Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

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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Dec
15

Accessory Supraorbital Nerve Surgery

The following images were from a surgery performed this Monday.  The first image details the Accessory Supraorbital Nerve seen laterally completely surrounded by bone at the Orbital Rim instead of coming out through a notch like its medial counter-part. The second image is the after image showing that now both nerves are released and ensconced in soft fat at the Orbital Rim with no residual compressive structures.  


Warning Peled

Warning Peled

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Dec
14

Real Patient Stories: Shirley

Shirley 3

What is your name?

 Shirley Jaeger

Where are you from?

 Brisbane, Australia

What was happening in your life before the headaches became chronic?

 I worked as a nurse for many years which eventually caused neck pain. I had a neck operation to alleviate the pain where they replaced the disc between C3/C4 with a metal cage.

How long ago was that?

 The neck operation was here, in Australia, March 2014. The operation left me with chronic pain above my left eye.

Describe a good day with chronic pain.

 5 on a scale of 10, but good days are rare.

Describe a bad day. What does/did the pain feel like?

 10 on a scale of 10, which included bad migraine symptoms.

Where did you experience the pain?

 At the supraorbital notch, near the middle of my left eyebrow, radiating out into most of my head.

What meds were you taking?

 I was unable to take opioid derivatives as I am allergic. I tried six other prescription drugs but they offered no relief and/or made me feel sick. A low dose of Gabapentin I could take, but still got very little relief.

Did you have any success with other pain relief methods besides medication?

 I received 10 Botox injections, on two separate visits, without success. I tried expensive, medical-grade cannabis oil--working up to a high dose--without any effect at all. For 6 months, I wore the Cefaly Tens head electrodes approximately 4 hours per day with no relief. I also tried handheld Tens treatments at the physiotherapists’ office. I then had a temporary, trial electrical nerve stimulator implanted underneath my skin, near my eyebrow, which very slightly reduced my pain, sometimes. During these years, I also had several anaesthetic block injections in the forehead and neck. These assorted treatments were the result of visiting three different, well-established, pain clinics, but in the end, no option provided sufficient pain relief.

How did you hear about Dr Peled?

 In despair, after suffering for 4 years, I joined a local, self-help group on Facebook where I read an article by Dr. Peled.

What inspired you to speak with him?

 I wrote to him, explaining how I had had dozens of types of scans, consultations with several top neurologists and neurosurgeons, and even a gamma-ray operator, without a solution. He then organized a Skype consultation with me.

Tell me about your surgery, including when you had it, what happened.

 My surgery with Dr. Peled was in May of 2018. The operation lasted for a bit over an hour. The pain originated from the supraorbital nerve, which did not have enough blood supply from the artery, due to restricted flow where the artery exits the skull. Dr. Peled corrected the blood flow issue during the operation, thereby rejuvenating the problem nerve.

 Do you remember how you felt in the first few days after surgery?

 I had nausea caused by an allergic reaction to the strong pain relief medication, but otherwise, I felt a lot better.

How are you feeling now?

 My pain is no longer. I still have slight nerve tingles in the area where I had the operation, but feel confident that these will lessen month by month.

How has your life changed as a result of this surgery?

 I am back to doing activities I did not do for over 4 years and now enjoy life again.

What is next for you?

 To go on a holiday with my husband.
What would you say to anyone wondering whether to meet Dr Peled?

 A consultation with Dr. Peled is worth every bit. My many other consultations before meeting Dr. Peled cost me a lot and achieved nothing.

Describe your overall experience with Dr. Peled and his office.

 Very professional and caring.

Do you have any advice for prospective patients who are thinking of coming to the practice?

 Have all your facts ready for discussion and bring any supporting scans, including reports. Ask his team for advice on how best to make your visit a success.

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Nov
26

Real Patient Stories: Natasha

Real Patient Stories

What is your name?
Natasha Turner.

Where are you from?
I am Welsh but I have lived in Brisbane, Queensland, Australia since 2001.

What was happening in your life before the headaches became chronic?
I managed an optometry store where I had worked for 4 years. In my spare time, I was an amateur actress, which also involved singing and dancing. I painted and strolled in the nearby forests and bayside, enjoying the almost constant sunshine and warmth here. I was a member of various social groups, and enjoyed catching up with friends over a cup of tea and bite to eat near our local, Pennisula beaches.

