phoneSAN FRANCISCO: 415-751-0583 WALNUT CREEK: 925-933-5700

healthgrades vitals

Peled Nerve Surgery Blog

Information and knowledge about migraine relief surgery.

Dr. Peled Featured in Article About Removing Belly Fat

Dr. Peled was featured in comments on a new article explaining ways to reduce or eliminate your belly fat.  Please read the full article below or click here for the original.

  • To remove significant amounts of fat, liposuction remains the safest, most effective treatment.
  • Abdominoplasty and panniculectomy are surgical procedure that flatten the stomach by removing excess fat and skin.
  • CoolSculpting, Vanquish and Velashape are good non-surgical options for smaller fat deposits.
  • Laser liposuction and Zerona are controversial as experts remain on the fence about their safety and efficacy.

It may be that you’ve lost a significant amount of weight and you want your smaller clothing and swimwear to fit better. Or perhaps you’re done having children and are ready to reclaim your pre-pregnancy figure.

Whatever the reason, there is a suitable fat reduction treatment to fit your individual needs.

Is Liposuction for You?

Sometimes, no matter how hard you try, localized areas of fat deposits persist, preventing you from achieving more definition or a sleeker body contour.

New York City plastic surgeon Dr. Leonard Grossman notes that “patients who are relatively young, have good skin tone in the abdomen, yet show signs of excess subcutaneous fat make perfect candidates for liposuction.”

In other words, if you’re working out at the gym and eating a healthy diet but still have stubborn pockets of fat, liposuction is right for you. Your skin will also be more likely to tighten up naturally after the procedure if you’re at a healthy weight and have good muscle tone.

Recovery from liposuction is fast and requires very little downtime. Another advantage is that it causes very little scarring, since the incisions are so small. Your surgeon may even hide some of the incisions in less conspicuous places like the navel.

Liposuction Drawbacks

It’s important to consult an experienced plastic surgeon to perform your liposuction. Otherwise, the risk of ending up with less than ideal results (e.g. uneven skin texture) is high.

Liposuction is not a weight loss solution, nor is it a good option for people who want to remove loose, excess skin. It’s also important to remember that weight gain, aging, and pregnancy can impact your results over time.

Liposuction is often used alongside other forms of belly fat removal surgery. For instance, plastic surgeons frequently combine abdominoplasty and liposuction.

When to Choose Abdominoplasty

An abdominoplasty, also known as a tummy tuck, is a procedure designed to remove loose, excess skin and fat from the abdominal area and tighten muscles in the abdominal wall. New York City plastic surgeon Dr. Joshua D. Zuckerman notes that for women who’ve had one or more pregnancies, an abdominoplasty is the perfect option.

A tummy tuck can eliminate fatty tissue, excess skin and stretch marks on the lower abdomen. The major body contouring advantage of this procedure is that it can actually reshape the belly and midsection, helping patients regain their “pre-baby” body.

Additionally, Dr. Zuckerman advises that abdominoplasty is an appropriate corrective option for women who experience ‘diastasis recti’ – an abdominal muscle separation that can occur during pregnancy.

It’s important to note that abdominoplasty is not a suitable option for women who intend to have more children. The muscles that get repaired during a tummy tuck can separate during future pregnancies, so it’s best to wait until your child bearing years are truly over and done.

Abdominoplasty can offer similar benefits to people who have lost a significant amount of weight by removing excess skin and reshaping the belly button.

Specific techniques are employed to target different areas: a full tummy tuck is best suited for the areas above and below the belly button. If you have small amounts of fat and skin below the belly button that need removal, or if you feel your abdomen protrudes a little too much for your liking, a mini tummy tuck may be preferable.

Abdominoplasty Drawbacks

Abdominoplasty is not a weight loss solution. The procedure is best suited to those who have achieved a stable weight, yet maintain a moderate amount of excess skin and subcutaneous fat on the abdominal wall.

