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Beyond the brow lift

Article-Beyond the brow lift

A surgery developed by plastic surgeons and based on a popular cosmetic procedure doesn’t necessarily make patients look younger, but it very well could make them feel better.

Dr. JanisDr. JanisMigraine surgery, developed after a plastic surgeon realized the brow lift was relieving — even eliminating — migraines in some patients, is a natural for plastic and other surgeons who perform cosmetic brow lifts, according to Jeffrey E. Janis, M.D.

“We have evidence-based options to help patients with chronic migraine who have failed traditional treatment, who may be eligible for nerve decompression surgery of nerves of the head and neck,” he says. “Plastic surgeons with proper training can add this to their surgical armamentarium. For as common as migraines are, these patients are already in their practices. Surgeons just haven’t thought to ask their patients about migraines, and it doesn’t occur to patients to ask their plastic surgeons about migraine treatment options.”

Dr. Janis, professor of plastic surgery, neurosurgery, neurology, and surgery at Ohio State University Wexner Medical Center, in Columbus, Ohio, and president of the American Society of Plastic Surgeons, says the numbers of people suffering from migraines are staggering.

“When you look at the number of people who have migraine headaches in this country, it’s 18% of all women and six% of all men, and that represents 35 million Americans or more that have migraine headaches. It’s actually more common than asthma and diabetes combined,” Dr. Janis says. “If you take a look at the lifetime incidence, in other words, the number of women who have had at least one migraine in their lifetime, that’s about 42%.”

NEXT: A Historical Context


A Historical Context

Migraine surgery has been around since about 2000, when Cleveland, Ohio-based plastic surgeon Bahman Guyuron, M.D., pioneered the procedure.

“Dr. Guyuron, who does a lot of aesthetic surgery, was doing cosmetic brow lifts when he essentially tripped on this discovery,” Dr. Janis says.

A few patients commented on how impressed they were by the migraine pain relief they had gotten after their brow lifts. And Dr. Guyuron likened the outcome to what happens when a nerve gets entrapped in the wrist, causing symptoms in the hands, and carpal tunnel release surgery relieves associated symptoms. In a cosmetic brow lift, surgeons might decompress the supraorbital and supratrochlear nerves in the head because those nerves run through the corrugator muscle, according to Dr. Janis.

“The pain relief is not because the brows are higher on your forehead. The pain relief is thought to be because we take out the muscles pinching those nerves,” Dr. Janis says. “That’s why Dr. Guyuron and I started to study nerves around the head and neck. We found that migraine patients tend to have pain in three typical locations: around eye, the temple and the back of the head.”

Based on their research, the plastic surgeons developed approaches to surgically decompress specific nerves, Dr. Janis says.

“Since the year 2000, we have 18 years’ worth of clinical data and experience, published in the peer-reviewed literature to support the fact that migraine surgery is not experimental; it’s not investigational. It has a lot of data and support behind it,” Dr. Janis says.

NEXT: A Team Approach


A Team Approach

Since he’s not a neurologist, Dr. Janis says he doesn’t diagnose migraines. Rather, he works with neurologists who do. Those neurologists know migraine surgery is an option for their migraine patients who have tried and failed usual standard medical therapy.

“The surgeons who do migraine surgery represent an alternative option,” Dr. Janis says. “Patients with chronic migraines basically live their lives either having a headache or waiting for the next one to happen. Many have tried and failed traditional treatments and many other things, such as massage therapy, acupuncture, chiropractic therapy, electrical stimulation, behavioral feedback, menthol patches, yoga and more. They’ve seen a whole host of doctors, including neurologists, primary care physicians, family physicians and pain management specialists. I call these patients “kitchen sink patients” because they’ve tried everything but the kitchen sink by the time they find me.”

Migraine surgery can help some — not all — migraine sufferers, he says.

The best candidates are patients in whom there is a high suspicion of nerve compression causing their headaches. Then, surgeons like Dr. Janis can design what is usually one or a series of outpatient procedures to treat the nerve compression.

Most patients, he says, get at least a 50% improvement in either the number of headaches, the severity of headaches or how long those headaches last. Some benefit in all three areas. Some have complete elimination of their headaches, he says.

NEXT: Not a Brow Lift


Not a Brow Lift

While migraine surgery was developed from the brow lift, today’s approach is not a cosmetic procedure, Dr. Janis says.

“These are focused procedures that do not really involve raising the position of the eyebrow, but rather the focus of those procedures is nerve decompression,” he says.

That’s not to say that an aesthetic brow lift procedure won’t work to relieve migraines. It very well might, according to Dr. Janis. The problem with that thinking is migraine surgery is not the same in everybody. Different patients have different nerves that can be compressed.

“So, the cosmetic brow lift may work for some patients who want the brow lift, have migraines and have migraines that occur in the area of the supraorbital or supratrochlear nerve. That’s really the subset of patients that’s most likely to benefit,” he says.

Dr. Janis and colleagues will put on a migraine surgery course at the American Society of Plastic Surgeons (ASPS) annual meeting, in Chicago, September 28 through October 1, 2018.

“We’ll be running an all-day course where we talk about these concepts and have a cadaver lab,” Dr. Janis says. “We also have a position paper about to come out from the American Society of Plastic Surgeons supporting this type of procedure as a legitimate way of treating these patients.”

The position paper should be coming in 2018, according to Dr. Janis.  

For more on the research behind migraine surgery:

  1. Janis JE, Barker JC, Javadi C, Ducic I, Hagan R, Guyuron B. A review of current evidence in the surgical treatment of migraine headaches. Plast Reconstr Surg. 2014 Oct;134(4 Suppl 2):131S-41S. doi: 10.1097/PRS.0000000000000661.

  2. Guyuron B, Nahabet E, Khansa I, Reed D, Janis JE. The Current Means for Detection of Migraine Headache Trigger Sites. Plast Reconstr Surg. 2015 Oct;136(4):860-7. doi: 10.1097/PRS.0000000000001572.

  3. Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009 Aug;124(2):461-8. doi: 10.1097/PRS.0b013e3181adcf6a.

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