Speaker 1:
Welcome to Headache 360 podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain, because information can be the best medicine.
Dr. Lowenstein:
Hello and welcome to the Headache 360 podcast. I’m your host, Dr. Adam Lowenstein. Today we’re going to talk about migraine surgery. That’s what I do as a treatment for migraines and chronic headaches of all types. The way that I want to address is I’m going to provide an excerpt from a podcast that I was on called Beauty and the Surgeon by Dr. Jason Martin. I strongly urge people to listen to his podcast. He has a lot of very interesting people on his show. He’s a board-certified plastic surgeon, very well respected. I am indebted to him for having me on his podcast.
Dr. Lowenstein:
But we went into a lot of the details about my brain surgery, nerve decompression surgery, the types of patients that I help, and I think that providing you with that information here will be an excellent introduction into the ways that I can help migraine sufferers.
Dr. Lowenstein:
So please enjoy the following excerpt from Dr. Martin’s podcast, Beauty and the Surgeon. In this format, he interviews me. So I hope you enjoy it and I hope you find it very informative.
Dr. Martin:
You made a name for yourself, a very talented surgeon. I know that. I came in contact with you through the American Society of Plastic Surgeons. You were on the board. You were the head of the Young Plastic Surgeons Organization, which is part of ASPS. You were part of the mentor board, I think, at one point in terms of the implants. A very successful surgeon, cosmetic surgeon-oriented primarily. Yeah, everything’s going well.
Dr. Martin:
Then all of a sudden I’m talking to you on the phone and you started talking about headache surgery. Here’s a person that has it all inherently with where they’re located, with their practice and everything, and you’re talking about headache surgery. In some ways, “I was like, “Oh, what’s Dr. Lowenstein talking about here? It’s a little bit crazy.”
Dr. Lowenstein:
That’s justifiable, right?
Dr. Martin:
Yeah, it’s justifiable. But I do think it’s important to note that your interest in headache surgery really goes back to all your experiences throughout training and also your personal experiences. You were micro-trained, a very successful surgeon, very talented, and you saw an opportunity to help people like yourself, then also use your surgical talents that you inherently have from your training and your private practice.
Dr. Lowenstein:
I’m not sure. This is probably not what you’re getting at, but I will say this about what we do. Plastic surgery is a very, very diverse field. Not a lot of people know that, for example, the first transplants were done by a plastic surgeon. The pioneering spirit of people in our field is great.
Dr. Lowenstein:
I’ve had a really great opportunity in my career to reinvent myself several times. I did reconstruction here in Denver for many years, and it was fantastic. Then I thought, “Okay. Well, what’s the next challenge that we can look at?” When I left Kaiser, and again it was a fantastic practice, but I’m an only child. At the end of the day, after a period of time, I’m better off making my own decisions and on my own than in a big company, which is why I decided to leave Kaiser. I ended up in Santa Barbara, not even knowing where Santa Barbara was or what it was like initially. But I got lucky and I ended up there.
Dr. Lowenstein:
I got to train there with one of the top aesthetic surgeons. As , a lot of fellowships for aesthetic surgery or, what, three months to maybe a year, I got to work with this guy for three years all the time and basically did that three-year aesthetic fellowship. Then he retired and I took over his practice. Then for the last 10 years, I’ve been doing aesthetic surgery.
Dr. Lowenstein:
It’s great. Love it. It’s lot of fun. But kind of thinking, “Okay. Well, what’s the next challenge that I can look at?” And so, this headache surgery just … It seems to be a great opportunity. It fits with my world because, again, I’ve had these issues, I can identify with patients, and I think a lot of patients really appreciate that, because, again, if you haven’t had this, you don’t know what it’s like. I mean at the end of the day, I’m just very, very lucky to be doing what I’m getting to do in the field that we’re both in.
Dr. Martin:
But in this podcast, we don’t believe in luck. I mean you have circumstances and then you have an innate ability to understand those opportunities and take advantage of them. When I say take advantage, I don’t mean it in a way that’s manipulative. I mean that you utilize all your experiences in life.
Dr. Martin:
You’re, fortunately, a good surgeon at the right time. You’re very well-connected and respected, so you came into contact with Dr. Guyuron or Dr. Janis or all these people working in this field, and you were able to reach out and implement that in your practice. You should be commended for that, but, more importantly, we need people like you in our field. We need people to reach out and grab some of these novel surgeries and to keep expanding, to keep on trying to improve the health of people from a plastic surgery standpoint, but, in this case, from a functionality standpoint.
Amy:
Have quality of life.
Dr. Martin:
Yeah.
Dr. Lowenstein:
Yeah. I mean that’s the biggest issue with what we’re doing, is quality of life issue.
Amy:
I can absolutely see that. I mean I’ve never had a migraine, but I can definitely understand, having spoken to people who have, that it can take a while to be understood, that there are so many symptoms that can add to it and it can become … They get so deep in their treatment or in their lack of treatment that people stop believing them. They think they’re some sort of fake. Going to someone who’s experienced the symptoms and knows that they’re not faking it, they’re not making these up …
Dr. Martin:
At the very least can be compassionate-
Amy:
That’s what I mean, yeah.
Dr. Martin:
… and relate.
Amy:
And understand that these symptoms are all real. They’re in your head, but they’re not in your head.
Dr. Lowenstein:
Yeah. I mean a lot of people get a social stigmata about them from having migraines.
Amy:
Missing work, yeah.
Dr. Lowenstein:
A lot of people lose their job because they can’t function at work, and six days turn into one after another after another. You don’t have an understanding boss. You can’t do your job. Yeah, it can ruin people’s lives. I’ve had patients tell me that they were considering assisted suicide. We operate on them and then they’re like, “I haven’t felt this great in years.”
Amy:
Wow!
Dr. Lowenstein:
You hear that from somebody and you can’t-
Dr. Martin:
I mean that fills you for the rest of your life.
Dr. Lowenstein:
Yeah, exactly.
Dr. Martin:
All right. Let’s get into it. If people have migraines, or migraine sufferers, what do they usually do first? They go see a neurologist or they get referred to a neurologist?
Dr. Lowenstein:
They usually go to their own doctor. Then their own doctor will often send them to a neurologist. From there, so many different things can happen. You can go to a headache specialist, you can go to pain doctors. A lot of my patients are seeing multiple physicians.
Dr. Lowenstein:
There’s so many different ways to try and attack this and a lot of people … One of the things that we get is a … We don’t get it, that the neurologist get is an MRI of the brain, because at the end of the day you want to make sure that there’s nothing else going on. You want to make sure there’s no brain tumor or anything like that.
Dr. Lowenstein:
Then you get people who they’re looking so hard for a reason that this is happening. They get an MRI and their brain looks normal, and they’re crushed, like, “I was hoping that there was going to be a tumor there.” But that’s normal. Then it’s how can we attack something that we can’t see the problem is right here, or it can devolve into a whole, “I’m seeing this person for my narcotics. I’m going to see this person to get a nerve stimulator put in.” That’s one of the things that some people do. “I’m going to see this other doctor for meditation issues.” A lot of these things are successful. A lot of people will do … There’s something called a daith piercing. Do what that is?
Amy:
Yes.
Dr. Lowenstein:
Right?
Amy:
Yeah.
Dr. Lowenstein:
A lot of people will get a daith piercing and it helps them with their headache, which is awesome.
Amy:
I didn’t know there was a correlation there.
Dr. Lowenstein:
Yeah. People say to me, “Should I go get this piercing?” Absolutely. Lots of different things work for lots of different people.
Amy:
That’s like on the theory then of eastern medicine, that it’s somehow disrupting your chi in that area.
