Every month Dr. Rohrich selects interesting and potentially controversial Letters to the Editor to post online ahead of the print edition. While the official solicited replies will appear in the printed issue, we encourage readers to submit replies as comments on this blog and continue the conversation.
The following letter- and its solicited replies- will appear in the November issue of PRS. We invite you to read it and let us, and the author, know your thoughts.
Five-Year Outcome of Surgical Treatment of Migraine Headaches
We particularly appreciated the article titled “Five-Year Outcome of Surgical Treatment of Migraine Headaches” by Drs. Guyuron, Kriegler, Davis and Amini (Plast Reconstr Surg. 2011 Feb; 127(2):603-8).
We read with interest about different techniques used in treatment of migraine headaches. The authors discussed the role of surgery in the amelioration of this disabling condition and tried to comprehend pathophysiological reasons for the surgical success their patients have been enjoying, affirming that many questions are still unanswered.
We agree with the consideration that an accurate identification of trigger sites is of critical importance, and we focused our attention particularly in reading about surgical techniques used by authors for occipital trigger point.
We would like to report our experience in treating chronic headaches related to occipital neuralgia, trying to explain what’s, in our opinion, the pathophysiological reason for the success of our technique. Occipital neuralgia results to be frequently resistant to pharmacological and surgical approaches. Many times, important anatomical variations related to occipital neuralgia can be found, compromising the effectiveness of procedures such as surgical decompression or nerve block [1, 2].
Cheered by our experience in using autologous fat graft in scar outcomes [3, 4], we decided to employ this technique in a case of severe unresponsive post-traumatic occipital neuralgia with cicatricial entrapment of greater occipital nerve. Autologous fat graft, harvested from trochanteric areas and centrifugated at 3,000 rpm for 3 minutes, has been injected at the clinical trigger point (indicated by the patient with manual palpation) and to anatomical scar entrapment. The stable, long-term, success of this procedure has been documented both asking the patient to indicate pain level using a Visual Analogue Scale (pre-operative level: 8, one month post-operative level: 3), and performing Magnetic Resonance Imaging: pre-operative exam showed a thinning of subcutaneous adipose tissue and the presence of cicatricial fibrous tissue, while 3 months post-operative exam showed restored appearance of subcutaneous adipose tissue in treated area.
Considering obtained results, we used this technique in other cases of occipital neuralgia, not related to post-traumatic scars, always obtaining a reduction of frequency, duration and intensity of headache episodes, and we are now performing an important clinical study with long-term follow-up in all treated patients.
Our hypothesis is that, in many cases of chronic headache related to occipital neuralgia, a pathologic thinning of the subcutaneous fat layer in this area is involved, making possible the contact between occipital nerves and other anatomical structures – such as occipital arteries – thus conditioning development of pain. Autologous fat graft procedure allows to thicken the subcutaneous adipose tissue layer, maybe acting as a “decompression neurolysis”. Furthermore, as showed in other our studies [3, 4, 5], adipose tissue has showed to have regenerative properties and, first of all, an analgesic effect. Biological reasons of these properties are still unclear, but appear to be related to therapeutic success we achieve in treatment of chronic headaches.
Considering also the simplicity of the procedure, the absence of residual scars and the virtually lack of complications, we believe that autologous fat graft is an excellent option for the treatment of migraine headaches.
Fabio CAVIGGIOLI, MD
Silvia GIANNASI, MD
Valeriano VINCI, MD
Guido CORNEGLIANI, MD
Daniel LEVI, MD
Paolo GAETANI, MD
1. Klinger M, Villani F, Klinger F, Gaetani P, Rodriguez y Baena R, Levi D. Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches. Plast Reconstr Surg. 2009; 124:1727-8; author reply 1728.
2. Janis JE, Hatef DA, Reece EM, McCluskey PD, Schaub TA, Guyuron B. Neurovascular compression of the greater occipital nerve implications for migraine headaches. Plast Reconstr Surg. 2010 Dec; 126(6): 1996-2001.
3. Caviggioli F, Klinger F, Forcellini D, Catania B, Salval A, Vinci V, Villani F, Klinger M. Scar treatment by lipostructure. Update in Plastic Surgery. 2009; 2:51-53.
4. Klinger M, Marazzi M, Vigo D, Torre M. Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction. Aesthetic Plast Surg. 2008; 32: 465.
5. Caviggioli F, Maione L, Forcellini D, Klinger F, Klinger M. Autologous fat graft in post mastectomy pain syndrome. Plast Reconstr Surg. 2011. In press.
There may be discrepancies between the blogged and printed versions of this letter.