While a mini tummy-tuck causes little scarring, a full tummy tuck leaves a longer scar that extends from hip to hip. For this reason, Dr. Zuckerman stresses that it’s critically important to select the right surgeon: those experienced in the procedure will place the incision very low – below the bikini line, ideally.

Another negative is recovery time. You may only feel ready to go back to work and other daily tasks 10-14 days after the procedure. Generally, patients are also required to maintain surgical drains for several days. These drains are then checked and removed by the surgeon during follow-up appointments.

On top of that, patients will be restricted from most physical activity for approximately six weeks to allow the incisions and damaged tissues to heal properly.

Panniculectomy Pros and Cons

A panniculectomy may be right for you if you’ve lost a significant amount of weight, either naturally or following bariatric surgery.

As a result of weight loss, you may have been left with an unsightly flap of excess skin hanging from the abdominal region and draping down over your genitals or thighs. This excess skin is referred to as the “pannus” or “abdominal apron.” Accompanying this uncomfortable protrusion of skin, you may experience frequent irritation and infections (known as intertrigo).

“A panniculectomy is a reconstructive procedure suited for patients who suffer from multiple episodes of fungal infections in their skin as a result of a significant excess of skin folds that are difficult to maintain,” explains San Francisco plastic surgeon Dr. Ziv M. Peled.

“During this operation, an incision similar to an abdominoplasty is made, but the abdominal wall tissues are not elevated to the xiphoid process (bilateral breast bone) to redrape them, and no abdominal wall tightening is performed. This procedure simply involves excision of a ‘pannus’ of fat and skin and direct closure,” he clarifies.

Panniculectomy Drawbacks

Expect a hospital stay from one to three days. Once patients leave the hospital, they may need to contend with surgical drains and return later to have them removed by a physician.

In most cases, patients will be required to wear compression garments and exercise will be off limits for approximately six weeks to allow for adequate healing.

Additional Fat Removal Options

Laser Liposuction

Laser liposuction entails passing a very thin fiber optic cable under the skin, which carries a laser beam that heats tissues to 900 degrees, thereby melting the fat.

With this procedure, however, it’s best to proceed with caution. A study published in The Journal of Clinical and Aesthetic Dermatology suggests that clinicians have been reluctant to accept the treatment as it carries significant risks for adverse reactions.

Plus, there are no proven benefits above and beyond a traditional liposuction procedure, which is considered a very safe and effective option for belly fat removal.


One of the most effective nonsurgical options available for belly fat removal is cryolipolysis, the best example of which is CoolSculpting. “During this procedure, a patient simply sits in a room while a machine is applied to the areas of excess fat in an attempt to ‘freeze the fat cells,’ which then die off and are absorbed by the body,” informs Dr. Peled.

The advantage of this procedure is that it entails very little downtime. The disadvantage is that multiple treatment sessions are often required, which can be inconvenient for patients. The results are also more subtle than any of the surgical procedures available for belly fat removal.


Vanquish is a radio frequency device designed to eradicate fat cells without even coming into contact with the body. On average, patients report losing one to two inches from their waist with a fat loss equivalent to two to three pounds.

This nonsurgical fat reduction method is suited to people who have reached a healthy weight but still have stubborn fat deposits that don’t seem to budge – regardless of how much exercise they do or how strictly they stick to their diets. The downside, however, is that the treatment results are only temporary.


Zerona uses a cold, low-level laser technology to directly target the cellular contents of fat cells. It claims to liquefy and shrink fat cells while also tightening the skin.

Clinical trials indicate Zerona may reduce waist circumference by an average of 1.8 inches and the upper abdomen by 1.3 inches. However, some researchers who have tested the technology warn that it doesn’t deliver on its promises. They suggest the technology doesn’t have the capacity to reach the fatty layers successfully and produces very little — if any — results.


VelaShape is a nonsurgical treatment that uses radio frequency combined with infrared light energy and mechanical suction massage to melt away the fat. The average reduction of fat in the belly region is half an inch. Velashape can also target other problem areas such as the love handles, thighs and buttocks.