Dr. Lowenstein:
There hasn’t been any studies.
Amy:
[crosstalk 00:10:05].
Dr. Lowenstein:
There’s a lot of discussion about this. It doesn’t work for everybody by any means. A lot of people said, “Yeah, I tried that. It didn’t work.” But it’s not really understood. That is part of the problem is that migraines are not completely understood. It’s interesting that in all of these doctors that you would see with a migraine, the plastic surgeon is about the last guy on that list.
Dr. Martin:
For the patient with a migraine, what percentage does first-line treatments really work for them, like 80% or 70%?
Dr. Lowenstein:
First-line treatments?
Dr. Martin:
Like medications.
Dr. Lowenstein:
I would probably say ballpark around 50%.
Dr. Martin:
Okay.
Dr. Lowenstein:
But then there’s a tiered thing of going through one thing and then another thing and then another thing.
Dr. Martin:
You’re literally at the end of the rope.
Dr. Lowenstein:
Yeah. I mean, look, I love the surgery. It’s awesome. But it’s not for everybody. I haven’t had the surgery because I take Zomig, which is a type of triptan. I can function on Zomig. Zomig wipes out some people. It makes them so exhausted. But you and I have had five days of operating straight without eating or sleeping. I’m used to that, so that side effect-
Amy:
It’s hard to [crosstalk 00:11:30] a surgeon down.
Dr. Lowenstein:
Yeah. It doesn’t bother me. I mean-
Dr. Martin:
Won’t stop, can’t stop.
Dr. Lowenstein:
Yeah, there you go. But some people can’t take that type of side effect, so Zomig doesn’t work for them. But a lot of people can. The point is that if daith piercing, meditations, nerve stimulators, if these things work for you, that is awesome, and that’s really the thing to do. You only go to surgery if nothing else works.
Dr. Lowenstein:
But in those patients where nothing else works and we can do some of our screening tests, which I’m assuming we’ll talk about in a little bit, the efficacy or the ability for this to actually work is extraordinarily high. And so, that’s a great thing.
Dr. Martin:
Right.
Amy:
Are you seeing an increase in the number of people who are finding out about this surgery and actively seeking you out?
Dr. Lowenstein:
That is a hard question. It’s are we seeing an increase? More people know about this today than yesterday, than last week. But today hardly any people know about it.
Dr. Martin:
Right. 15% of all Americans, 35 million people, right, migraine sufferers?
Dr. Lowenstein:
Oh, right. Yeah, yeah.
Dr. Martin:
50% of those, the first-line therapies, the drugs and stuff help out. Then you do the CAM stuff or alternative treatments, all these kind of things. I mean there’s millions of people out there suffering from migraines that are not totally getting relief or even functional improvement with all these therapies. In reality, the surgery has a lot of potential, at least from the data that’s out there.
Dr. Lowenstein:
Yeah, I mean the data that’s out there is very favorable. My personal experience is very favorable. But the biggest problem with migraine surgery is people don’t know it exists. Honestly, we also have a reasonable amount of difficulty with getting people to refer to us because, as I was talking about earlier, the neurologists, I think they feel similarly, like the plastic surgeon’s about the last person you need when you have a migraine.
Dr. Lowenstein:
For a plastic surgeon to go to a neurologist and say, “The subset of people that are not getting better with what you’re doing, I may be help,” they’re skeptical. I can understand that because, look, if I was a neurologist and you said-
Dr. Martin:
“Look at my plastic surgery research.”
Dr. Lowenstein:
… “I have a great way to do a facelift. You should look at it,” you’d be like, “Come on, man.”
Dr. Martin:
Yeah.
Dr. Lowenstein:
I totally get it, but it’s on us to get people the data, to review and actually see the success rates, which are better than 90%. That’s part of what we’re having to do right now.
Dr. Martin:
I’m sorry, just real quick. The data goes back 15 years, or more than that, 18 years now almost, and it’s robust data. I personally looked at it. I highly advise people who like that kind of stuff to look into it themselves and see that these are real studies with larger numbers, statistical significance, that is formidable in efficacy. We can go into that, what that means, but an efficiency or an improvement that is really there.
Dr. Lowenstein:
Dr. Guyuron in Cleveland is the father of all of this. His first study used sham surgery. I don’t even know how you get that past through the IRB [crosstalk 00:15:27].
Amy:
Right. How do you get approval to put somebody to sleep and that kind of thing?
Dr. Lowenstein:
Half of the patients go to sleep-
Dr. Martin:
[crosstalk 00:15:30] Cleveland Clinic or Mayo Clinic, you can do what you want.
Dr. Lowenstein:
Maybe. Well, Dr. Guyuron is Dr. Guyuron.
Dr. Martin:
Easily.
Dr. Lowenstein:
He’s a very, very, very, very well-respected plastic surgeon in the world.
Dr. Martin:
Probably the most [crosstalk 00:15:38].
Dr. Lowenstein:
Exactly. But I mean he put people to sleep, made incisions. Half the people, he went and did a decompression. In others, he didn’t do any decompression.
Amy:
[inaudible 00:15:52].
Dr. Lowenstein:
Right. You can see I mean that’s as strong a study as you can possibly do. When you see huge statistical significance, that the people who got the surgery largely got better and the people who didn’t, got the sham surgery, largely didn’t get better. It’s not vague, right?
Dr. Martin:
What percentages are we talking about here in some of those studies? I know it depends on the site. We’ll get into it more in detail. But what percentage are we talking about?
Dr. Lowenstein:
When we talk about improvement, we’re looking at there’s a subset of patients who never get another migraine. That can be variably in the high 30s to low 40%. If you’re looking at-
Dr. Martin:
So a third are cured with surgery?
Dr. Lowenstein:
Cured, never have another migraine, right. Then if you look at having a successful procedure as being decreasing your migraine symptoms by at least 50%. That means that you have at least less than half the number of headaches that you used to and those headaches are less than half as severe as they used to be. There are some studies that show that to happen in the high 80%, some in the low 90%.
Dr. Lowenstein:
But in the worst case scenario, let’s say 80%, but in fact it’s more close to 90%, we can decrease these headaches to be basically normal headaches. Everybody has headaches. I have patients who they still have headaches, but they’ll email me a happy email, “Hey, I have a headache today. I took Tylenol and it got better.” That is unheard of to a migraine patient. That’s never happened to these patients before. Even just to celebrate having a normal headache, that’s what these patients are dealing with.
Dr. Martin:
If you think about it, plastic surgery is criticized a lot for the level of data they have in studies. These are one of the situations where we actually did a pretty good job. I’m saying that from my professional opinion. Other people may differ with me. But that’s what I thought was remarkable when I was researching for this podcast.
Dr. Lowenstein:
Yeah, there are a lot of data. Now they’re looking at five and 10-year data, and it’s all favorable.
Dr. Martin:
Yeah.
Dr. Lowenstein:
But I do want to say this one thing. There are people who have this surgery and it doesn’t work.
Amy:
Non-responders.
Dr. Lowenstein:
Right, there are non-responders out there.
Dr. Martin:
And that’s going to happen with any surgery. No surgery has 100% success in most cases. But do you think some of those people have etiology so that really have not been deduced and it’s even more complicated than we think, or is that a technical error?
Dr. Lowenstein:
Well, I think there’s a lot of different possible reasons. I mean I’ve seen some redo operations of other surgeons that maybe didn’t release the entire nerve adequately. I think that some people may have gotten this operation and not necessarily been great candidates. I have a particular way that I diagnose as to whether or not a patient’s a candidate. For me, that’s worked consistently.
