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Dr Ziv Peled

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Dr. Peled Speaks at Plastic Surgery The Meeting 2016

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 03 October 2016
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Masthead AR

Dr. Ziv M. Peled, M.D. was recently a lecturer, injector and surgical trainer at the largest plastic surgery meeting in the world. Plastic Surgery The Meeting 2016, held in Los Angeles, CA in September and sponsored by the American Society of Plastic Surgeons is the premier meeting for plastic surgeons globally. Dr. Peled gave four talks in two sessions over two days on subjects ranging from occipital nerve surgery to coding for headache surgery. The talks were well received and are likely to be repeated in future meetings and to include an expanded curriculum on additional aspects of this exciting treatment option for chronic headaches refractory to conventional therapy.

For more information on how headache surgery can help reduce your "migraine" symptoms, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule an appointment with Dr. Peled.

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What is the Difference Between Occipital Neuralgia and Cervicogenic Headaches?

by Dr Ziv Peled
Dr Ziv Peled
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on Friday, 16 September 2016
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I recently read a comment from a patient asking a very interesting question - “What is the difference between occipital neuralgia (ON) and cervicogenic headaches (CH)?”

Unfortunately the answer to this question is not a straightforward one. It has been postulated that pain in the head/neck region can be referred from problems in the bony or soft tissues of the neck, but there is still some controversy as to whether cervicogenic headache constitutes a distinct clinical entity. The upper-most cervical nerves and their branches are the most commonly cited sources of CH with the most common source being the C2/C3 levels. The actual definition of cervicogenic headaches is also not firmly established. One accepted way of defining this disorder is by its clinical characteristics. Specifically, it is a unilateral pain of variable severity that is not stabbing and radiates from posterior to anterior. It doesn’t shift from side to side, is brought on by unusual head position or neck motion and may be associated with shoulder or upper extremity pain on the same side. The biggest issue with this definition is that it overlaps with many of the characteristics of other headache disorders such as tension headaches and migraines without aura. Another way of defining CH is by demonstrating a cervical source of pain and confirming that source with a nerve block.

Diagnostic criteria for CH have been established by the Cervicogenic Headache International Study Group (CHISG) and by the International Headache Society (IHS). The former’s criteria require signs or symptoms brought on by awkward head movements or positioning or by pressure over the occipital nuchal structures and possibly confirmed by anesthetic blockade. The IHS criteria mandate that the pain be referred from an identifiable and plausible source in the head/neck (as demonstrated on imaging such as MRI) or by successful blockade of a nerve or cervical structure. Moreover, the pain must resolve within 90 days of successful treatment of the underlying problem. However, the IHS criteria do not define when, where, and how much pain is caused by CH (i.e. the clinical features).

In contrast, most neurologists would define ON in a very specific way. The classic description is that of paroxysmal pain in the distribution of the occipital nerves, sometimes, but not always accompanied by changes in skin sensation in the back of the scalp. The symptoms of ON are also thought to have a character of burning or hypersensitivity that may be constant on top of the intermittent shooting pains described above. These symptoms should be temporarily relieved by occipital nerve blocks.

So what to do with all of this information? Unfortunately, I find these definitions and descriptions minimally helpful since many of the symptoms of ON and other headache disorders for that matter can overlap with those of CH. For example, many of my patients with ON who have been successfully treated with decompression had exacerbation of their pain with awkward head positions and motions because these positions further compressed and irritated the occipital nerves. There are many patients who have unilateral ON. Therefore is ON a subset of CH? From my reading of the literature, most neurologists would seem to disagree, but I am uncertain as to why. Is CH a distinct clinical disorder? As stated above, there is disagreement as to whether it is versus just a descriptor of where the pain is coming from.

All of which brings me to the take home message. When it comes to any disorder, but especially chronic headaches, the only relevant questions in my humble opinion are: 1) can you figure out what’s causing it and 2) if you can, can you do anything about it? You can call the headache whatever you like - migraines without aura, CH, George - the names are irrelevant. With that in mind, I believe that the literature has shown that accurate diagnosis of ON with nerve blocks or Botox is a good predictor of a good result with surgical decompression. Moreover, surgical decompression has been shown to be very effective and have a very low complication rate with good long term results.

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THE NEW BOTOX

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 10 October 2011
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Many people have been asking me about the newest Botulinum Toxin available for cosmetic use. It’s name is Dysport and later I will be posting more information about this exciting new product which we now offer in our office.

Dr. Peled

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THE NEW BOTOX PART II

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 10 October 2011
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As promised, more info on Dysport. Basically, this new product is the identical substance as that found in Botox - Botulinum Toxin type A. It carries pretty much the same indications as Botox does according to the FDA. It is formulated slightly differently which basically accounts for the minimal differences in results with Dysport. So far, much of the published clinical cosmetic experience with Dysport is in the form of a few initial studies. The bottom line from these studies is that results with Dysport are very similar to those with Botox. Dysport has a slightly quicker onset of action, but not significantly so. In equivalent doses, the effects of Dysport lasted a bit longer than those with Botox, but again the results were not significantly different. Finally, there were no significant differences in side effects between the two products. The upside of Dysport is that it is a bit less expensive than Botox at present and with the initial promotion from Ipsen BioPharm (the company that makes Dysport), the prices are even sweeter. The only real downside at present is that there is relatively little experience with Dysport as compared with Botox, so theoretically you are taking a small chance with a newer product, although the risks are minor.

