Plastic Surgery May Also Ease Migraines

MANY of the nearly 30 million Americans who suffer from migraines end up feeling like guinea pigs. Chronic patients — those who are laid low 15 or more days a month — often cycle through drug after drug in search of relief. They also contend with side effects like mental sluggishness and stomach upset. Treatment involves guesswork because doctors have not pinpointed what causes migraines, nor do they know which drugs will best help which patients.

“It can be a merry-go-round going from medication to medication in pursuit of control,” said Dr. Roger K. Cady, the vice president of the board for the National Headache Foundation, a nonprofit organization devoted to patient education.

No wonder that last month, news of a surgical “cure” that touts a high success rate ricocheted worldwide. The double-blind study, published in the journal Plastic and Reconstructive Surgery, found that more than 80 percent of patients who underwent surgery in one of three “trigger sites” significantly reduced their number of headaches compared with more than 55 percent of the group who had sham surgery. More than half of the patients with the real surgery reported a “complete elimination” of headaches compared with about 4 percent of the placebo group.

Forehead lifts are cosmetic procedures that plastic surgeons typically perform to smooth furrowed brows. But a decade ago, after some of his patients reported that their migraines improved post-operation, Dr. Bahman Guyuron, a plastic surgeon and the lead author of the study, began to search for a surgical solution that could address migraine trigger points — which he defines as where the headache begins and settles — in the forehead, temples and the back of the head

Headache specialists tend to be neurologists or internists, so Dr. Guyuron’s work has not always been taken seriously. “If I had a neurologist tell me there’s a new way of doing a facelift, I would have been very skeptical about it also,” said Dr. Guyuron, the chairman of the plastic surgery department at University Hospitals Case Medical Center in Cleveland. “But honestly I would have had an open mind.

”In the last month, the press has made much of the fact that a single operation could relieve migraines and turn back the clock in one fell swoop. But it is the potential that surgery for migraines may offer a viable alternative to drugs that has migraine specialists intrigued. “A very large subset became headache-free and remained headache-free for a year — that is a fantastic result,” said Dr. Richard B. Lipton, the director of the Montefiore Headache Center in the Bronx.

Especially considering that in the field of migraines, success is defined “as a reduction of 50 percent of attacks,” Dr. Cady said. Going from 10 episodes monthly to 5 is a welcome change, he added, but “it’s still a lot of migraines.”

The theory behind the surgery is that because some migraines are caused when sensitive nerve branches are squeezed and irritated by muscles, deactivating those muscles could bring prolonged relief. In the off-label use of Botox for migraines, those same muscles — when paralyzed with Botox injections — have eased headaches in some patients for roughly three months. Forehead lifts, Dr. Guyuron reasoned, might result in a longer-lasting, perhaps permanent, alleviation of pain. Only study participants who responded positively to Botox were offered the surgery.

(Dr. Cady cautioned that the research on Botox as a treatment for chronic headaches is not yet ironclad. Allergan, Botox’s maker, is pursuing the approval of Botox as a treatment for chronic migraines by the Food and Drug Administration.)

Many headache specialists, Dr. Lipton and Dr. Cady included, emphasize that this migraine surgery isn’t applicable to most sufferers. “Folks who are appropriate for this procedure — they are the tip of the iceberg, not the vast majority,” said Dr. Jennifer S. Kriegler, a neurologist who is one of the study’s authors and who works at the Cleveland Clinic’s headache center.

At this stage, suitable candidates are those who endure frequent migraines and have failed more tried-and-true methods of controlling their headaches, several doctors said. The bottom line, Dr. Lipton explained, is if you can’t identify a point of irritation and “if you don’t respond to Botox, we don’t know if this treatment works for you.

”Some doctors fear that the surgery may be offered to inappropriate patients before further research confirms its efficacy for a broader group of patients. “I don’t want us to overshoot and start doing widespread surgeries in not very well selected patients until we are convinced this is broadly effective,” said Dr. F. Michael Cutrer, the chief of the headache division in the neurology department at the Mayo Clinic in Rochester, Minn. “You can always stop a medication but you can’t reverse a surgery.”