Dr. Lowenstein:
But there are always going to be mistakes in that diagnostic situation, for example, and we can talk about that in a little bit. But we do a local block to see whether somebody’s headache gets better, whether or not that nerve is something that we can work with.
Dr. Lowenstein:
I guess those certain people could get a nerve block and get better, but it’d be serendipitous rather than an actual anatomic issue, and those people that get an operation, but this wasn’t the problem in the first place. I mean I think, just like any surgery, there’s going to be lots of different reasons that a small subset of those people [crosstalk 00:20:24] helped.
Dr. Martin:
[crosstalk 00:20:25].
Dr. Lowenstein:
But we are fortunate in the fact that the people who are not helped by this are a very small subset.
Dr. Martin:
Right. I would say-
Dr. Lowenstein:
Less than 10%.
Dr. Martin:
… to have a surgery … I mean I know that I’m generalizing here that it has a 90% success rate. It’s pretty darn good. If I was going to implement a different surgery in my practice, I would be okay with a 90% success rate being open to the patient themselves. All right, we’re a patient. We have severe headaches. We have migraines. We go through all the treatments beforehand.
Dr. Lowenstein:
Excuse me.
Dr. Martin:
That’s all right. We get referred to Dr. Lowenstein, who, by the way, is in Southern California. We get referred to Dr. Lowenstein. So what is the process by which we, as the patient, get evaluated?
Dr. Lowenstein:
In an ideal situation, you show up in my office in pain, to the point that we’ll talk to you before you come for your visit and say different people have different triggers. We talked about people with perfume, a lot of people, red wine, caffeine, chocolate. We say, “The night before you come in to see me, have-
Amy:
Trigger yourself.
Dr. Lowenstein:
… chocolate with red wine and a coffee chaser and do-
Amy:
Walk by the perfume counter [crosstalk 00:21:41].
Dr. Lowenstein:
… everything that you can do to try and come in with a migraine. Optimally, patients come in in pain, which is a strange thing to say, but it is what it is. Then we have you fill out prior to this a very, very detailed history. We want to make sure that you actually have migraines and that you actually have seen a neurologist and you’ve had an MRI and we know that this is the problem that we’re working with.
Dr. Lowenstein:
Now I’ll do a physical exam. There are about 14 nerves in the head and neck, seven on each side, that we know can trigger these headaches. One of the things I do is I’ll, just from the history, try to find out where a person’s headache is coming from. Is it coming from above the eye and radiating to the back? Is it coming from the back and radiating here, et cetera? We try to figure out where that is from and I look for what’s called Tinel sign. A Tinel sign is what you … You know what a Tinel is.
Dr. Lowenstein:
A Tinel sign is where you tap on the nerve and you get some reaction, either increase in pain, tingling. A lot of patients will have sensitivity to tapping or a Tinel sign in various nerves. That’s where the headache seems to be coming from primarily.
Dr. Lowenstein:
In my practice, then what I’ll do is use some local anesthetic, lidocaine and Marcaine. Lidocaine is a quick onset, lasts for about an hour. Marcaine has a little bit of a longer onset, but lasts for about four hours. I will give you a shot where I know that nerve is.
Amy:
Do you use an ultrasound guidance, or do you just-
Dr. Lowenstein:
No. A lot of people do. I don’t. You’ve operated on the nerve enough times-
Amy:
Know where it is.
Dr. Lowenstein:
… you kind of know where it is. A lot of the ultrasounds are also used. Again, this is a couple of layers further than we’re going here, but to try and find the blood vessels that could be crossing these nerves and causing [crosstalk 00:23:59].
Dr. Martin:
Yeah, we’ll get to that, though.
Dr. Lowenstein:
But basically I’m going down to where the nerve starts and giving this local anesthetic. Then we turn off the lights in the room, and I go back to my office and I do some charting. I come back in about five minutes. More often than not, the patient will say, “My pain has decreased from a … ” Let’s say they started an eight to X. If they say, “I had an eight five minutes ago and now my pain is gone,” then we can be pretty certain that that nerve is the problem and most of the problem, if not all of the problem.
Dr. Martin:
Can I ask you a question?
Dr. Lowenstein:
Yeah.
Dr. Martin:
You said there’s-
Dr. Lowenstein:
It’s your podcast, right?
Dr. Martin:
Thank you very much.
Dr. Lowenstein:
No.
Dr. Martin:
I have only one question for you. Do you inject only one nerve at a time or do you inject multiple areas? How do you deduce that out?
Dr. Lowenstein:
I inject one nerve at a time. This is what I call targeted injection mapping. The idea is we’re mapping out the problematic nerves. When I have injected that first nerve and I come back, and let’s say they say, “I had an eight and now my pain is down to a three,” so we basically start again. Now where is it coming from? Well, it was coming from back here-
Dr. Martin:
Like here behind the head.
Dr. Lowenstein:
… and we fixed this.
Dr. Martin:
Behind the head.
Dr. Lowenstein:
Right, behind the head. Now the remaining pain is in my temple or above my eye. We look for a Tinel sign there. But even if there’s not a Tinel sign, if this is where it’s coming from, then we give another shot there. I leave the office, go do some charting, come back in five minutes. Now what’s your pain?
Dr. Lowenstein:
What we’re doing is trying to work down to a pain of zero and, in doing so, mapping out each of the nerves that are problematic in a targeted way. By the end of the consultation, you may have several injections or you may just have one. But the idea is that we’re moving from severe pain, if not to a pain-free state, by blocking these nerves.
Dr. Martin:
You’re localizing the areas. Also, in some of these studies, like PREEMPT, where the neurologist do Botox. You can Botox to the areas. Some of these studies actually use Botox as the localizing agent. Explain the difference between lidocaine and Botox in that situation.
Dr. Lowenstein:
Lidocaine literally blocks the nerve. It works directly on the nerve to prevent any signals from going through that nerve or back to the brain. Botox, we know Botox has some effects on the actual nerve itself, but the majority of the effects of Botox are on the muscles surrounding the nerve. I guess we should track back and say that what we’re trying to fix is nerve compression.
Dr. Lowenstein:
What we found is that compression or chronic irritation of these nerves are what are causing or triggering the migraine headache. What we’re trying to do in the endpoint is take these compressed, tight areas around these nerves and releasing them so the nerve can be in a relaxed situation without these compressions causing this chronic irritation, causing the migraines.
Dr. Lowenstein:
By using a nerve blocker like lidocaine or Marcaine, we’re actually preventing any signal from that irritation further out to get back to the brain to cause the pain.
Amy:
[inaudible 00:27:48] still compressed by muscles, it’s [crosstalk 00:27:51] stop the symptom.
Dr. Lowenstein:
The nerve can’t relay those distress signals back to the brain. Botox works by relaxing those muscles that are causing the compression. Ideally, let’s talk about the nerves in the brows. You have the supraorbital and supratrochlear nerves.
Dr. Lowenstein:
This is when people get aesthetic Botox. What we’re doing is putting Botox in what’s called the corrugator muscle, which causes the wrinkles in the glabella, the 11s that people say when they’re frowning. These nerves go through that muscle. Botox often will prevent headaches in patients who have these muscles causing this compression, which is causing the migraines.
Dr. Lowenstein:
Some people, instead of doing this with lidocaine, will give Botox and then assess over a period of time, because, as we know, Botox only … It takes about four or five days to take effect. The issue that I’ve found with Botox is because you are adding volume to the muscle, which is already compressing the nerve, things get worse before they get better. Not always, but sometimes.
Amy:
Really interesting because people sometimes, especially people who haven’t had Botox before, will complain of headaches after their first Botox injection.
