Speaker 1 (00:01):
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.

Dr. Guyuron (00:20):
Discovery of surgical treatment for migraine headaches is one of the most fortunate incidences in my professional life. Two patients, one after the other, about two weeks apart, told me that after forehead rejuvenation, their headaches were gone or improved drastically. One said, actually, she's migraine free completely. The other ones said headaches were improved drastically and in medicine we don't consider two statements from two patients science. So we did go back and studied patients who had undergone forehead rejuvenation. And within 10 years I had done about 314 surgeries. And all of those 314 patients, 31, had experienced improvement from surgery in terms of migraine, and 39 of them had migraine headaches before the surgery. So out of 39 patients that migraine headaches prior to the surgery, 31 had experienced either complete elimination or significant improvement, and that was statistically significant. But that study was retrospective study, meaning we went back in a study, studied those patients.

(01:54):
Now it has enormous implication, positive implication that this is not what we were seeing was not placebo because they had no idea what we are studying. And initially when some of the neurologists criticized us that what we are doing is actually a placebo effect, but this study negates that kind of notion because they didn't know what we were studying, what we're after actually. So the fact that they had experienced improvement in their migraine headache was a very strong evidence that surgery worked. But retrospective studies evidence wise are not as strong as prospective studies, meaning selection of the patient to undergo surgery. But we don't do that also indiscriminately. So we designed a study where neurologists selected the patients and we actually used Botox to see if they respond to this Botox and operated on the patients who responded to the Botox. This was a pilot study.

(03:08):
Pilot means selection of a small group of patients just to test the hypothesis that what we are doing is effective and safe and the results were extremely gratifying. So we then did a major study, much bigger group of patients, over a hundred patients entered in the study and we operated on different sites this time because they have discovered the ones that did not respond to the surgery completely had responded to the surgery on the site we operated, but they still have headaches on other sites that we had not operated. So discovered that actually forehead is not the only site for migraine headaches. Migraine headache can arise from other sites. So we included those sites this time. And before we did that, we went to the anatomy lab and did a research to see what is causing, what could be causing headaches in different areas. And I designed at the time four different procedures for each trigger site.

(04:17):
And again, we demonstrated that scientifically it was effective, it was safe. And anytime we have done any studies, we have looked into the risk factors. What are the complications that we may be causing for these patients because that's extremely important. Anytime we have a new operation to make sure that it is safe and sound. And there was no question that the safety was there. There was no question that the surgery was effective. In fact, subsequently we did one other procedure that is rarely done today, and that's because of the limitations that we have in the studies. But with the proper consent, we operated on some patients and did the surgical procedure and made the incision on the others, but did not deactivate the trigger sites to see if it works. That's the ultimate science. When we do that kind of a study, nobody can question it whether it works or not.

(05:23):
And we were able to prove through that study that the surgery is again, safe and effective. Obviously the patients underwent placebo surgery ultimately was part of our deal, that they had the real operation and benefited from the surgery as we did the initial surgeries. And I was confident that surgery works. We started giving courses in Cleveland. It was a two day course and the surgeons from different parts of the country and world came to Cleveland. And I had a didactic lecture for them for a whole day along with some other people that they had been working with me in the research team, including the neurologists. And the next day we did a dissection on their cadavers and perform surgery, live surgery to educate them how to do the procedure. And this went on for several years. And now every year before the main meeting of the Plastic Surgery Society or ASPS American Society of Plastic Surgeons, we have a whole day course on migraine headaches.

(06:43):
I also wrote a book about migraine surgery and two other books have been written since one from Europe, another one from the United States that I was involved with it. But other surgeons whom I trained contributed their expertise and experience to be able to share with others. Again, we have continued doing studies all along, and when you think about something being perfect, that means that you're not analyzing carefully enough. And I have been refining the techniques and so are some of the individuals that have been passionate about this surgery and doing their own researches to see how we can actually make the operations less invasive and safer and improve the recovery for these patients. So that's our focus. We are no longer interested in proving that it works. Not only I did this study, studies were done in Harvard and many other centers and they showed almost similar results in terms of safety and effectiveness.

