largest area of sensory distribution of any nerve in the occipital region. Therefore, performing a greater occipital neurectomy would leave the patient with a relatively large area of numbness. Personally, I have a relatively high threshold for transecting the GON. By contrast, the third (a.k.a. least) occipital nerve is many times smaller than the GON and has a minimal area of sensory distribution that is often also supplied in a redundant fashion by the GON. Therefore, if the third occipital nerve is damaged, I have a lower threshold for performing a neurectomy since it is likely the patient wouldn’t have much numbness, if at all, were that nerve to be cut and buried in a muscle. Lastly, is what I would call the “x factor”, in other words clinical decision making. I’m often reminded of a saying I heard once that went something like this, “Good judgement comes from experience and experience comes from bad judgement”. In other words, experience counts and takes into account a myriad of other variables before ultimately making decision A versus decision B. What was the mechanism of injury and how long ago did it occur? What other treatments have they had that might have affected the nerve along its length (e.g. RFA or cryoablation) and how many times have those modalities been performed? How did the patient respond to the numbness from the nerve blocks? How old is the patient and how likely is it that they would tolerate a repeat procedure if decompression fails? Alternatively, how young is the patient and what is their regenerative potential? If you cut that young person’s nerve, how would they tolerate 50 years of numbness as opposed to the 70 year-old patient who may only live with it for a few years and has many other medical problems more pressing than a little hypoesthesia. The take home message is that electing to perform a neurectomy as opposed to a decompression involves a multifactorial decision making process so have a frank discussion with your surgeon about how s/he will decide which path to take.

At the most recent Plastic and Reconstructive Surgery- Global Open (PRS Global Open) Managing Committee and Editorial Board meetings held in October 2017 in Orlando, Florida, I was nominated and elected as an Associate Editor to the Editorial Board of PRS Global Open. My nomination and election has been subsequently forwarded to the ASPS Executive Committee. They have approved my selection, and I am now an official member of the Editorial Board of PRS Global Open!

Read the whole statement here!

Over the past few weeks I’ve had a number of people in the office tell me that they heard you should never cut a nerve because it would grow back and cause more pain. I have always been baffled by this comment since nerves can be repaired, reconstructed and dealt with much like blood vessels and bones. Obviously, there are differences in that, for example, you would never use plates and screws on a nerve like you would for a long bone (e.g. the femur – thigh bone). Moreover, if you think about it, what would happen to all of those poor souls whose nerves are injured and cut in accidents? Would they be doomed to a life of numbness and pain? Of course not. So let’s delve into this issue a bit more.

When a nerve has been permanently injured and a piece of that nerve must be removed, there are several options for repair. Ideally, a primary repair (i.e. putting the ends back together directly) would be performed, but this maneuver is only possible in certain specific situations such as when there has been a sharp cut (e.g. with a piece of glass), very little nerve is actually missing and relatively little time has elapsed from the injury to presentation. If a primary repair is not possible, there are other options including repair with nerve conduits, nerve grafts (both autologous [i.e. from the person themselves] or exogenous [e.g. cadaveric]) and perhaps even nerve transfers. Similarly, if a sensory nerve is transected and implanted into a muscle, the majority of patients do well albeit with possible numbness in the former nerve distribution. However, in some cases of nerve transection and implantation, just like in the cases of nerve repairs following injury, the procedure does not go as planned and numbness, loss of function and/or pain remains. In some of those cases a neuroma forms. So now what?

Well, one of the best things you learn as a plastic surgeon and one of the things that makes our training unique (admittedly I’m biased) is the ability to use surgical principles in creative ways. For example, you can learn all sorts of flap and graft techniques for facial reconstruction following removal of skin cancers, but if you really think about it, everyone’s face is different. Their skin quality, skin amounts, the location of the holes left by tumor removal, the orientation of those defects, the degree of exposed underlying structures are absolutely unique in every case. Therefore, the plastic surgeon must apply the principles s/he has learned and create a reconstructive plan that is similarly unique in each case. The same is true if a neuroma forms. As we noted above, there are several options for nerve injuries and those principles can be applied to the treatment of neuromas.

If a nerve was happily ensconced in a muscle, but was jarred loose by a subsequent accident, then that nerve end may simply be found, freshened and re-implanted further into a muscle. Another treatment option for a post-operative neuroma is to perform an end-to-side repair of that nerve to another sensory (or perhaps even motor) nerve. We do these types of re-innervation procedures to help amputees power the newer myoelectric/bionic prosthetics you may have seen on TV. Yet another option is to excise that neuroma and connect that new nerve ending to a long cadaveric nerve graft (i.e. an allograft). In this case, the surgeon would be utilizing the principle of distance in that it is unlikely the cut nerve would actually grow all the way through the entire graft and hence the end of the allograft would be quiescent and unlikely to cause further pain. So you see, there are almost always ways of dealing with issues that arise. In other words, a neuroma is not necessarily the end of the story.

Dr. Ziv Peled will be speaking today at Plastic Surgery: The Meeting 2017 TODAY at the meeting in Orlando, Florida.  Dr. Peled will be discussing Migraine Surgery and its benefits to patients.  He will also help teach a cadaver course to teach his techniques for migraine surgery to other surgeons.

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that is permanent.

I received some great news yesterday. I was speaking with one of my patients discussing their current condition six months following her operation. Happily, she is doing quite well and has no more headaches except with severe barometric changes. She rarely requires any opiates except in those unusual situations which thankfully occur very infrequently. This patient does have a little are of sensitivity, but with a postage-stamp sized Lidoderm patch worn overnight, she sleeps well and is extremely happy; which makes me extremely happy. But this result is not the best part. As we spoke, I asked her about her plans to adopt a child, something we had discussed on many occasions in the past as it has been a goal of hers for quite some time.   She relayed that her status was “going to committee” later that day, when a group of people would decide whether this child would be adopted by her or one of two other families. A few hours later, she received great news - she was going to be a mom. I had a big fat grin on my face for several hours thereafter knowing how happy she was and what a great mom she was going to be. As a father of three, I can totally relate. During clinic in the afternoon, another patient came back several months following her operation. She and her husband had recently returned from a trip to Iceland which they told me they enjoyed more than any vacation in recent memory, in large part because she did not have any more headaches, something that had plagued her on many prior trips. When I first walked into the room, the smile on her face said it all. Still later that day, I also heard back from the mother of a third patient who is now 18 months following her operation. This woman told me that her daughter is now also a new mother! Moreover, she felt that her daughter would not have been doing the things she was doing at the present time were she to be in the same state she was prior to her operations, which her mother credits with helping her daughter achieve these milestones.

This is the good stuff. As physicians, we are often trained to be very clinical which is important and rewarding. After all, it feels good to something well. It can also be daunting hearing about how many people suffer, often for long periods of time without much relief. However, it is the human aspect of what we do that is truly gratifying and these challenges are also great opportunities. To see and feel that we can touch people’s lives in such meaningful ways, is difficult to put into words (despite this blog’s attempt at doing just that). Yesterday was a good day.