Dr. Lowenstein:
Because that volume that you’re putting in there is causing more irritation. That’s tough for the patient because, “I came to the surgeon to get better-
Amy:
And now he made it worse.
Dr. Lowenstein:
… and he made me worse.” For the first week, there’s a lot of phone calls. But a lot of those patients, after that period of time, will then find that their headaches are improved because as the Botox takes effect, there’s less compression, less irritation, less of that distress signal going back.
Dr. Lowenstein:
However, Botox, again, works on muscle, but it doesn’t work on blood vessels or bones or fascia, which is connective tissue. A lot of times there are these other non-muscular things that are causing the compression. If Botox doesn’t work, it doesn’t necessarily mean the surgery won’t work. Does that make sense?
Amy:
Yes.
Dr. Martin:
Yeah, totally.
Amy:
Absolutely.
Dr. Lowenstein:
But-
Dr. Martin:
If the lidocaine-
Dr. Lowenstein:
… if the lidocaine doesn’t work, that’s a better prognostic thing in my world, that even if we block the nerve-
Amy:
[crosstalk 00:30:26] going to change.
Dr. Lowenstein:
… the headaches not getting worse. I can tell you I’ve seen that twice. I mean almost everybody that gets to me is improved by these blocks, which is remarkable, because granted I’m seeing a very small subset. But if almost everybody that I’m seeing is responding to this, you’ve got to wonder how many people are out there that are potential responders, right?
Amy:
Yeah.
Dr. Martin:
Yeah. You have peripheral nerves, and those nerves get compressed. That’s what we think is going on. There are certain areas of the head that we see this over and over with migraine sufferers. Most of the time it’s muscle, but it can be other things, like you’re talking about, fascia or where the nerves come out of the bone, the bone itself. Just different types of differing anatomy can affect that.
Dr. Martin:
They come in, you use the lidocaine to numb the nerve. if they get resolution of symptoms or improvement, then you have a good idea that something around this nerve is irritating it. If I can go in there and release it and give it some freedom, it won’t be so angry and send back painful stimuli to the brain, which then relates to this chronic problem called migraines.
Dr. Lowenstein:
Yeah. I guess we’re done. You’re just doing the [inaudible 00:31:41].
Amy:
[crosstalk 00:31:41].
Dr. Lowenstein:
Exactly.
Dr. Martin:
I just want to add one thing, and it’s really interesting. Science, you come on things sometimes just accidentally. The way this all came about was that in the old days, we used to do … Well, I mean some people still do it. But endoscopic brow lifts, where you would go in with small holes up in the hair area and you would take out the muscles between the eyebrows, the corrugator and procerus, the ones that cause the 11s. You would actually physically remove them.
Dr. Martin:
What they saw in a small subset of those patients who were migraine sufferers, that they didn’t have migraines in that area anymore. Luckily, we had intelligent physicians, surgeons who said, “Well, maybe there’s something around these muscles or is this muscle itself is causing something to lead to these migraine symptoms.”
Dr. Lowenstein:
Yes, I agree that luckily we have intelligent people, but don’t point at me. That was Dr. Guyuron who really noticed that and then he did a whole bunch of subsequent studies. He and another friend of mine, Jeff Janis, who’s at Ohio State, they did all of these anatomic studies on cadavers, finding different nerves, testing with Botox and lidocaine, and really figuring out which of these nerves are problematic.
Dr. Lowenstein:
Again, we’re in the, relatively speaking, early stages of this. We may find other nerves down the line that are still an issue. But right now we’re dealing with three nerves in the back of the head, two nerves in the temple area, and two nerves above the eye, and we’re having good success with this.
Dr. Martin:
Let’s get into that. For those listening to this, you can also watch it on video. We’re going to describe it to you when we’re talking about different nerves, but there’s also going to be an associated video with this that you can look and see Dr. Lowenstein actually pointing at … We actually have a head here.
Dr. Lowenstein:
Yeah.
Amy:
What is his name? I have to know.
Dr. Lowenstein:
The patient’s head?
Amy:
Yes.
Dr. Lowenstein:
You know something, gosh, I feel bad.
Amy:
You’ve never named your head?
Dr. Lowenstein:
I haven’t named the head, right.
Amy:
Oh, I’m sad.
Dr. Lowenstein:
I think Amy, maybe. No.
Dr. Martin:
It’s a male. It’s a male.
Dr. Lowenstein:
That’s right.
Dr. Martin:
Or a short-hair female, I don’t know-
Amy:
That’s right. [crosstalk 00:34:02].
Dr. Martin:
… with dark eyebrows.
Amy:
Can I say one thing for just the common person out there? Most people who are listening to this, probably haven’t been in a cadaver lab to understand the beautiful, delicate nature of nerves. When you’re in a cadaver lab doing dissections and you find these nerve bundles, they’re amazingly intricate and so delicate, but they’re also at the same time are shockingly large in some areas of the body. These nerves are big.
Dr. Lowenstein:
There’s a couple of these nerves that are big and there’s a couple of these nerves that are wispy small. A lot of the nerves actually branch. Again, who are the non-responders? To get a complete surgical outcome, we’ve got to ideally find each branch and decompress each branch, which can be challenging.
Amy:
It’s kind of like a maze.
Dr. Lowenstein:
Yeah, exactly.
Amy:
Yeah, these beautiful long tendrils. Nerves are really beautiful.
Dr. Lowenstein:
Exactly.
Dr. Martin:
All right. So let’s imagine we have a patient, and all areas are involved. We’re going to have you quickly go through the different areas, the trigger areas, or the localized areas, and give an idea what that patient would go through on the day of surgery, how many surgeries it would take, and the process of surgery for each location.
Dr. Lowenstein:
Okay. Let’s actually move back. We’re going to call the head Thomas because I’ll tell you where-
Amy:
Thomas.
Dr. Lowenstein:
There is Dr. Muehlberger in Germany and England. He has several centers in Europe and treats a lot of migraine patients. He was good enough to send me this head, this prop, so we’ll call it his name.
Amy:
He looks like a Thomas.
Dr. Lowenstein:
There you go. There’s some of these stuff that is really nicely shown here. There’s a couple nerves that are not shown. But here we can see this is the greater occipital nerve.
Dr. Martin:
He’s pointing to the back of the head, right?
Dr. Lowenstein:
Yes. That nerve comes from what’s called C2, which is one of the branches of the spinal cord. It goes through several different muscles, including the trapezius muscles, which, as we know, when we’re stressed, a lot of people hold their stress in their neck and shoulders. This nerve can be compressed by the trapezius as well as what’s called the splenius capitis, which is a deeper muscle and helps with head stability. It can also be compressed by the occipital arteries, which are often up here in the … Now I’m pointing to the higher portion of the back of the head. It can have arteries that cross and cause problems.
Dr. Martin:
Right. If you feel your neck and you go up to where the skull, you can start to feel the skull, that’s the area that he’s pointing at right now.
Amy:
Right, like where your spine meets up with your head.
Dr. Lowenstein:
Exactly.
Amy:
It makes sense why motion would be such a trigger then for people, because some of those muscles you’ve mentioned are really key in keeping our head stable, like keeping our horizon where it is.
Dr. Lowenstein:
Interestingly, a lot of patients who have this problem … And when we’re dealing with these nerves, it’s called the occipital neuralgia. Neuralgia is an inflammation of the nerve. Occipital is occipital area or occipital nerves. A lot of these patients have had either a recent or distant history of whiplash, because what’s happened is you get a whiplash injury and then scarring down of the muscles, which were torn during that during the whiplash injury. Then all of that causes tightness around these nerves.
