Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

Mar
01

Am I Safe For Migraine Surgery?

Am I Safe For SurgeryOne of the more interesting questions that has come up recently is whether or not a person is safe for surgical intervention if they have other medical conditions.  This query is very important and was addressed in part on a recent episode of Burning Migraine Questions on FB Live, but I’d like to go into more detail here.

The first item that needs to be in place is an accurate diagnosis and cogent surgical plan.  After all, if a person is having the wrong operation, or it is performed inadequately or both, the outcomes will be suboptimal.  The best way to address this issue is to see a headache/migraine surgeon who not only understands the pathology for your particular case and has experience in treating it, but also has specific training in doing so and who understands you and your particular challenges. All of these points have been discussed in greater detail in a previous blog post (How To Choose A Headache Surgeon), but the latter item is the focus of this particular entry.

Since every patient is unique, each will have a specific nerve or nerves that will need to be addressed. Further, each patient will have different medical problems that have nothing to do with their nerve issues.  While no operation (or medication for that matter) is without potential risk, the most important thing a surgeon can do is give the patient as safe a procedure as possible. In some patients, especially those above a certain age and/or those with pre-existing medical issues, a thorough medical workup by the patient’s primary care provider is important in achieving that goal.

For example, one patient may have an aneurysm in a large vessel.  This patient clearly needs to see a vascular surgeon before undergoing headache surgery. While headache surgery is significant, an aneurysm may be life-threatening and should be addressed first.  If cleared and the patient is deemed a candidate for surgery, then they can reasonably proceed.

Alternatively, if a patient presenting for headache surgery is on blood thinners because they have an abnormal heart rhythm, that person must be cleared by their cardiologist before entertaining surgical intervention. The cardiologist and headache surgeon must confer on how to manage that patient’s anti-coagulation around the time of the planned procedure.

Finally, one of the more common issues is how to manage pain medication.  Many patients presenting for headache surgery are on a lot of pain medications because of the severity of their symptoms and the inevitable question arises, “Who will manage those medications before and after the operation?” Do you add another medication to deal with the acute on chronic pain following an operation in a chronic pain patient or do you double the current dose of medication? There is no one right way to handle this issue, but again, a thorough discussion needs to take place between the patient, the headache surgeon and the person prescribing those medicines.  

One of the key aspects of a headache surgeon’s role is to understand you, not as a disease or a medical challenge, but as a person with a medical problem.  We can only do that in partnership with your existing medical team.

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Feb
15

Ziv M. Peled, MD Named to Top Doctors 2019

San Fran Mag CoverSan Francisco Magazine has named their Top Doctors for 2019 and included Ziv M. Peled, MD among their number.  Dr. Peled was chosen from hundreds of physicians in the area, and was one of only 22 plastic surgeons named to the list.  You can read the entire list in San Francisco Magazine.  

The list was compiled by Castle Connoly Medical Ltd, which is a health care research and information company that asks licensed MDs and DOs, hospital execs, and county medical societies to nominate their own. Doctors cannot nominate themselves, and cannot pay to be ion this list.

Castle Connoly’s research professionals screen each doctor that is nominated for educational and professional experience, and checks for personal identifiers like a top medical degree, what hospitals the doctor is affiliated with, faculty appointments, experience, and board certifications, along with malpractice suits and disciplinary action. With 930-plus nominees over eight Bay Area counties—Ala­meda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara and Sonoma—they shortened their list of top docs to 616 names.

The list of Plastic Surgeons is below and we're proud to be included among these fine surgeons on this list. We want to thank San Francisco Magazine and Castle Connoly for this honor, and we can't wait to be back on this list next year!

Ziv M Peled Top Doctors 2019

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Feb
14

Ziv M Peled, MD Answers Your Burning Migraine Questions February 7th, 2019

Ziv M. Peled MD Presents Landscape

Ziv M. Peled, MD answered your Burning Migraine Questions on Facebook Live on February 7th at https://www.facebook.com/pg/MigraineSurgery.
If you couldn't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the next stream.

