Tell me about this surgery. How did you find that plastic surgery could help people with migraines? How did that all come about?
Dr. Guyuron: This is merely coincidence. It was based on facts relayed to me by the patients. The first patient who told me about the liberation of migraine headaches was actually a surgeon’s wife who had come for a follow-up and I asked her how she was doing. Her answer was, ‘Not only do I feel good about my forehead [where we had done the surgery], my migraine headaches have gone away.’ I thought it was just a coincidence. But a week later, I had a patient repeating the same answer. It occurred to me it doesn’t sound like a coincidence. I do a lot of research, presentations and I activated my research team and we looked into it. We found out that of the 314 patients we had operated on, merely for the sake of cosmetic reasons on their forehead area, 39 had migraine headaches and 31 had experienced either complete elimination or very significant improvement in their migraine headaches. When I say very significant, at least reduction in intensity and frequency of 50 percent. Since then, we have actually finished another study. We are operating on the patients who have migraine headaches for the sake of migraine headaches — these are the patients who have no interest in cosmetic improvement. Because of the way I am going to tell you in a short while how we select these patients, we’ve been able to achieve 95-percent elimination or again, significant improvement in migraine headaches.
Dr. Guyuron: It is, its very fascinating and I keep repeating this statement: It is absolutely true that is has made my medical practice even more fulfilling than it has been so far.
What is the surgery actually? What is it doing?
Dr. Guyuron: Based on the initial finding, I suspected that muscles around the nerves or the muscles through which the nerves pass through pinch the nerve and stimulate a process, which is an inflammation of the nerve that gradually travels along the nerve and reaches the brain and causes localized meningitis, which is the migraine headache. This is why we sense that severe headache, along with nausea and vomiting, which makes the patients extremely uncomfortable. These nerves are irritated. The release substances that cause the inflammation and reach the brain membranes, for many years — this is 30 years ago actually — its was known that the trigeminal nerve has a role in migraine headaches. They knew that the inflammation of this nerve is perhaps a culprit but they didn’t know why this nerve get inflamed. What I believe is that the nerve ends are caught in the muscles and the muscles pinch them, resulting in the stimulation and inflammation that we talked about. By removing some of the muscles, or detaching some of the nerves, we can actually shut off that process and eliminate the migraine headaches.
Why does somebody have the surgery for cosmetic reasons? What does it do? You said its cutting this muscle, right?
Dr. Guyuron: Yes. During the cosmetic surgery, what we’re doing for patients of migraine headaches, is remove the muscles that cause lines, the vertical lines between the eyebrows. Those are called the corrugator muscles. They are there only for the sake of frowning, they are not really useful muscles, so they can be eliminated, they can be removed. That is part of our routine, actually, when we do cosmetic surgery of the forehead. We remove those muscles and incidentally, again, we found that happens to be the most common trigger point. What we do now, initially inject those areas that we suspect are trigger points, using botox. I’m sure that you know botox is a small dose of botulinum toxin that does not really have any systemic effects. We inject muscle, paralyze muscle, and emulate what the surgery is going to be doing. If the patient responds to the injection of botox, we know that there’s a really high chance that the patient is going to respond to the operation as well. If the patient responds only partially — some of the headaches do go away, but some are still there — then we look for the other trigger points that may exist. As we identify, we actually develop a map, an algorithm that we follow so one-by-one we identify the trigger points and incorporate into the surgical procedure. Fortunately, almost all of the trigger points can be eliminated with surgery. But, it may not be just the removal of this muscle; it can be releasing a nerve in this area. It can be removing your muscle in the back of the neck that really has no function that we can’t see. Or sometimes, actually, deviation of the septum causing inflammation of the sinuses can be the trigger point. By elimination of those anatomical abnormalities, we can eliminate the migraine headaches.
A good reason for deciding to get a nose job.
Dr. Guyuron: The septum surgery doesn’t really change the outside of the nose, but sometimes we combine those. The patients undergo surgery and want some other cosmetic surgical procedures to be performed at the same time as well.
Do these people feel pain in a specific area when it is related to those certain trigger points, or is there any way to narrow these down without even doing the botox?
Dr. Guyuron: That’s how we start. We select a site based on the information we see from the patients. For example, if a patient tells me that all of my migraine headaches start from this area, I know pretty much that it is the muscle in this site that is causing the migraine headaches. Still, I want to make sure that we are not operating on these patients indiscriminately and operating for reasons that we merely cannot be sure that its going to work. So, I’d sooner inject that patient with botox first and if all of the migraine headaches go away, then I have a high degree of security that my operation is going to be serving that patient. But, there are patients who have multiple trigger points and it shifts. Sometimes thy get it here, sometimes they get it in different places. Then again, I use my algorithm that I discuss with you and follow that. We can actually detect all of the trigger points and help the patients more effectively.