Dr. Lowenstein:
A lot of patients that I’ll talk to who’ve had this surgery, who are considering this surgery, I’ll ask, “Did you ever have a car accident?” They’ll go, “I forgot about this, but back in so and so, I did get into a car accident.” “When did your headaches start?” “About that time.” It’s interesting to see that a lot of these can be post-traumatic issues.
Dr. Lowenstein:
But back to these nerves, there’s also here a third occipital nerve. There are three occipital nerves. The third occipital nerve is in the same general area, just a little further down on the neck. It innervates a much smaller area, but can also be a trigger.
Dr. Martin:
We see a third nerve. Are they branches or just three different distinct nerves?
Dr. Lowenstein:
They’re three distinct, different nerves.
Dr. Martin:
Okay.
Dr. Lowenstein:
They’re all in the occipital region.
Amy:
[crosstalk 00:38:47] spinal nerves.
Dr. Lowenstein:
Therefore, occipital nerves. The lesser occipital nerve actually is not shown here, but it’s down in the lower lateral neck, comes out around what’s called the sternocleidomastoid muscle, which is another neck stabilizer and helps with turning of the neck. For example, for me, that’s one of my triggers. When I have a really significant headache, I’m just rubbing right on the side of my neck. Before I knew what I was doing-
Dr. Martin:
Relaxing.
Dr. Lowenstein:
… I was trying to, right, massage those areas to try and relax the muscles. Then when I learned, I progressed through plastic surgery and learned about this, like, gosh, oh, it all makes sense. In order to get to these nerves, the way I do this is a vertical incision that’s largely here in the hairline.
Dr. Martin:
Right. It’s in the midline.
Dr. Lowenstein:
In the midline.
Dr. Martin:
Okay, a vertical incision. Now do you have to shave the hair?
Dr. Lowenstein:
Yes.
Dr. Martin:
Okay.
Dr. Lowenstein:
We do, in women, and a lot of patients are women because more women suffer from migraines than men. We can shave the head in a manner if you have long hair, you’d never know the difference unless you actually lift up your head. Some patients go with it and show up to my office with the partially shaved head and a totally new hairstyle. But, yes, we do have to shave around the incision. Then I go down through the fascia of the midline down to the muscle layers, and then dissect to one or the other side without going too deep to go.
Dr. Martin:
Right, [crosstalk 00:40:39].
Dr. Lowenstein:
Find the nerve. Then we trace the nerve from its deepest point to its most superficial point in what we call the subcutaneous tissue or the fatty area just below the skin, because these are all sensory nerves. At the end of the day, at the end of the course, they are providing feeling or sensation to parts of the scalp. They’re going up into the fat below the skin, and there’s no compression there. We trace it to get up to that point. Back here, I’m going through the trapezius, through the splenius capitis, taking out little pieces of muscle and also making a trough for the muscle to lie in.
Amy:
For the nerve.
Dr. Lowenstein:
For the nerve to lie in, excuse me.
Dr. Martin:
Yeah, the nerve.
Dr. Lowenstein:
Thank you. I do that for the greater occipital and for the lesser occipital. Then before we close, we take a flap, so a little piece of fat that is just below the skin, and put it along the nerve to, again, prevent further scar tissue of compression from happening, so pad the nerve with this fat.
Amy:
A little phospholipid cushion.
Dr. Lowenstein:
There you go. For the lesser occipital nerve, I usually make a smaller separate incision, again down the back of the neck towards this side. That incision is usually an inch maybe, and go down to the muscle layer. We can find that nerve relatively easily. If it’s easily decompressed, then we’ll decompress it.
Dr. Lowenstein:
But for the smaller nerves, of which the lesser occipital, and we’ll talk about the ones in the temple as well, these nerves really innervate very, very small areas. Sometimes if the nerve looks really bad, we’ll just cut the nerve and bury it in an adjacent muscle to prevent what’s called a neuroma or an abnormal growth of the nerve, which can also be painful. Patients won’t even really recognize a deficit of feeling from those small nerves that are out there.
Dr. Martin:
But the greater occipital, you do not, because that’s something that would be [crosstalk 00:42:51].
Dr. Lowenstein:
Right. The greater occipital, we can cut it. If it’s severely diseased, we’ll cut it. If it’s a secondary operation where we’ve done a release and it has not been successful, but the patient is still showing us that this is still the problem, then we’ll sometimes go and cut that nerve. But that can cause numbness and tingling in larger aspect of the scalp, and that can be unpleasant.
Amy:
Yeah, people find numb scalp disconcerting.
Dr. Lowenstein:
Right. But given that or the severity of their migraines, a lot of patients say, “That’s fine.”
Amy:
Cut it.
Dr. Lowenstein:
“Cut the nerve.” But if we don’t have to cut that nerve, we try not to cut that nerve. Then we close things up. We use buried sutures, so there are no sutures to come out. Some people use a drain. I don’t use a drain. After surgery, you can be sore because we’re cutting muscles.
Amy:
Right. It’s still surgery.
Dr. Lowenstein:
Right. But patients can tell the difference between postoperative soreness versus migraines, two totally different things. Patients will have soreness for a couple of days, sometimes a couple of weeks. Actually, sometimes they’ll have good and bad days of actual migraines afterwards. Again, the nerve has been manipulated during the surgery, and it’s kind of angry.
Dr. Martin:
You get postoperative swelling, too.
Dr. Lowenstein:
Exactly. Some patients will have worse days, better days and, over time, over the next few months, equilibrate to it to a situation which, in more cases than not, is favorable to what they had before surgery.
Dr. Martin:
So in the occipital area, you make a small vertical incision in the midline. That’s in the hair-bearing area. Once that heals, you’re not going to see that. You have small little incisions on the back of the neck, a little bit to the side, if necessary.
Dr. Lowenstein:
If you have short hair, you could see them. But they tend to heal very well.
Dr. Martin:
It does go away.
Dr. Lowenstein:
Yeah.
Dr. Martin:
How long does that specific procedure take, just for the back of the head?
Dr. Lowenstein:
It takes two to three hours if you’re going to do both sides.
Dr. Martin:
Okay. Then for that surgery, you’ll be laying face down, which we call a prone position. It’s under general anesthesia, which means there’s a tube to help support you breathing. It would be done in a surgery setting like a surgery center or a hospital, just FYI. All right. There’s other areas, too. Where are those?
Dr. Lowenstein:
We can take Thomas’s-
Dr. Martin:
Poor Thomas. You just took his eye off.
Amy:
[crosstalk 00:45:34] bone off, yeah.
Dr. Lowenstein:
[crosstalk 00:45:34].
Dr. Martin:
If people can see this, he just took his eye off. What he did is now he’s looking at the left eye, the bones around the eye, and then the temporal area. If you go from your eye and you go to the outside where your side burn is, that’s the temporal area.
Dr. Lowenstein:
Right. The nerves above the orbit or above the eye, the supraorbital and supratrochlear nerves, they go through variably either holes or notches in the bone, in the superior orbit or the eye socket.
Dr. Lowenstein:
A lot of times there’s compression in there. And so, we’ll go and we’ll actually unroof what’s called the foramen or the hole that the nerve goes through. If it’s a notch, which is also common, a lot of times there’s this fascia or connective tissue that’s forming a bridge over the notch, will release that, will release as … Here we’re looking at the corrugator muscle, and we’ll trace the nerves and all of their branches through the muscle to try and release these areas as well.
Dr. Lowenstein:
A lot of times there’s blood vessels associated with these bundles will ligate or disrupt, cut those blood vessels, so they’re not a problem. Again, tracing the nerve from the deeper portion through all these areas of potential compression out towards and to the subcutaneous tissue.