The advantage of the treatment is that relatively no downtime is required. The disadvantage is that the treatment is only temporary and must be repeated every one to two months. The procedure is also best suited to people who are closer to their ideal body weight and are looking to reduce small fat deposits.

Continue reading
1276 Hits

Dr. Peled Speaks at Plastic Surgery The Meeting 2016

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 or call 415-751-0583 to schedule an appointment with Dr. Peled.

Continue reading
1718 Hits

What is the Difference Between Occipital Neuralgia and Cervicogenic Headaches?

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.

Continue reading
1318 Hits


I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication ( which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).

                           BEFORE                                                                     AFTER

Before After

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit to learn more about migraine relief through surgery.  

Continue reading
1931 Hits

The Staged Approach to Migraine Pain Relief

headache medium

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive. 

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, causes the headache and discomfort to spread to other areas.  For example, s/he will state that their neck gets tight, they get occipital headache pain and if the medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required.  Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild such that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have.  Doing so is making a value judgment - only the patient can and should make that determination.  Secondly, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful.  The converse is also true, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful.  Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is given them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia.  While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues. 

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic.  In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  I also believe that among the many questions patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit to learn more about migraine relief through surgery.  

Continue reading
1470 Hits


Over the years, I seem to have had this question come up on a fairly consistent basis and the answer is actually relatively straightforward.  Let’s assume that we have an arbitrary portion of the scalp which is innervated by 3 different nerves.  When someone touches that area, sensation is mediated to some degree by each of those nerves, all of which likely branch to some degree within that particular area of skin. In other words, the areas of sensation mediated by each of those nerves likely overlap, much like a Venn diagram (see below).  Now let’s assume that one of those nerve is injured.  It is likely that the person in question now has some degree of discomfort in that area.  If a procedure is performed in which that injured nerve is transected and implanted deep within the local muscle, hopefully with time, the painful sensations mediated by that nerve also diminish.  However, s/he still has two nerves which innervate that portion of skin.  When that same person touches that area of skin, s/he will feel it almost the same as before the operation.  This person has no idea which nerve is mediating that perception of feeling, but for all practical purposes it doesn’t matter.  Hopefully, this explanation clears up some confusion.  This phenomenon of overlapping nerve territories also explains why patients tolerate the transection/burial of some nerves better than others.  It is not the only reason to consider when deciding whether or not a nerve can be transected and buried in the local muscle, but it is an important one.



Continue reading
1442 Hits

Dr. Ziv Peled Invited To Speak At Plastic Surgery 2015

Ziv Peled, MD has been invited to be a Panelist at ‘Plastic Surgery 2015’ in Boston, Massachusetts on October 17 – 20, 2015 held by the American Society of Plastic Surgeons (ASPS).  This meeting is the largest and most prominent plastic surgical meeting internationally.  This panel is sponsored by ASPS and held in cooperation with the Plastic Surgery Foundation (PSF) and the American Society of Maxillofacial Surgeons (ASMS).  Dr. Peled will speak on his established experience with surgical intervention for chronic headaches. A specific emphasis of the program will be on incorporating the latest in plastic surgical techniques in order to understand what the future holds for plastic surgery as a profession and medicine in general. 

Dr. Peled’s panel will teach the participants to:

  1. Identify current and emerging issues and advances affecting the diagnosis and delivery of treatment for plastic surgical problems and assess their potential practice applications.
  2. Compare and contrast therapeutic options to determine appropriate recommendations for patient treatment.
  3. Incorporate into practice, new technical knowledge, state-of-the-art procedures, advanced therapeutic agents and medical device uses.
  4. Communicate current practice management and regulatory issues necessary for the efficient and safe delivery of patient care.
  5. Translate expanded knowledge into practice for the improvement of patient outcomes and satisfaction

Ziv M. Peled, MD is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut, School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of 
Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a peripheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from chronic headaches as well as neuropathy due to diabetes, chemotherapy and thyroid disorders.  He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national and international meetings. He has performed several hundred peripheral nerve procedures of various kinds.  Ziv is an Active Member of the American Society of Plastic Surgeons and a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.  He continues to volunteer for the American Diabetes Association and has recently traveled to South America to provide reconstructive surgery to underprivileged children. In his spare time, he actively competes in both Half-Ironman and Ironman-distance triathlons.