What is your response from patients?
Dr. Guyuron: It has been unbelievable. I can’t tell you how often that I walk into the room and these patients smile and the next remark is like a broken record. ‘You have changed my life. You don’t understand. You have changed my life.’ It is amazing. I am getting a lot of letters. We have patients from all over the country coming here. In fact, I can ask my staff to share some of those letters with you. In listening to the patients, reading those, gives me a great deal of appreciation of what they go through.
Up to three years ago, I knew about migraine headaches as much as medical student knows because in plastic surgery, we really didn’t used to deal with migraine headaches. But, since then I have made a mission for myself to go back and review and read numerous articles. I know a great deal about migraine headaches now. I have also neurologists I work with. I never operate on a patient who does not have a diagnosis of migraine headaches by a neurologist. As much as I know about migraine headaches, I still don’t consider my specialty neurology, so I need a diagnosis of migraine headaches by someone who has the expertise to make the diagnosis. From there on, we coordinate our efforts and jointly decide what needs to be done for these patients.
How long does this procedure take?
Dr. Guyuron: We do this as an outpatient procedure. It takes only an hour to an hour and a half, sometimes in 45 minutes, depending on the magnitude of the surgery. Septum surgery takes only half an hour to perform. These patients can go back to work in a couple of days if we just operated on the septum; if it’s the forehead part, it may take a week to 10 days before they look socially completely presentable, although many of them can resume light activities or some of their work a little sooner. But, most of them will require about a week to 10 days before they go back to work. It is not under anesthesia or deep sedation.
How badly does it hurt?
Dr. Guyuron: There’s not much discomfort, not much pain related to these surgeries. Some of these patients do actually experience migraine headaches right after the operation, and I tell all of them, or sometimes right after the botox injection, that the reason is we are actually irritating those nerves. So that is expected. What I’m interested is in what happens a month later, or two or three weeks later, have the migraine headaches gone or improved.
Are there any side effects?
Dr. Guyuron: They experience some numbness in the forehead area, but that is part of any surgery; gradually the numbness will go away. There’s a remote chance that it may not go away. Complications like infection, bleeding can happen. Those are extremely, extremely remote. Since we really do not go deep enough near the bone or the brain, there’s really no chance of damage to the brain. If we make the incision to the upper eye, there’s a remote chance that something can happen to the vision. I’ve never seen one. I don’t know anyone who has had this complication. In fact, this is a technique that I have developed that we would go through the upper eye, that the incision to find these muscles and remove them. I’ve been using it for about 8 10 ten years and we’ve never seen an eyesight complication.
What do most migraine patients go through in their search for relief?
Dr. Guyuron: For patients to make a diagnosis of migraine headaches is very difficult because the range of similarities and combination of symptoms vary tremendously. Initially, they take aspirin or Tylenol and they go to their medical doctor. Usually, the medical doctor makes the diagnosis of migraine headaches. Initially, they will use medications. We do not operate on any patient who, again, has not had a diagnosis of migraine headache for at least a year. The reason is some of these migraine headaches do go away, but very rarely. They use medications that the doctor prescribes. If the migraine headaches do go away, fine. But, the fact is that there is no cure for migraine headaches through medications. They are prophylactic or they take the symptoms away. They don’t give the patients long-lasting relief. There are some medications that they have to take daily, occasionally to reduce the severity and frequency of the migraine headaches. But, what we are offering is hope that there is going to be a cure. We haven’t operated on these patients for a long time enough to be sure that this is going to be a cure, but from our retrospective study of patients who have surgery for the sake of rejuvenation, we know we follow those patients for about 10 years, some of them. When their migraines were eliminated, they remained eliminated. So, based on that study, I’m fairly confident that the ones who have no symptoms for a period of time will most likely not have more symptoms. But, the medications do help some of these patients. These patients, they actually react to the medications. Even some of the patients with the most sophisticated injections, they can’t take away all of the pain and discomfort they feel.
Why would somebody have this surgery for the cosmetic side of it?
Dr. Guyuron: The reason that we are removing muscles that cause lines in the forehead area, it makes the forehead smoother and they are the same muscles that are pinching the nerve. So not only does it become smoother, they also lose that dreadful migraine headache that is caused by contraction of those muscles and pinching of those nerves.
After somebody has this surgery, how do they look different cosmetically?
Dr. Guyuron: They will have smoother forehead and the eyebrows will be slightly higher, which is beneficial for practically everybody. Another is it suggests a more balanced appearance, because as we get older, gravity pulls eyebrows down and also lines develop in between the eyebrows. This operation would make the forehead smoother, raise the eyebrows and the fact that we remove the muscle takes the migraine headaches away.
Source: Ivanhoe News