Plastic Surgery Perspectives: Migraine Surgery
Editor's Note: "PRS Perspectives" is a recurring series featuring leaders in plastic surgery led by Stav Brown, MD. In this installment of the series dedicated to migraine surgery, Dr. Brown interviews William Gerald (Jay) Austen, Jr., MD, Chief of the Plastic and Reconstructive Surgery Division and Burn Surgery at Mass General Hospital, Boston. – Rod J. Rohrich, MD, PRS Editor Emeritus
PSN: Why did you choose plastic surgery and what attracted you to migraine surgery?
Dr. Austen: I always wanted to be a surgeon and an inventor, and those two things came together very nicely in plastic surgery. I also wanted to take care of kids, so in medical school, I thought I would go into pediatrics. When I had my first exposure to pediatric plastic surgery, I realized it was the coolest thing I had ever seen. I didn't know much about migraine surgery until Bahman Guyuron, MD, came to Boston as part of a visiting professorship in 2008. I had just became chief of plastic surgery at MGH and knew him as a great rhinoplasty surgeon and great cosmetic surgeon – but all he really wanted to talk about was migraine surgery and what a difference it made in these patients. His passion for migraine surgery was amazing. It was powerful enough that I knew I had to go visit him.
I went to his course and was very intrigued by this idea that you can take patients who were totally disabled and could not otherwise be helped and cure them with a very interesting surgery. Unlike breast cancer patients, for example, migraine patients come into your office with a 10/10 pain for 10 hours a day for years. Some of them are suicidal – when you fix them, you literally save their life. You have not saved the breast cancer patient's life, like the oncologists or the radiology people do. Migraine surgery has such a profound effect on these patients' lives, including their families. I also loved that it was a frontier. I found it an incredible area for research and everything we looked at became a paper, because it was so novel. I love everything I do in plastic surgery – I love cosmetic, I love doing a cleft lip – but I don't think any patient is truly happier than some of these patients. The impact on their lives is hard to beat.
PSN: How has migraine surgery changed since you started?
Dr. Austen: I think our understanding of the problem and treatment are better. Many of us are finding that the pipeline to get patients to us is improving. In my first year, I operated on only two patients. Both patients and doctors did not know about this new frontier. Doctors who did know about it did not believe in it and the neurology community wrote many negative editorials about it. In some instances, patients even told me that their neurologists said that they would stop seeing them if they came to me, which was incredibly disappointing. Since I was able to solve much of their problem, most of them would not go back to see their neurologists – and I had to convince them to do that to help other patients. Some of these patients do need a neurologist since most of them experience 80 percent improvement, and they still need medication and non-surgical management. Some have other triggers that are not possible to operate on so the patients are certainly better off if we work on this as a team.
Many of us have realized that we hurt ourselves early on by calling it "migraine surgery." Many neurologists would argue that migraine cannot be cured since it's a genetic problem of the brain, but for a lot of patients, their neuralgias and trigger sites stimulate the migraine. If you get rid of the trigger site, they never have migraines again – but to go around and say that we are curing migraines was not helpful. Interestingly, about 15 years ago there was a neurologist that wrote a very negative editorial about migraine surgery. We shared quite a few patients and had a great conversation because it was a matter of semantics. He was a believer of occipital neuralgia, which is what many of our patients have, and I invited him to come to my O.R. He began sending me patients that we agreed upon, and he ultimately became a real believer and a great ally. We had a series of patients that were all his, I operated on them, and we both followed – and he says that 100 percent of them are better. Most of them still have migraines, but the acute lancinating pain is 100 percent better in all of them. We wrote about it and presented our findings at the International Headache Society meeting in Austin, Texas. When we tried to get this published in the neurology literature, however, most of the neurology journals refused to even review it. We just had it accepted to Frontiers in Neurology.
PSN: Tell us about a case that has influenced you or shaped your view of the field.
Dr. Austen: There was a woman who came in who was very difficult and skeptical. I genuinely have empathy towards these patients. They are incredibly miserable – for many of them, it is an unbelievable effort just to get out of the house to come see me – and I do not expect them to be pleasant. I thought she was a really good candidate. She had pain in the back and front. I operated on the back, which we often do, and I noticed that she became an entirely different human being. I followed her and since she had an 80 percent improvement, I suggested an option to fix the pain in the front. She refused and said that her family was upset because she had changed so much that they hardly recognized her. Our patients start off with disability scores completely off the charts and when they get better it is an improvement that is not seen in any other surgery. It's very rewarding to see.
PSN: What advice do you have for residents interested in migraine surgery?
Dr. Austen: Most people tend to go through training and feel like they are done. However, if you look at my career – and this is true for many people – most of what I do now are things I did not learn in training. Very few people were doing DIEP flaps during my training, there was no such thing as single-stage breast reconstruction and I had never heard of migraine surgery. What we are talking about today will be very different in 20 years. Would you want to be that person who just goes out doing what you were taught and not learning anything new or different? Or do you want to be a part of the process towards these novel solutions? The evolution is going to happen with or without you and it is very rewarding to be a part of that. It can be scary sometimes because doing new things can be painful. The operation is the easy part; what really requires time and effort is patient selection, management and complex problem solving. However, headache surgery and peripheral nerve surgery in general is extraordinarily rewarding and there is a tremendous amount of opportunity. I think there will be a dedicated fellowship for migraine surgery in the future. At my institution, our breast fellows get a good exposure to migraine surgery in addition to cosmetic surgery and complex reconstruction. They spend a lot of time with me in clinic and the O.R. and I am trying to prepare them for life, which is equally important.
Dr. Brown is a plastic and reconstructive surgery research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York, and a Resident Advisory Board member for PRS.