You are listening to HEAD ON with your host, board certified plastic surgeon Dr. Bahman Guyuron, the pioneer of a life-changing surgery for permanently eliminating migraines and a specialist in plastic surgery of the face, head and neck.

When a patient calls my office to make an appointment to see me, we're going to need a month worth of a log that recording the duration, intensity, and also frequency of headaches. So when I look at, and also they're going to complete several forms for us when they sit across me and I look at the forms, I have a really good idea where the headaches are coming from, what I'm going to do, but I actually confirm it. I spend at least half an hour with every patient, even after a review of all of the forms to go over everything that we are going to be what I'm seeing, and make sure that what I'm reading is accurate. Most of the time it is, sometimes it is not. Sometimes we change the plans and the other thing that should be clear, for those who are interested in having the surgery, they don't have to come to Cleveland to see me.

(01:21)
We offer virtual visits and they come to Cleveland the day before surgery and we make sure that our plans are accurate, confirm our plans, make sure that we are exactly the same page in terms of trigger size, expectation and everything else. And then we go to the operating room the next day and almost invariably patients can go home the next day, whether I do no surgery or migraine surgery, they can travel the next day and we give them all kind of precautions that they need to exercise.

(02:02)
And the surgery is done almost invariably as an outpatient operation. Unless the patient has such a BMI the patient is so heavy that it is not safe to do the surgery in the outpatient surgery facility, it usually is done under general anesthesia if they're this more complex. But today, I would say more than half of the patients that I operate on the operation is done on the local anesthesia through a tiny incision for each trigger site where I remove the vessel release a tiny nerve.

(02:42)
And as I said, the patients can often go back to work the next day, the same day if they work. That type of surgery doesn't work for everybody. There are patients that are required two to and a half hour surgery, rarely three hour surgery. When the forehead is involved, when they're behind, the eyes is involved when the back of the head is involved in the back of the head, if the pain is close to the ear, again, I can do that under local anesthesia and I've done each of these, I have done over a thousand of them and most of the time it works. Now our failures are usually related to inability to detect a trigger site. That is obviously to a degree my responsibility and to a degree is the patient's possibility to point me in the right direction. What I tell the patients is that most of the time I get what I want for the patients, but they need to be prepared that this could be a phase or process for the patient that we do trigger surgery.

(03:52)
They headaches go away on that side, but they may have other sites that we don't know about. And the reason is sometimes when you have intense pain on one side can mask the headaches on the other side and that we are going to know about that side only when the headaches and the intense sight, more intense sight are eliminated. And again, the incisions are usually very small.

(04:20)
Often the patients actually recover from the major part of the surgery within a week, meaning if we do the surgery in the forehead through an eyelid incision or a forehead incision in the hairline, they can look socially presentable in about a week to 10 days in the back. When we operate in the back of the head socially, they're ready to do everything the next day because you can't see the incisions, but we limit their activities. Usually I tell them not to participate in heavy sports, playing tennis, jogging, swimming, golf for three weeks and not to take any aspirin, aspirin type medications three weeks before a week after the surgery.

(05:03)
Again, most of these limitations apply to the major operations and even the major operations are outpatient, again, under light anesthesia and very fast recovery. If the patients, again are taking aspirin, Advil, Aleve, we tell them not to take those medications, then they need to understand that the surgery is likely to work. There's this small chance that we may have to operate on other trigger sites, and I have mentally ready to be ready for the surgery not to work, which is extremely unlikely. If the patients stay with me, there's a really good chance that I'm going to find a way to help them. I always have a plan A, plan B, plan D, plan C for every patient, the average age for a migraine patient is 44, where they can benefit from some other procedure. For example, they may have redundant eyelid skin that they were considering to seek advice from a plastic surgeon.

(06:12)
And that actually not only can be combined with what I'm going to do for their forehead, migraine headaches, it can also facilitate the surgery because it would give me a little bit larger feel that I remove the redundant skin so I can see the area a little bit better. Or some patients undergoing migraine surgery, they tell me, you know what? I have been considering nose operation to improve my nose for a long, long time and this would be an opportunity while I'm recovering from the surgery. That would be a good choice. And I can tell you that that commonly happens and some patients want a whole face rejuvenation. In fact, I had a lawyer from Chicago came to Cleveland for migraine surgery. She actually wanted me to do a whole face rejuvenation. I did this for her and I followed her for several years and she became totally migraine free.

(07:09)
So that combination, it really is gratifying in some ways because if the migraine headaches do not go away completely, at least they have some benefits otherwise. And whenever we do the surgery in the forehead, there is a definite side gain, meaning even for the migraine headache surgery, we gain smoothness for the forehead. The elevens will go away and they won't be able to frown to cause lines in between the eyebrows and or whenever we operate inside the nose for migraine headaches, most of the time the patients can breathe better than they used to. So there's always that side gain that helps me to feel good about patients that may not have complete elimination of migraine. But fortunately that's rare. Most of the time I get what the patients, what I'm after when the migraine surgery patients tell me that their headaches are not gone completely.

