Plastic and Reconstructive Surgery

Skip Navigation LinksHome > Blogs > PRSonally Speaking > PRS Correspondence- Letters to the Editor in Advance: Five-Y...
PRSonally Speaking
Tuesday, October 4, 2011
PRS Correspondence- Letters to the Editor in Advance: Five-Year Outcome of Surgical Treatment of Migraine Headaches
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.



Valeriano VINCI, MD


Daniel LEVI, 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.

About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.


Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently Chief of plastic surgery, Baptist Cancer Center; Research member, Vanderbilt- Ingram Cancer Center; Adjunct clinical faculty, St. Jude Children's Research Hospital. He also acts as Program Director for the plastic surgery microvascular surgery fellowship. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.