To find your answers in the video, here are the times to fast forward to for each Burning Migraine Question of the video:

1:09 Is it possible to have nerve decompression surgery on all of the areas at the same time?
6:10 Can Occipital Neuralgia develop as a result of a B12 deficiency?
8:35 When my ON flares very badly, it feels like my right ear is hot and someone is stabbing a knife in it. Could the auricular nerve be affected as well as the lesser occipital nerve?
11:24 Could nerve decompression surgery be successful for someone with Ehlers-Danlos syndrome, and who isn't responding to nerve blocks?
13:42 What qualifies and disqualifies a patient as a candidate for nerve decompression surgery?
14:29 What defines a "successful" nerve decompression surgery result?
17:07 Why is it that when you have a barometric pressure change or a cold that symptoms flare up?

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Jan
24

Ziv M. Peled, MD Answers Your Burning Migraine Questions

Dr. Ziv Peled Presents 3

Ziv M. Peled, MD answered your Burning Migraine Questions on Facebook Live on January 24th at 2:45pm PST (or January 25th at 9:45am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
If you couldn't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the next stream.

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Feb
07

Ziv M. Peled, MD Answers Your Burning Migraine Questions February 7th

Ziv M. Peled MD Presents Landscape

Ziv M. Peled, MD answers your Burning Migraine Questions on Facebook Live! Join us on February 7th at 2:00pm PST (or February 8th at 9:00am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
You can ask us questions during the Facebook Live chat or, if you can't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the stream.
We're looking forward to seeing you there!

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Mar
08

What To Look For When Choosing A Migraine Surgeon

What To Look For When Choosing A Migraine Surgeon

Dr. Ziv Peled explains how to choose a peripheral nerve surgeon, what qualifications to look for and how to decide who is the best fit for you!

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Oct
23

Migraine Solutions Discussed in USA Today

Dr. Ziv Peled, Peripheral Nerve and Plastic Surgeon, was recently asked to sit down and answer some questions about migraines and migraine relief.  Here is a transcript of the interview.

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Oct
05

Dr. Peled Named To Young Plastic Surgeons Steering Committee

Dr. Peled Named To Young Plastic Surgeons Steering Committee

Another exciting honor for Dr. Ziv Peled!

Dr. Ziv Peled was recently asked to serve on the Young Plastic Surgeons (YPS) Steering Committee of the American Society of Plastic Surgeons (ASPS). This Committee is comprised of several up and coming thought leaders in the field of Plastic Surgery and is in charge bringing information on the ASPS/PSF (Plastic Surgery Foundation) to residents and young plastic surgeons and to encourage their professional development through membership in the ASPS. Members also act as liaisons between plastic surgeons in the early stages of their careers and established ASPS Member Surgeons.
The YPS Steering Committee works proactively to convey information about ASPS/PSEF to residents and young plastic surgeons and encourage their professional development through membership in ASPS. Participation on this subcommittee is an opportunity for young members to become actively involved in the Society and Educational Foundation; the committee also promotes a YPS auditor program that invites young plastic surgeons to audit committees of interest.
The YPS Steering Committee also develops the programming for the Annual Meeting's Residents Day and provides input to the Practice Management Education Committee on programming for the annual Senior Residents Conference. In addition, the committee has responsibility for the Breakfast of Champions event and the Fresh Faces panel presentation during the annual meeting.

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Sep
21

The Road To Recovery From Migraine Pain

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply.

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply. First and foremost, each patient is different in terms of their tolerance for discomfort. What may be a 9 out of 10 pain to one person may only be a 5 out of 10 pain to another person. Secondly, the number/distribution of the nerves which are decompressed is also unique to each individual. Obviously, if someone has 8 nerves decompressed in one procedure they are likely to have more discomfort than someone who only had one nerve decompressed. Finally, surgical technique and appropriate post-operative care are also important in achieving optimal results with minimal discomfort and downtime.

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Aug
30

But the Botox Didn't Work On My Migraines! What Now?

But the Botox Didn't Work On My Migraines!  What Now?