(08:01):
So we are no longer focused on that. We are now focused on improving the results. After analyzing about 1200 patients who have had an undergone surgery, I came to the conclusion that about seven trigger sites can exist. Almost nobody has all of the seven trigger sites, but I also developed constellation of symptoms and studies that lead us to detect the trigger site as to where the headaches are originating from, which is our map to the success. Because if we don't know where the headaches are coming from, we can't be precise about the surgery. So in fact, I've written an article about this in our main journal, which is the Journal of Plastic and Reconstructive Surgery about finding the trigger sites. And that comes from, again, constellation of symptoms initially, asking the patients where do the headaches start from? Patients can actually help us, lead us to the trigger site by being very precise, being very observant as to where in the temple I point to the spot with the index finger.

(09:28):
I make them commit to that after fair amount of discussion. Originally they say it's the whole temple. But I just asked them, just touch you for it. Find a spot that is tender. Almost invariably we get to the point that I'm sure that, okay, this is one trigger site. Then they say, okay, no, I asked the patient, do you have any other trigger size anywhere else that I had? Yes, I may have headaches in the forehead area. Then I ask, can the forehead headaches be there without the temple headaches? If they are at the same time? And if the answer is yes, they can be independent, then I have two independent triggers. But sometimes they, no, the headaches start from here, then travel to the forehead. That's not two trigger sites. We have one trigger site that spreads the headaches to somewhere else. I am going to only only operate on the temple on that patient.

(10:33):
And we have discovered that actually in average each patient has two and a half trigger sites in average, obviously. And what it means that some patients have only one trigger site. Some patients may have four or five trigger sites. Again, seven trigger sites that we have discovered is very, very unusual. And in fact, I don't think that I've ever seen somebody having all seven of the trigger sites that we have discovered and what it means that actually each patient may have different type of surgery. Now, this variation does not mean we're not knowing what we are doing. It's actually exactly the opposite. We don't have a technique that works for every single trigger site. So we have developed a technique that works for a specific trigger site. So this questioning will be continued until I'm convinced that we have covered everything, every trigger site and also listen to the patients.

(11:36):
We have a form the patients complete that has many questions, including where the headaches start from, what elements cause reduction in the headaches, what do you do that can make it worse? What do you do that can make it better? Those lead us to suspected trigger size. Then we have other things that we do. One of the discoveries that I have made, and I have written articles about it, is using a device called ultrasound doppler. Ultrasound doppler. It's a handheld device, a larger version of which is used to detect the heart sound for the fetus during the pregnancy. And many of the ladies who have been pregnant remember that it's the same direction. What we are trying to do is see if there's a vessel irritating the nerve. This device can actually detect the pulse in a very, very small vessel that can actually trigger the headaches.

(12:43):
It is amazing how a tiny nerve, tiny vessel can make the patients so uncomfortable. So that is the device that I use very commonly. Then we have technique called nerve block, meaning we inject a small amount of numbing medicine in the spot. And if the headaches go away, means a lot. If the headaches do not go away, it doesn't mean much. And then we actually have patients who have been using Botox. The patients who respond to the Botox are more likely to respond to the surgery. But the ones that do not respond to the Botox, it doesn't mean that they're not going to respond to the surgery. And finally we do have a CAT scan for patients who have headaches starting from behind the eyes for those patients, we get the CAT scan and I not only can see what I'm looking for, I actually can show the patients and they don't have that medical background. They will see vividly what is different between the two sides of the inside of the nose. And it is very convincing actually for the patients when they see that. And it is also a great tool for me. So these are the tools that we use to make sure that surgery is going to work. It is not just guessing. We use a lot of means measures to detect a trigger size and most of the time, and we are right as a group of us who do this type of surgery, and we can help these patients

Speaker 1 (14:31):
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, THE AXIS.io.