As word of the surgery spreads, Dr. Cutrer said that he anticipated pleas for referrals to the few plastic surgeons nationwide who offer the operations, but that “until we maybe have studies that are a bit larger, and some longer follow-up I’m going to be very cautious.”

So far, Dr. Guyuron has trained roughly 150 doctors, and other plastic surgeons are refining their own migraine operations, even though they barely advertise.

Two years ago, an aunt told Shannon Byrne, from Mayfield Heights, Ohio, about Dr. Guyuron’s migraine surgery. Ms. Byrne said that she had already spent a decade on “every single medication you can think of.” Still, pain hammered her head more days than not. “You’re willing to try anything,” she said. Dr. Guyuron’s surgery, which she had 18 months ago, was a godsend. The migraines that led to her dropping out of college and to a stroke at 20 are gone. “My dad told me not to worry about the money,” Ms. Byrne, now 22, said of the thousands paid out of pocket.

A classic forehead lift for cosmetic effect differs significantly from surgery for migraine sufferers. The latter removes frown muscles more thoroughly and entails padding nerves with fatty tissue, said Dr. David A. Branch, a plastic surgeon in Bangor, Me., who performs migraine operations.

Sometimes, migraine surgery doesn’t involve the forehead at all. It varies according to where the patient’s trigger sites are: forehead, temples or back of the head. If Dr. Guyuron operates on the temples, the eyebrows are rejuvenated, he said. It is only the surgery at the back of the head that has no added perk, he said.

It’s unclear whether or not the migraine sufferers whose pain had disappeared a year post-operation will remain headache-free for life.

“My goal is zero headaches,” said Dr. Jeffrey E. Janis, a plastic surgeon in Dallas, who has performed roughly 100 operations in the last five years after training with Dr. Guyuron. “I might be able to achieve that in some, not in all.”

Complete elimination is “a pretty strong claim after one year of follow-up,” Dr. Cutrer said.

As a way of dampening expectations, Dr. Kriegler, who has referred patients to Dr. Guyuron, frequently tells them: “Once a migraineur, always a migraineur.”

The Importance of Nutrition & Surgery

Surgical outcome tends to improve when the patient is in good physical health. Optimizing a patient’s nutritional status is an important part of this process and is essential for proper wound healing.

Wound healing sets off a complex chain of events that involved increased cellular activity and an intensified metabolic demand for nutrients. This activity requires a number of vitamins and other chemical cofactors to complete its job. Without these building blocks, wound healing takes longer and may be compromised. Patients who don’t meet their nutritional needs may be at risk for increased bruising and swelling, delayed wound healing, and other wound-related complications.

To augment their health, many Americans are taking nutritional supplements on a routine basis. While generally beneficial and safe, the uses of several popular supplements, around the time of surgery, are not recommended. Certain nutritional supplements may cause adverse reactions during or after surgery, including prolonged bleeding.

We offer our surgery patients a line of vitamins and healing supplements that are formulated with essential nutrients to support wound healing, enhance tissue repair, support the immune system, prevent infection, minimize inflammation and reduce bruising. At the same time, the products have selectively excluded any nutrients that can cause problems during peri-operative period.

Guidelines to Healing (Post Surgery)

1. Schedule elective surgery when you're healthy. This will optimize your immune system and improve your chances for a speedy recovery.
   
2. Consume sufficient calories and protein. Two of the most important elements for healing are calories and protein. Extra protein is needed to build new tissue and blood vessels, repair injured tissue and increase production of cells to repair the wound.
   
3. Stay well hydrated by drinking water. It is important to drink at least 6-8 glasses of water each day and especially the day prior to surgery to help cleanse and hydrate the body. Water is especially important prior to surgery as fluid intake is reduced the day of surgery.
   
4. Do not take aspirin or aspirin-containing products for ten days prior to surgery. Aspirin is not recommended prior to surgery because it is an anti-coagulant (blood thinner) and can promote bleeding during surgery.
   
5. Do not drink alcohol one week prior to surgery. Alcohol suppresses the immune system and should be avoid around the time of surgery.
   
6. Do not smoke one month prior/after your surgery. Smoke inhibits wound healing because less oxygen is supplied to the operative site. In addition, smoking increases the risk of various complications during surgery. If you smoke, use your surgical procedure as an opportunity to quit.