One of the questions that I‘m frequently asked during consultations with patients regarding their chronic headaches is, "If I’ve had Botox injections done with other doctors in the past and they have failed, does this mean that Botox injections done with you would not work either?" This is an excellent question and the simple answer is, “No".

One of the questions that I‘m frequently asked during consultations with patients regarding their chronic headaches is, "If I’ve had Botox injections with other doctors in the past and they have failed, does this mean that Botox injections done with Dr. Peled would not work either?" This is an excellent question and the simple answer is, “No".

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Aug
24

How Can You Define Peripheral Nerve Surgery?

How does peripheral nerve surgery help my life, and what can it mean for my migraines?

What exactly is meant by the term, ‘peripheral nerve surgery’? Peripheral nerve surgery specifically refers to operations performed on nerves within the peripheral nervous system, in other words those nerves located outside of the brain and spinal cord (aka the central nervous system). It also helps to think of these nerves as being located in the periphery of the body such as the arms and legs although it also includes nerves located in trunk and scalp/face regions. Pathology causing problems within the peripheral nervous system can take many forms. There can be pressure on a nerve as it passes through its normal route from the brain and spinal cord to its final location, for example at the toes or back of the scalp. There may be pressure on a nerve from a tumor within the nerve itself or from a tumor external to the nerve. A nerve may have been cut from a prior accident or prior surgical procedure. There can also be injuries to nerves that have been excessively stretched such as may occur following a whiplash-type of injury.

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Jul
25

How Can Peripheral Nerve Surgery Help My Migraines?

What do migraine headaches and peripheral nerve surgery have to do with each other?

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Jun
05

Ask me, ask me, ask me!

A recently published study in Health Affairs demonstrated that many patients still have significant reservations about asking their doctors questions regarding their health care.

A recently published study in Health Affairs demonstrated that many patients still have significant reservations about asking their doctors questions regarding their health care (). Many of the patients in the study stated that they feared upsetting their physicians and were scared that doing so would negatively impact their care. Moreover, many patients also apparently felt as though their physicians did not listen to or respect what they had to say. These findings are especially poignant in light of the fact that many of the patients surveyed in his study had a very high education level and an annual income greater than or equal to $100,000 per year.

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May
18

Decompression, neurolysis and ablation

Several people have had questions about what ‘neurolysis’ actually means and how it might differ from the term ‘ablation’.

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Apr
15

Let's go to the numbers, shall we....

I just finished reading Dr. Guyuron's article on the finances associated with migraines in its entirety.  The numbers are truly staggering.  Did you know that:

1. Medical resource use for the treatment of migraine headaches is significant, with the fourth most common emergency room complaint being headaches.
2.Patients with migraine headaches generate nearly twice as many medical claims and nearly two and a half times as many pharmacy claims when compared with patients without migraine headaches.
3. Researchers have estimated the annual direct costs of migraine treatment to be as high as $7089 per patient and the annual indirect costs to be as high as $4453 per patient.
4. AFTER TAKING INTO ACCOUNT THE COST OF SURGERY (surgeon, anesthesia, facitlity fees) - the 5-year cost savings were over $11,000 per patient.
5. IN ADDITION, over 5 years, patients can expect to have 43.5 fewer doctor visits, 25 fewer alternative treatment sessions, and 40.25 fewer days missed from work!
6. OVER AND ABOVE ALL THAT, patients reported significant improvements in their overall quality of life on just about every parameter measured!

I guess none of this should be surprising, but it is rare to see numbers like this in the medical literature.  This type of treatment is truly a paradigm shift.

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Apr
07

A Pain in the Neck!

Over the past few months I have seen quite a number of patients who’ve told me that they believe their migraines began not long after a motor vehicle accident. Many of them said they were initially told they suffered from “whiplash” by their treating physicians. These patients tried and subsequently failed several treatment modalities such as physical therapy and muscle relaxant medications.

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Mar
21

Are You Experienced?