(08:15)
The first question that I ask them is where do headaches start from? And commonly, again, is a separate trigger site that we have operated. We have not operated, so we operated on, let's say that their headaches do not go away completely. And the question is what type of pain they have? Sometimes they have pain from scar tissues. If that's the case, I may inject some fat in the area, their own fat that contains the stem cells and the stem cells have the power to dissolve the scar tissue, reduce the inflammation. If that wouldn't work, there's a last resort and that's cutting the nerve. Have I ever done that? Yes, but it is extremely rare. Usually the other mechanisms that we have available work for the patient will get the results that we want. But I can also add one other thing.

(09:17)
Almost invariably, patients who do not have complete elimination of migraine headaches tell me and my colleagues that have been doing this, this is something we discuss in panels and we all are in agreement that they tell us, "yeah, my headaches did not go away completely, but my headaches are responding to the medication a lot faster. My headaches are significantly less frequent and less intense." So that is the minimum that we get for almost everybody.

(09:51)
Again, nothing works for everybody, but that is a positive side that even the neurologist agreed to it. Anytime we do any surgery, there's always a potential for infection, excessive bleeding. Those are extremely unlikely. After this type of surgery, there's going to be some numbness wherever we operate that's part of the course. Gradually the numbness goes away and often the numbness goes away completely. There is occasional rare residual numbness, and when we operate on the forehead, there's a possibility for intense itching of the forehead. And we do have means of controlling that, but that is not very common. Whenever we operate around the eyes, there's always potential for scar formation, which is called neuroma. Neuromas are scarring of the end of the nerves. And if that happens, sometimes the pain is extremely intense and continues, and if it happens, we take care of it.

(11:02)
But fortunately, that's another thing that we discuss during our national meetings or society meetings. In fact, this would be a good occasion to say that we actually have developed a society for migraine headaches for public, and our colleagues public can go to the migraine society site and get the name of the doctors who are doing this type of surgery in their area. And there are a lot of information for the public. And when we get together, we talk about these complications. And to the best of my knowledge, there aren't many incidences of neuromas if there are any. Actually, I don't recall anybody talking about neuromas after this type of surgery. We do for the migraine headaches because we have means of measures of, again preventing that if we have to cut the nerve, we implant it in the muscle. That would reduce the potential for any kind of a scar formation at the end of the nerves.

(12:06)
Anybody who has not been responding to medications properly cannot tolerate medications, has at least two severe migraine headaches that last several days and they're disabling. And for patients who have tried everything else and they have no choice, would be the candidates for us. But it doesn't have to go that way. Again, if the medications are not working, we are there to help them. And I think that, again, as I mentioned, there are many surgeons that we have trained internationally who are doing this. This is being done in many countries. Actually now, our studies on teenagers actually have demonstrated that this surgery can work for pediatric population. We have a way of knowing whether migraine headaches and pediatric population is going to go away or is going to last because some patients have migraine headaches around teenage that goes away when they become an adult. But their family history is going to help us detecting whose headaches are going to stay, whose headaches are going to go away.

(13:25)
Family members can tell us whether their headaches went away or not when they got the adulthood. So we operate on the patients only when their parents or siblings. Headaches did not go away when they reached their adult age. They're actually very young kids that they can't go to school. They lose a lot of education. And I have had, actually, even in early adulthood, I have college students that they could not continue studying until we did the surgery. Then when they went back to finish the school. One of the gratifying aspects of this surgery for me, which is absolutely thrilling, is patients telling me that you don't understand. You've have changed my life. And many of them also tell me that they have control of their lives for the first time because many patients have migraine headaches. They don't know when the headaches are going to hit or come about.

(14:37)
Even on their wedding night, they may have headaches or wedding of their sisters, brothers, so they can make plans. They can't make plans to be in their children's events. So giving them that potential to plan their lives is really very, very, very gratifying to me. There are rare occasions that I tell the patients, I don't think I'm going to be helping you. Those are the patients who have been on heavy narcotic medications for a very, very, very long time. And I don't think that their expectations from the surgery is realistic or I don't think that the patients are going to follow my instructions to help me to serve them, but that is extremely rare. That's a little bit more common on the nose surgery patients. But I don't deny helping patients with pain unless I'm absolutely convinced that I'm not going to be able to help this patient.

(15:46)
On the other hand, also, I don't operate on anybody unless I'm convinced that I'm going to be able to have the patient. Unfortunately, many of the insurance companies consider this experimental except for Medicare. Actually, Medicare covers some of the procedures and it is a hit and miss. I'm hoping one of these days our patients are going to get together and find a way, whether it is employing a lawyer or filing a class lawsuit or whatever to get these insurance companies to cooperate. I feel bad for them. And there are patients that cannot have the surgery because insurance doesn't cover any part of it. And there is also an anesthesia of facility cost that they have to pay for. So we try to help as many patients as possible. The price range is really very variable from one trigger site, two trigger site, three trigger size, five trigger sites, and what needs to be done for the patients. So it can range from couple thousand to 15 to 20,000 maximum for some patients, or it could be higher for somebody else or depending on what the condition is. We do not have financing available through our clinic for the patients who cannot afford doing migraine surgery, but we do work with companies that provide that kind of service to the patients, and CareCredit is one of them.

Links to learn more about Dr. Guyuron and anything else mentioned on this podcast are available in the show notes. HEAD ON is a production of The Axis, T-H-E-A-X-I-S dot I-O.