How long ago was that?
My headaches started to become really bad 7 years ago. In 2015, I went part-time after my surgeries, but even a 15 hour week was still too much to bear. I stopped working in 2017, when I couldn’t even manage a 4-hour shift.

Describe a good day with chronic pain.
On a good day, I would manage a conversation with a friend face to face for 60 minutes maximum. I may even manage a little early morning or late afternoon walk by the local canal.

I spent most of my time in shady, quiet places, mainly my home and the local library. I wore earplugs all the time. I couldn't wear sunglasses, spectacles, a hat, sleep on my back, nor use digital screens. I was exhausted and medicated all the time, so socializing was draining and focus was impossible. 

Describe a bad day. What does/did the pain feel like.

The pain is like a red-hot iron being held against the right-hand side of my face; it burns into my head, radiating across the right-hand side of my face. My skin feels hot to the touch, and my ear swells. Even the wind blowing against my skin hurts.

After a night of being woken every few hours by the pain, or if I had turned onto the back of my head at all, my only option would be to reach for my anti-epileptic drugs and muscle relaxants. I would angle the blinds in my house nearly closed to minimize glare and keep the doors and windows shut to minimize noise. I moved very gently and slowly due to pain and being medicated. The pain medications make me thirsty so I would drink a lot. I could only answer mobile phone text messages, not phone calls, due to focus issues. 

In the mornings, I read a lot and sometimes find a shady spot to sit in my garden. When the pain is peaking, I meditate and practice mindfulness. Though I barely move, the pain increases as the day goes on. When I can’t read anymore, I listen to audio books and meditation tapes. At 5 pm, I have another dose of anti-epileptic medication. This blurs my vision due to the side effects, so reading is difficult. After dinner, I watch a DVD with the color and contrast turned down. At 7 pm, I take my anti-depressant medication. It is a relief to knock myself out with drugs, as I can no longer function with the level of pain by evening.

I battle suicidal thoughts frequently. I dread the day when I wake. I long for an escape. Every month I get worse. My life gets smaller. I have lost so much. I exist in my room.

Where did you experience the pain?

Lower right side at the back of my skull, arching behind my right ear, over my right ear, inside my right eye socket, and down the right-hand side of my face.

What meds were you taking?

Lyrica 150mg 3 times a day

Endep 75mg at night

Baclofen 20-30mg, when needed

If worse, a 5% lignocaine topical skin patch all day and night

Did you have any success with other pain relief methods besides medication?

No. I tried Botox, nerve block and facet joint injections. I had prolotherapy, physiotherapy, acupuncture, bowen therapy, and reiki. I tried the Cefaly tens machine and low-level laser therapy. I went to two chronic pain clinics. I saw a total of 54 therapists. In December 2017, I even had 85% of my breasts removed in an attempt to reduce a pain trigger, all to no avail.

How did you hear about Dr. Peled?

I am a member of 6 Occipital Neuralgia Facebook support forums, in order to share information, learn all I can about my pain and talk to others who understand. Dr. Peled is frequently mentioned on these forums. His articles are posted along with many patient success stories.

What inspired you to speak with him?

A fellow sufferer had actually spoken with him about my case and urged me to consider surgery with Dr. Peled. I had not entertained this thought prior because:

  1. I was petrified of having another failed surgery that could leave me with the same or worse pain.
  2. I was worried about how I could afford such a trip and also knew that I would have to travel alone, due to finances.
  3. The last time I had been to America I had suffered many panic attacks. This was prior to getting sick, and I could not imagine how I would manage the pain and anxiety on my own.

Tell me about your surgery, including when you had it, what happened.

In May 2015, I had my GON and LON excised and in July 2015, I had my Greater Auricular nerves excised. Both these surgeries took place in Brisbane, Australia and did not result in any numbness or significant pain relief.

My occipital neuralgia pain increased and by 2017, I  had developed Trigeminal and Supraorbital neuralgia. The pain increased continually.

On October 24, 2018, I arrived in San Francisco. The next day, I met Dr. Peled and he performed diagnostic nerve blocks. I had received blocks 4 times in Australia with no success. Dr. Peled was able to reduce my pain from 9/10 to 1/10 within 30 minutes! I spent the weekend staying with a very kind prior patient of Dr. Peled, who lives a 4-hour drive from San Francisco.