Amy:
You’re coming out of that superior or you’re coming [crosstalk 00:47:09].
Dr. Lowenstein:
No. There’s two ways to do this. There’s this endoscopic way, which is the way Dr. Guyuron originally described it. Then there’s … It’s called the transpalpebral or upper eyelid approach.
Dr. Martin:
Just real quick, it’s the same incision or the same scar you would have if you went in and did your eyelids for cosmetic reasons. In the crease of the upper eyelid.
Dr. Lowenstein:
Some patients, they will say, “Okay. Well, let’s-
Dr. Martin:
Just go ahead-
Amy:
Let’s do it [crosstalk 00:47:35] while you’re in there.
Dr. Lowenstein:
… get my eyelids done, too.”
Dr. Martin:
Let’s get my migraine and my upper eyelids taken care of.
Amy:
My droopy eyelids.
Dr. Lowenstein:
Right. It’s an aesthetic scar. You’re going to end up with basically a very, very, very fine transition or a white line in the upper lid, in the fold of the lid, where people just don’t see things. That’s a very, very well tolerated incision. Then lateral to your eye, you have crow’s feet.
Dr. Martin:
Right, which means to the outside of your eye. Everybody knows the crow’s feet.
Dr. Lowenstein:
Here you can see this is the zygomaticotemporal nerve, which if you feel this bone on the side of your eye and then you push towards your ear, you’ll see there’s a little divot, there’s a little depression there. That’s where the zygomaticotemporal nerve is.
Dr. Martin:
Right. If you’ve always seen the classic thing when people have headaches, they’re rubbing their temples.
Amy:
[crosstalk 00:48:34].
Dr. Martin:
They’re literally rubbing right in there where the nerve-
Amy:
Yeah, right there.
Dr. Lowenstein:
Right in the nerve, trying to release that.
Dr. Martin:
Right.
Dr. Lowenstein:
They don’t even know that they’re doing this. But we can use this upper lid incision and have it go into the crow’s feet to access that nerve.
Amy:
A cat eye eyeliner.
Dr. Lowenstein:
There you go.
Amy:
Stretch that out.
Dr. Martin:
Right. We already use that incision from a cosmetic standpoint. It’s well-known to heal well and not be a [crosstalk 00:48:59].
Dr. Lowenstein:
Very. I mean I use the same incision when I’m doing mid-facelifts, which was interesting to me because when I learned how to do all of this surgery, like, “Oh, yeah. I know that that nerve is right next to the sentinel vein.” I mean you know exactly. I’ve been looking at this nerve for years, but now we’re doing a similar operation for a different reason. That nerve will either decompress through the temporal muscles, or sometimes that nerve will just get cut.
Dr. Martin:
Because the distribution for sensation for that nerve-
Dr. Lowenstein:
Very small.
Dr. Martin:
… the zygomaticotemporal is small, and you can cut that.
Dr. Lowenstein:
Exactly.
Dr. Martin:
Whereas the ones, the supratrochlear or the supraorbital, which again is in your eyebrow area, you don’t usually cut those because those are a little bit more [crosstalk 00:49:47].
Dr. Lowenstein:
We try not to cut that. But as you know, whenever we do a brow lift or talked about doing these kinds of things, one of the risks we talk about patients is that you might have that nerve cut.
Amy:
Yeah, [crosstalk 00:49:58].
Dr. Lowenstein:
Fortunately, knock … Is there wood here? Never happened to me. But one of the risk factors is that you would have a numb forehead. We certainly want to avoid that. Those nerves, when we’re identifying the nerves and actually tracing them out through the muscles, the only really way they get cut is if we’re doing it intentionally, because we’re going in to look at the nerves. So just tracing that.
Dr. Martin:
I mean there’s a part of this that’s a little bit funny, because in plastic surgery, we spend so much time not cutting nerves.
Amy:
Right, trying to avoid them.
Dr. Lowenstein:
Right. We’re trying to avoid-
Amy:
Yeah, trying to avoid them.
Dr. Martin:
I mean that’s like the main complication with most cosmetic procedures. You actually cut the nerve [crosstalk 00:50:36].
Dr. Lowenstein:
Right. But we spend a lot of time avoiding the area of a nerve.
Dr. Martin:
Exactly.
Dr. Lowenstein:
Here we’re actually looking at the nerve.
Dr. Martin:
And going in it.
Dr. Lowenstein:
And so, when you’re looking at the nerve, it’s hard to cut it unless you’re trying. Anyway, that’s-
Dr. Martin:
One question, just real quick. Dr. Guyuron, in one of his discussions on his technique, talks about taking the fat from the inside portion of the upper eyelid and putting it like you did in the neck, doing the same thing.
Dr. Lowenstein:
And I do that.
Dr. Martin:
Okay, for around the supratrochlear and supraorbital-
Dr. Lowenstein:
Thank you.
Dr. Martin:
… nerve and eyebrow area.
Dr. Lowenstein:
Yes. That’s exactly right. We do take some fat from the medial compartment and use it as a little flap there, again to provide a little pillow for the nerves so it’s not subjected to [crosstalk 00:51:21].
Dr. Martin:
Right. There’s a common theme here. We’re going in you, or going in we as a profession. We’re going in and releasing the compressing areas around these nerves. Then what we’re doing is wrapping those nerves in soft tissue or fat, which allows for it to create a buffer, so when it starts to heal and scar down, you don’t have this scar effect around the nerve, compresses it down and you’re running into the same effect.
Dr. Martin:
Remember, Dr. Lowenstein talked about whiplash. That’s from scar tissue going down and compressing that nerves. The same thing in effect, if you go in there and actually do surgery and using fat. Fat grafting is really common in plastic surgery in terms of softening areas and decreasing tension on things. Fat has a positive component, and also stem cells supposedly. The jury’s still out on that. Okay, so you’ve done around the eye, the zygomaticotemporal, which is the temporal area going near your side burns.
Dr. Lowenstein:
Then here there’s an auriculotemporal, which is a nerve that is just in front of the ear. There’s a blood vessel that is often the culprit there. That’s where sometimes we’ll use ultrasound to find the area where those things cross. We can actually trace out the blood vessel and at the same time look for a Tinel sign. Where we see the Tinel sign at the blood vessel, that’s where oftentimes that nerve is getting oppressed.
Dr. Lowenstein:
That nerve is the easiest to get to. We can just make a little incision. It’s usually within the hairline and dissect right down, and there it is. Ligate the blood vessel, do a little, again, releasing of the nerve in that area or, in a worst case scenario, cutting it, because, again, it’s really just innervating a relatively small area.
Dr. Lowenstein:
That’s a very common area again between the temporal headaches that you were discussing and people massaging those areas. That’s probably the easiest approach to get to that particular nerve.
Dr. Martin:
Is there any other areas on the front of the face that you would address? We have three areas so far. We have the base of the skull, in the back, where your neck meets your skull. We have above the eyebrow or in the eyebrow area, the upper eyelid. We have the temporal area where your sideburns are. Is there any other areas?
Dr. Lowenstein:
Then there’s the nose. A lot of people will have nerves, variable compression in the nose from turbinates, which are part of-
Dr. Martin:
They’re outcroppings that-
Amy:
They’re like the humidifier [crosstalk 00:54:00].
Dr. Martin:
Humidifier, the air that goes to your nose. We’ve talked about actually on a rhinoplasty podcast-
Amy:
[crosstalk 00:54:05].
Dr. Martin:
… so you should definitely check that out, Beauty and the Surgeon.
Dr. Lowenstein:
There you go. Sometimes your septal deviation. That’s that central portion of your nose.