Smart Sun Habits

Cincinnati summers are full of outdoor activities – golf, swimming, tennis, biking, hiking, kayaking. You name it, we’ve got it! Though each outdoor activity requires its own special equipment, one item is common to them all – sunscreen. Most people remember to apply sunscreen for a day at the beach or the pool, but participants in outdoor sports and other activities are much more likely to forget to apply sunscreen and run the risk of being burned. Did you know that even one blistering sunburn in childhood doubles the risk of getting melanoma later in life?
People most at risk for developing skin cancer are those that burn easily in the sun, have fair skin, light-colored hair, green or blue eyes and freckle easily. BUT, skin cancer can occur in people with darker skin tones including those of Hispanic and African American backgrounds. More teenagers and young adults are being diagnosed with skin cancer than ever before. This includes a rise in the deadliest form of skin cancer - melanoma.

Yearly skin examinations are recommended to identify precancerous and cancerous lesions prior to significant growth. So what do we look for? The most common precancerous skin lesion is an actinic keratosis, which usually appears as a red, scaly patch of skin. The most common locations for actinic keratoses are the face, ears, scalp, arms, hands, upper back, and upper chest. These lesions are usually treated with various topical therapies.

Basal cell carcinoma is the most common form of skin cancer. 800,000 Americans are diagnosed each year. Basal cell carcinomas most commonly present as pearly, raised papules with a central ulceration. Treatment of these cancers is usually complete surgical excision.
Approximately 250,000 new cases of squamous cell carcinoma, the second most common skin cancer, are diagnosed in the US each year. These cancers usually present as crusted, scaly patches with a red, inflamed base. Treatment is usually surgical excision. If left untreated, these lesions can spread throughout the body.

The most deadly form of skin cancer is melanoma. Melanoma is diagnosed in approximately 53,000 people in the US each year. Melanoma usually arises from an existing mole. To identify melanomas use the ABCD’s. A stands for asymmetry, B stands for border irregularity, C for color variegation and D for diameter greater than 6mm. Asymmetry, border irregularity, and color variegation are all associated with melanoma lesions whose diameter are more than 6 mm. If you discover an abnormal mole, be sure to show your doctor.

Even if you have tanned or been burned before, it’s never too late to protect your skin. Sunscreens protect your skin from UV rays and are classified according to the Sun Protection Factor (SPF). The higher the SPF number the greater the protection level. Specifically, an SPF sunscreen rating of 30 means if you use the sunscreen properly you can stay in the sun 30 times longer than without the sunscreen and get the same level of sunburn. Unfortunately, most people don't put on the right thickness of sunscreen and they don't reapply it frequently enough. As a result, many people who use sunscreen actually end up with sunburn. One ounce, enough to fill a shot glass, is considered the amount needed to cover the exposed areas of the body properly.

What else can we do?

• Apply sunscreen with an SPF of 30 or greater.• Apply sunscreen every day, all year long, for maximum protection and to prevent sun-related aging.
• Apply sunscreen 60 minutes before going outside to allow time to bond with your skin.
• When possible, avoid outdoor activities between 10 AM and 4 PM, when the sun’s rays are the strongest.
• Be sure to reapply sunscreen frequently, every two hours, and after swimming, perspiring heavily or drying off with a towel.
• Wear a hat with a 4-inch brim all around to protects areas often exposed to the sun, such as the neck, ears, eyes, forehead, nose and scalp.
• Wear clothing to protect as much skin as possible. A tightly woven fabric provides greater protection than loosely woven fabric.
• To protect your eyes from sun damage, wear sunglasses that block 99 to 100 percent of UVA and UVB radiation.
• Swimmers should remember to regularly reapply sunscreen. UV rays reflect off water and sand, increasing the intensity of UV radiation and making sun protection especially important.

Allison M. Holzapfel, MD, FACSFacial Plastic and Reconstructive SurgeonMangat-Kuy-Holzapfel Plastic SurgeryBoard Certified, Facial Plastic and Reconstructive SurgeryBoard Certified, Otolaryngology – Head and Neck SurgerySpecializes in cosmetic and reconstructive surgery of the face and neck. She specifically performs multiple skin cancer reconstructions on the face and neck each week.