On October 29, Dr. Peled successfully excised my GON, LON, and third occipital nerves. He also removed a neuroma. I spent the night in the Surgery Clinic as my host lived too far away. I was given Norco throughout the night when needed, which was twice only. The following morning, my host and another fellow sufferer shared the drive to take me back to my host’s residence.

On October 31, I returned to Dr. Peled for a pre-flight clearance check-up and he gave me more nerve blocks to boost my in-flight pain relief. My occipital area was numb, the surgical pain manageable. I was definitely better than pre-op!

At all times, I was treated with kindness, which eased my anxiety. I knew that I was receiving expert care.

Do you remember how you felt in the first few days after surgery?

Despite the jet lag, I felt quite energized. I was not battling 24-hour searing pain! My friends and my partner remarked that my face looked younger. I moved less stiffly. The incisions were sore, but nothing compared to the pain I had suffered pre-op. My neck muscles were quite tight but I couldn’t believe that I had no pain at the back of my head. I did have tenderness behind my right ear, and at times, trigeminal twinges, which I had expected. I was able to stop the surgical pain medication within a week post-op.

How are you feeling now?

It has only been a couple of weeks, but I feel different - physically and mentally. I still have no occipital pain. I have trigeminal and supraorbital twinges on some days. I have a very tender spot in my right shoulder. All of this I expected. It is very early on in my recovery, and my nerves are settling, with occasional referred pain. I massage my shoulder and my head twice daily.

Mentally, I am letting go of my identity as a person who suffered pain that stole and crushed her soul. I still have anxiety about various activities, as they caused me pain for so long, but I am breaking through this habituated behaviour. I am remaining cautious while I evaluate the extent of the pain relief. I am scared to get too excited after having my hopes being dashed so many times. I truly believe that my pain relief will remain as this recovery is so different from the post-op periods of the previous two surgeries.

How has your life changed as a result of this surgery?
I can wear sunglasses and a hat. I can turn my head to the right. I can go out in the sunshine without pain. I slept on my back for the first time in 5 years! I am not exhausted all the time. I can catch up with friends for a couple of hours in a café because the noise is no longer an issue and I’m able to focus. My depression has reduced significantly (which I’ve had since I was a child, not caused solely by chronic pain).

I have the option of activities in the day. I went for a walk by the beach without an umbrella, in the early afternoon! I recently finished a presentation for a support group that I co-facilitate and I have started another counseling course. I have resumed gallery and museum visits. I am living!

What is next for you?
Eventually, I want to get back to singing, acting, and dancing. I love being on stage! I continued to go to shows whilst sick, with earplugs and medications. I cried through the performance because I wanted to be where the performers were. I hope to resume weekly acting classes and regular performances.

Due to the number of years I have been in pain, I have few friends. I would like to join social groups to expand my circle.

I would like to return to forest rambling, going on day trips, attending cultural festivals, and painting. I would like to explore more of Queensland with my partner.

I would love for my partner to be able to cradle my head, to touch my hair, to kiss me without being so gentle that it feels like a whisper.


By the end of 2019, I hope to set up my own counseling practice. I am about to qualify as a counselor and will specialize in: chronic pain, mental health, LGBTIQA+, abuse and addiction, grief and loss. Until then, I will continue to add to my qualifications, set up local chronic pain face-to-face support groups, and offer Skype counseling sessions. I have already started a local LGBTIQA+ peer support group.

What would you say to anyone wondering whether to meet Dr. Peled?

I wish I had paid the money, got over my anxiety and had my operation with Dr. Peled in 2015. I would have saved over $20,000 in Australian medical expenses, I would still be employed, and I wouldn’t have had to battle suicidal urges for 3 years.

Dr. Peled is the only person I was willing to let open my head up after the first two failed surgeries in Australia. In my opinion, he is the world expert in this field. Why wouldn’t you want him to take care of you?

Describe your overall experience with Dr. Peled and his office.

Dr. Peled’s team is very accomplished with assisting overseas patients and with personalized communication frequently made via Skype.

Dr. Peled has the best bedside manner of any specialist I have ever met, and I have met a lot! He is a kind man. Dr. Peled and his team assisted me patiently with the many travel dramas that occurred.

The surgery center staff knew that I had traveled alone, and also showed me a lot of warmth.

Do you have any advice for prospective patients who are thinking of coming to the practice?

Make the call, change your life, do it now.

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