Dr. Martin:
The temple of the nose.
Dr. Lowenstein:
And so, you can get compression there. That is the other approach that we do to disrupt those areas of compression. You’ll either do a septoplasty where you’re decompressing and straightening the septum or a turbinectomy where you actually take out the turbinate. But to be honest with you, what I usually do for those patients is I will send them to an ENT surgeon, just-
Amy:
I was going to ask if you work in conjunction with an ENT [crosstalk 00:54:51].
Dr. Lowenstein:
Right, because I’ve done those surgeries, I do those surgeries, but these are not aesthetic things. These are functional things, and we’ll, a lot of times, incorporate several different people who work in the nose, do a lot of nose [crosstalk 00:55:13].
Dr. Martin:
Yeah. We’ve talked about it before. I mean their primary job is the nasal airways-
Dr. Lowenstein:
Exactly.
Dr. Martin:
… and sinuses, so it doesn’t make sense that you wouldn’t send it to them, especially for someone who needs a functional improvement.
Dr. Lowenstein:
Exactly.
Dr. Martin:
It has nothing to do with aesthetics. There’s four different areas. When you’re talking about the face or these areas we’ve talked about the face or these areas that we’ve talked in the face, you do that with the patient lying on their back, which we call supine. Again, it’s general anesthesia. Is that correct?
Dr. Lowenstein:
Unless we’re just doing a small cut down on the auricular temporal, but, yes, it’s general anesthesia.
Dr. Martin:
Okay. Then-
Amy:
And no twitching allowed during this kind of surgery.
Dr. Martin:
Yeah.
Dr. Lowenstein:
[crosstalk 00:55:45].
Amy:
You want somebody out.
Dr. Martin:
All right. Depending on the area, how much improvement can people get?
Dr. Lowenstein:
We often see no more headaches. I mean you can get the entire spectrum, obviously. But I’ve seen just a lot of success in all of these areas, patients coming off narcotics, which right now is a touchstone in this country of how-
Amy:
Opioid use.
Dr. Lowenstein:
Opioid issues. Again, this is a little off-topic, but a lot of these patients are doing ER visits because their head is exploding. Something’s got to be done, and they end up in the emergency room. The doctors won’t give them narcotics because they think they’re narcotic-seeking.
Amy:
They’re pain-seekers.
Dr. Lowenstein:
Exactly.
Dr. Martin:
Right. There is no laboratory study or a scan. An MRI won’t show it.
Dr. Lowenstein:
Exactly.
Dr. Martin:
You have to trust the patient’s history.
Dr. Lowenstein:
Yeah. I mean I’ve had patients who are on fentanyl patches, which is a very, very, very strong opiate that subsequently wean themselves off of narcotics. I try to get them almost immediately back with their pain doctor, because you take yourself off narcotics too quickly, that can be a problem. But the patients are so eager to actually be rid of these things that they start to do it themselves. So just great success with decreasing medication, getting people back to work, getting people back with their families.
Dr. Martin:
One of the questions … What I meant by that question is is there more success in certain areas and less in others?
Amy:
Or what percentage of each type of surgery are you doing? Does one seem to be predominant than the others?
Dr. Martin:
Right. That’s another question I had, too.
Dr. Lowenstein:
Yeah. Classically, this started out in the front. So it was the supraorbital and supratrochlear nerves that [crosstalk 00:57:57].
Dr. Martin:
The stuff near the eyebrow.
Dr. Lowenstein:
Exactly. I know a lot of people who say whatever nerves you’re doing also go do the supraorbital and supratrochlear nerves in the eyebrow, because many patients have that problem as well. In my practice, we see a little bit more occipital neuralgia, just because I think that that’s kind of an emerging region. Of all of these areas, it was the last to be discovered. Now that we’re seeing success with that, there’s a lot of patients who have these problems back here.
Dr. Lowenstein:
But honestly I think that the questions you’re asking are very regional in surgeons specifically. I think Dr. Guyuron does probably more of the brow surgery because that was the original thing, and he fostered a very large practice doing that in the beginning. Whereas others of us, I think we’re finding that a lot of patients are having these posterior neck issues. That is expanding and growing area. As far as the efficacy, I can tell you my experience is equivalent in all different areas.
Dr. Martin:
Got it.
Dr. Lowenstein:
I think we can look at different people’s experience, but again some people are going to have better and more experience in one part of the face than the others. We’re doing surgery in all of these areas and having good success.
Dr. Martin:
Yeah. I think it’s important to note that if you have multiple trigger areas and they’re on the back of the head, in the front, it’s going to be two different surgeries in most cases.
Dr. Lowenstein:
I mean some people will do both the front and the back, some people will do the front then the back. In my practice, it depends on what the patient wants and what their particular circumstance is. There are some issue with operating on the back of the head and then turning the patient and putting pressure right on the back of the head while you’re doing the front of the head, and vice-versa.
Amy:
Right, vice-versa.
Dr. Lowenstein:
But as far as getting everything done at once, it’s also a very attractive thing for people. It depends on patient division.
Amy:
Is any of this covered by insurance?
Dr. Lowenstein:
Unfortunately, this is the-
Dr. Martin:
That’s a very loaded question.
Dr. Lowenstein:
… loaded question. Insurance, in my experience, will sometimes pay for some of it, rarely pay for all of it, often pay for none of it. Yeah, that is a very, very difficult thing for all of us because, again, for me, I know what this is like. I won’t operate on everybody, but at the same time I want to keep my doors open. We certainly do everything we can to help people with financing or whatever we can, but the current insurance milieu in this country, they want to for less rather than more. If you’re looking at appendectomy or this, there’s a lot-
Dr. Martin:
Appendectomy is when you take out the appendix.
Dr. Lowenstein:
Yeah, there’s a lot more longer period of time that people have been doing appendectomies than this. So the insurance companies will often say, “Well, this is an experimental surgery.” Read the data, it’s not experimental. I mean there’s a lot of good data there, but getting the word out to the public is one issue. Getting the insurance companies is a whole other issue as far as just having them learn about what the surgery is, how effective it can be, and as well that, frankly, we’re improving the costs-
Amy:
Yeah, it’s a huge cost-saving.
Dr. Lowenstein:
… afterwards because you’re getting people who are going to the ER weekly, having pain doctors, neurologists, MRIs. After surgery, that’s all going away. But that is a separate fight that right now we’re all just working towards public knowledge that there can be help out there for a lot of people who are hopeless. There are things that can be done. Once we tackle that … And tackling the insurance issues are [crosstalk 01:03:04].
Dr. Martin:
Yeah, but that grows organically. It starts with the public these days. I mean insurance companies do offer a great service but, they’re also proprietary and for shareholder entities. It’s the way it goes. You have to get the word out. People have to be informed.
Dr. Martin:
We talked about the whole basis of this podcast is about education and empowerment, getting someone like you on, and then espousing what Dr. Guyuron has developed, and Janis. I mean this is what it’s all about. Getting the word out for people that are struggling and severely debilitated is so important. Then to add on top of that, you suffer from the same thing. It’s pretty gripping in terms of the story and the fact that you’ve done all this research and now you’re actually doing the surgery.
Dr. Martin:
That’s the last thing I think that we need to bring up. Can you, without violating HIPAA, maybe even give us a story of someone who came to you, kind of the backstory, and how it transformed their life?
Dr. Lowenstein:
I’ll tell you, as a resource rather than a plug, we’ve got some video testimonials or whatnot on our-
Dr. Martin:
On your website?
Dr. Lowenstein:
… on our website, headachesurgery.com. The other thing I want to just get in before the end here is that there’s a growing number of people that are interested in this, but there are a very select number of us who are really-
Dr. Martin:
Proficient.