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Excessive sweating can be treateted effectively

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 10 October 2011
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Hyperhydrosis or excessive sweating is a problem that can be a real source of frustration and embarrassment. Until now, when the usual deodorant and antipersperants have failed, the only next option was an operation to physically remove the offending sweat glands. Now, however, it has been realized that BOTOX (yes that BOTOX) can be used to treat this problem with great effectiveness. The overwhelming majority of patients treated in this way had a significant decrease in the sweat produced by these glands (usually in the armpit) that lasted over 6 months. Patients can be treated in the office with minimal downtime and the procedure is minimally invasive and uncomfortable. If you would like to learn more about this exciting new treatment, please feel free to call the office.

Ziv M. Peled, MD

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YOU GET WHAT YOU PAY FOR

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 10 October 2011
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Plastic Surgery News, a publication of the American Society of Plastic Surgeons, recently published an article describing the unethical practices of well known company called Lifestyle Lift. According to the article, this company was “charged with ‘astroturfing’ - publishing fake, online reviews of its procedure using employees who posed as independent consumers to express their ’satisfaction’ with the company and it’s product.” In fact, Andrew Cuomo, the Attorney General of New York stated on his website (http://www1.plasticsurgery.org/ebusiness4/OnlineCourse/CourseInfo.aspx?Id=12791) “this company’s attempt to generate business by duping consumers was cynical, manipulative and illegal.”

I am posting this blog because I am often asked by my patients seeking facial rejuvenation about the Lifestyle Lift procedure. In plastic surgery, as in life, you get what you pay for. While we are all looking to save money these days, your body and health are the few things which you only get one of and simply searching out the least expensive alternative can often have distastrous consequences. Among board-certified (American Board of Plastic Surgery) plastic surgeons, this company has a dubious reputation as one that refuses to do state exactly which techniques their physicians use to achieve their results, thereby potentially opening themselves to criticism as those of us who publish in scientific, peer-reviewed journals do all the time. Therefore, the company’s methods are suspect from the outset and stories like the one above are not that surprising. Buyer, and patient beware!

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NEW HOPE FOR MIGRAINE SUFFERERS

by Dr Ziv Peled
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on Monday, 10 October 2011
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New Surgical Procedure Holds Promise for Permanent Relief from Migraines

Existing treatments for migraines, such as oral medication or injected drugs, have been shown to temporarily alleviate symptoms in some, but not all, patients. In some instances, these treatments, whether effective or not, have unwanted side effects. But now there is good news for the more than 28 million Americans who suffer from migraines: According to a recent study, an outpatient surgical procedure provided 80% of patients with pain relief at or above 50%, and over 43% with complete and lasting relief from their migraines, altogether.

Over the past few years, several studies have been performed to test a recent theory that migraines are caused by nerve compression: Nerves in the neck, temples or forehead that are pinched as they pass through various anatomic structures or canals. As a result, the severe and recurring pain is similar in origin to carpal tunnel syndrome, a commonly diagnosed condition for which surgical decompression is frequently performed. This surgical method has now been adapted for headaches caused by neuralgia, or trapped nerves.

I am a San Francisco-based, Harvard-trained plastic surgeon with specific training and experience in a variety of different peripheral nerve operations, including successful nerve decompression to treat migraines. I have performed well over 100 different peripheral nerve procedures and feel fortunate to be among the few surgeons in the world with the background and training to perform these delicate operations. Moreover, most procedures can be done as an out-patient. For example, in a patient with the most common site of pain originating in the back of the head/scalp, the procedure involves a small incision on the nape of the neck, just above the hairline. Once the surgical site has healed, typically in a couple of weeks, patients report significantly fewer headaches, lower headache severity, and shorter headache duration in those who still report headaches at all.

For more information about this exciting new treatment, please contact our office at (415) 751-0583 (San Francisco) or (925) 933-5700 (Walnut Creek). I can also be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

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5-YEAR OUTCOMES OF MIGRAINE SURGERY DEMONSTRATE PERSISTENT RELIEF

by Dr Ziv Peled
Dr Ziv Peled
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on Monday, 10 October 2011
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Just this month in Plastic and Reconstructive Surgery (the leading plastic surgery journal in the world), Dr. Guyuron published his five-year results with surgical decompression for migraine surgery. The findings of this study show that relief of headaches persists even five years from the time of surgery. More specifically, at five years post-surgery, the average number of migraines per month were reduced to 4 from 11, average migraine intensity decreased from 8.5 out of 10 to 4.5 out of 10 and the average duration of a migraine if and when it occurred was reduced from 1.4 days to 8 hours. Just as impressive were the findings that 88% of patients still reported a significant decrease in their headaches after five years and that 29 reported elimination of their migraines altogether! These results suggest that surgical decompression can produce a lasting if not permanent degree of relief from the debilitating headaches that affect so many people worldwide. If you suffer from migraines and would like to learn if you are a candidate for decompression surgery, please contact our office at (415) 751-0583 or (925) 933-5700.

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