An interesting article was published just this month in the journal Plastic and Reconstructive Surgery. Members of the American Society of Plastic Surgeons (ASPS)

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Mar
07

Peled Migraine Surgery is Your Source For Migraine Nerve Surgery!

Peled Migraine Surgery is Your Source For Migraine Nerve Surgery!

Peled Migraine Surgery is one of the foremost organizations in migraine pain relief surgery.  The surgery is nerve based and has been proven to lessen or eliminate migraine pain.  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.

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Jan
23

Ziv M. Peled, MD Answers Your Burning Migraine Questions

Ziv M. Peled, MD Answers Your Burning Migraine Questions

Come join Dr. Peled on Facebook Live!

Ziv M. Peled, MD answers your Burning Migraine Questions on Facebook Live! Join us on January 24th at 2:45pm PST (or January 25th at 9:45am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
You can ask us questions during the Facebook Live chat or, if you can't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the stream.

We're looking forward to seeing you there!

If you missed our January 11th Facebook Live, you can watch it here to learn more about Migraine Surgery.

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Jan
15

MIGRAINE SURGERY - WHEN THE NERVE HAS TO GO

Dr. Ziv Peled Presents

We had a very successful “soft opening” to our Facebook Live series of events, which we hope to be able to do with some frequency in the future.  After we went ‘off the air’, many people contacted us who didn't get a chance to ask their questions live.  I have decided to address a few of these over the next few weeks.  

One of the more interesting questions that I would like to address now is: Have you cut the nerves and attached them to another rather than bury them? What was the outcome?

What I tell my patients pre-operatively is that I will often make a ‘game time’ decision as to whether or not any particular nerve I am operating on can be saved or if it needs to be transected.  That is because one can never predict what one will find once the nerve has been exposed - if it is too badly damaged, a decompression alone will not suffice.  As I have mentioned in a previous blog post (Lions & Tigers & Neuromas…Oh my! – Nov 21, 2017), there are several possible options if a neuroma forms following a nerve transection and the same principles apply to a nerve that has just been cut on purpose:

  1.  The cut nerve end can simply be freshened and implanted into the local muscle.  
  2.  The transected nerve end can be connected 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 passive and unlikely to cause pain.
  3.  The nerve can be “re-innervated” via a procedure where the nerve is repaired end-to-side or end-to-end to another sensory (or perhaps even motor) nerve. This ‘re-innervation’ procedure is often used to help amputees power the newer myoelectric/bionic prosthetics that appear on the news from time to time and can also be used during migraine surgery.  

It is almost always possible to find another nerve (let’s call it the recipient nerve), adjacent to the nerve that has been cut (let’s call that one the donor nerve), to attach the cut nerve to.  However, any time one operates on any nerve, there is always a possibility that the nerve being manipulated may be injured.  Therefore, the surgeon must recognize the possible negative outcomes if the recipient nerve becomes damaged.  After all, the recipient nerve, is presumably a normal nerve with no pathology relevant to the condition being treated. 

If the recipient nerve is a purely sensory nerve and is injured inadvertently, then possible negative outcomes from damage to that nerve include decreased sensation, complete numbness, or chronic pain in a new location.  If the recipient nerve is a purely motor nerve and is injured inadvertently, then the patient may experience weakness or even complete paralysis of the muscle which that nerve supplies. 

Many of the recipient nerves in the neck region are motor nerves. If, for example, the greater occipital nerve is too damaged and must be cut, one can find a local motor nerve to which to attach it, but if that motor nerve is injured and stops working then the patient might experience neck weakness and may be unable to fully extend their neck. Therefore, in my humble opinion, if the surgeon is planning on manipulating those motor nerves, it should only be because there is no other option available to prevent a neuroma.  

Since the other options noted above are readily available and often successful, I have never personally had to attach a cut occipital nerve to a recipient motor or sensory nerve.  There are also no data on success rates with such re-innervation procedures for the treatment of chronic headaches.  The take home message is as always - please have a frank discussion with your surgeon about what s/he is planning on doing if a nerve is too badly damaged and decompression may not be successful. 

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