Dr. Lowenstein:
… running with this and really trying to make this a big part of our practice. That’s also an issue. I mean there’s Dr. Peled who was very instrumental in teaching me things, Dr. Afifi at my alma mater in Wisconsin, and there’s some people on the east coast. Dr. [Duchak 01:04:55] does a lot of this.
Dr. Lowenstein:
We all try and get … We hear a lot about these patients on Facebook and whatnot, and we try to get these people in with those of us who are really interested. Obviously, Dr. Janis and Dr. Guyuron are also awesome. But a lot of states don’t have anybody, which is one of the reasons that I’m interested in doing some of this in Colorado, because there’s nobody else at the moment doing this surgery. So trying to bring this service to as many people as possible.
Dr. Lowenstein:
But I can tell you that with my practice in California, I had a gentleman, and I alluded to this earlier, from Kansas. He actually flew out for the surgery. Again, I don’t know when you all are watching, but relatively recently we’ve had some tragedy in Santa Barbara, and his surgery was scheduled during this horrific fire that we just had. He had to go home because I had canceled the surgery because my office was in an evacuation zone.
Dr. Lowenstein:
I’m a very conservative guy, and it was likely not going to be an issue, but I didn’t want to be halfway through the surgery and have the police knocking on my door, saying, “You have to go.”
Amy:
Right, have a firefighter trying to roll you out.
Dr. Lowenstein:
So we canceled the surgery. He went home, came back after the fires and the subsequent floods that we’ve unfortunately had. I did his surgery. He stayed in Santa Barbara for two weeks, which is not necessary, but he wanted to do that.
Amy:
He’s from Kansas. Let’s be real.
Dr. Lowenstein:
There you go.
Amy:
It might have been necessary for him.
Dr. Martin:
Don’t hate on Kansas. [crosstalk 01:06:41] right next to it.
Dr. Lowenstein:
I saw him just before he left. This was a very specific gentleman. He actually has a brain tumor, a known brain tumor, a small one that he’s had for years, and he had gamma knife or radiation treatments.
Dr. Martin:
Radiation, yeah.
Dr. Lowenstein:
That’s a 33-treatment thing and, on his 30th treatment, began having headaches, and severe headaches. This gentleman is financially successful, a loving family who I’ve met. I mean he’s got everything he would want, including … And, not including, and a really, really bad pain issue.
Dr. Lowenstein:
We operated on him and, again, in the face of this radiation scarring, I told him that I’m not sure this is going to work. I mean we were just … He’s at the end of his rope. He had tried everything. I said, “I’m willing to try this, but you have to understand that it might not work.”
Dr. Lowenstein:
Before he left, he told me that he had been previously, again, planning on making appointments in Washington State where you can have assisted suicide because his pain was that bad. He told me that he hadn’t felt this good in years. On his way back to Kansas, he decided he was going to stop in Telluride and go fly fishing.
Dr. Lowenstein:
Now it is winter right now. You’re going to Telluride fly fishing in the winter. You’re tolerating some baseline pain right there in your legs. This guy felt so good that that was what he was planning and looking forward to doing. That was just an amazing, amazing story.
Dr. Lowenstein:
Again, I just feel real thankful that I get to change people’s lives in that kind of fashion. But story after story about, “I used to not go to my daughter’s softball games. Now I travel all over the country with her.” Single parents who … You’ve got to imagine what it’s like to be a parent of a small child and trying to lock yourself in a room quiet and dark just because you don’t know what else to do. You still have a child who’s got to be attended to and fostered and all of that kind of stuff. So just getting patients out interacting with their family and friends again. It’s fantastic.
Amy:
Yeah, that’s awesome.
Dr. Martin:
I’m completely envious to the fact that you get to help people that much. I mean that.
Amy:
But I think it’s so important, though, that people actually know this exists. I mean that’s so key.
Dr. Martin:
Yeah, in a small way, this podcast and the associated video is going to be helpful. But I just think that starting the discussion with people, and those people there at their wit’s end that they may not be a candidate, that’s the most important thing that Dr. Lowenstein said, as he’s board-certified plastic surgeon, very ethical, you need to go to people that know what they’re doing. He was talking around it. You need to go to people that are specializing in the surgery.
Dr. Martin:
But as long as you go to someone who’s knowledgeable and ethical and board-certified, you should go and seek out information and advice, make sure you’ve had your full neurology workup, you’ve been treated, and go see if maybe you might be a candidate for one of these procedures.
Amy:
Absolutely.
Dr. Martin:
The downside is it’s not massive, it’s scars and some things like that, maybe some numbness in areas, but the upside could be completely transforming.
Amy:
Yeah, getting your life back.
Dr. Martin:
You could be fly fishing in Telluride.
Amy:
In two weeks.
Dr. Lowenstein:
There you go.
Dr. Martin:
There’s nothing more pretty than Telluride, by the way.
Amy:
Oh, my goodness.
Dr. Lowenstein:
Oh, yeah.
Dr. Martin:
Winter or summer.
Amy:
That’s true. It’s gorgeous any time of year.
Dr. Martin:
All right, so let’s go through your Instagram handle real quick.
Amy:
How can patients find you?
Dr. Lowenstein:
So headachesurgery.com is our website. Frankly, my whole thing on that website is education. I mean I can’t say this for sure, but I think it’s the most comprehensive headache surgery website that is out there. I’m not a social media maven-
Dr. Martin:
[crosstalk 01:11:06] so terrible.
Dr. Lowenstein:
… but, let’s see, I think I’m @migrainesurgeon on Instagram.
Dr. Martin:
There you go.
Amy:
[crosstalk 01:11:07] @migraine-
Dr. Martin:
I was kind of testing you.
Amy:
He’s at @migrainesurgeon on Instagram.
Dr. Martin:
I just want you to know that.
Dr. Lowenstein:
There you go. Then we’re on Facebook.
Dr. Martin:
I think it’s under Migraine Surgeon. Then also you have a YouTube channel, too.
Dr. Lowenstein:
Right.
Dr. Martin:
I think it’s also Migraine Surgeon.
Amy:
But all your social media links are on your website.
Dr. Lowenstein:
Yeah, exactly. That’s the best way to do it.
Dr. Martin:
Then for us, our social media link’s @jasonmartinmd. If you have interest in plastic surgery, please visit our … Or actually just visit Dr. Lowenstein’s in terms of the cosmetic stuff. If you liked this podcast, please rate it or rank it-
Amy:
And review us, share it with your friends.
Dr. Martin:
… and review us. Then also share it with friends, especially on a topic like this where people may not know. If you know someone who’s suffering from migraines, share this podcast. Let them listen to Dr. Lowenstein, a true expert in this surgery, talking. And …
Dr. Lowenstein:
Hey, everybody. This is Dr. Lowenstein once again. I have two last things to ask of you. Firstly, the thing you can do for fellow headache sufferers is to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get and the more listeners that will be able to find us and the more help and information we’ll be able to provide a huge population of people who suffer from headache pain.
Dr. Lowenstein:
Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice. So please use the information here on this podcast and elsewhere that you hear on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts or see on YouTube or read anywhere on the internet.
Dr. Lowenstein:
I as a physician don’t necessarily endorse the opinions or practices of my guests. If you have particular questions that you’d like to consult with me directly about, please call our headache surgery center. Our phone number is 805-969-9004. Or you can email us at info@headachesurgery.com, and my staff will set up a consultation. We can discuss your specific case over the phone or in person. Our website is filled with information as well, and that is headachesurgery.com. Thanks and best wishes from all of us here at the Headache 360 podcast.