Continue reading
1435 Hits


Axon -mediumRelease Techniques (ART) are just some examples of therapies that focus on the muscles and which are common components of patients’ past medical histories.  The point is that if you’ve unsuccessfully tried to release, lengthen or relax your neck muscles in a number of different ways and still suffer from occipital neuralgia, then perhaps attempting to address another component of the ON symptom complex is also reasonable.


In these same people, I often find that a well-placed nerve block or blocks not only seems to relieve their pain, but several minutes after the block has really set in, they are able to move in ways they have not been able to in years.  I use long-acting blocks and then have those same patients leave the office and engage in several provocative maneuvers to try and exacerbate their ON.  Many of them find that those typical “triggers” now don’t bother them and they remain relaxed until the blocks wear off.  What do these results tell you?  Among other things, they suggest that if the nerve, which has been chemically and temporarily “calmed”, can be treated permanently, perhaps the muscles that have relaxed will also benefit secondarily.  Moreover, they suggest that other distant muscles in other parts of the body may also benefit as they no longer have to compensate for spastic and ineffective muscles in the neck.  The take home message is that just because you can’t figure out which came first, the chicken or the egg, doesn’t mean that you can’t still treat the problem of occipital neuralgia effectively.  


To learn more, visit today, or call 415-751-0583 to schedule an appointment.

Continue reading
1524 Hits

Why Did I Get Occipital Neuralgia?

headache - mediumThe title of this post is really the $60,000 question. I have posted many times in the past about how Occipital Neuralgia can be caused by compression from spastic neck muscles, compression by tight connective tissue (i.e. fascia) and/or compression from surrounding blood vessels. Many of the patients I see have had headaches ever since they can remember. However, there are just as many for whom the headaches began seemingly spontaneously one day. The question for these folks remains: What happened? Why now?

There have been recent articles that hint at possible answers to these questions and they may surprise you. One of the most surprising comments was that craning the neck downward only 60º puts as much as 60 pounds of pressure on the cervical spine and neck muscles. With that kind of pressure, you can imagine that nerves (among other structures) would be compressed. So the explanation as to why you might all of a sudden develop ON can almost be summed up in one word - overuse. This explanation is one of the potential causes of carpal tunnel syndrome, the most common compression neuropathy recognized (even by neurologists). Why could that not be the case for ON. Nerves are very susceptible to chronic compression (see post - ‘What Causes Occipital Nerves to Malfunction’) even if intermittent. The occipital nerves take very circuitous routes through all of the nuchal soft tissues. When you add to that fact the constant motion of our necks that require the nerves to glide constantly and then compound those factors with an additional 60 pounds of added pressure, there are many things that may occur to those nerves.

One, they may simply get kinked as they make their way through the neck to the scalp. Not a week goes by when I don’t see a patient in the office who, in describing their headaches contorts their head to recapitulate their symptoms and when they get it just right, it’s like a thunderbolt of pain. Two, even if not kinked, the pressure will compress the vasa nervorum - the microscopic blood vessels within the nerves themselves that supply blood to those nerves. After numerous episodes of compression, especially if for prolonged periods, these blood vessels can clot and the nerves become ischemic (i.e. choked). The neurons that comprise that nerve then die off and try to regenerate causing the hyperesthetic symptoms so typical of ON. Three, even if the nerves recover from each successive insult, the additive microtrauma will likely result in some inflammation and the subsequent formation of scar tissue in the surrounding structures, thus closing off already tight corridors through which these nerves must pass - another compressive force. While no one has demonstrated these possibilities in real time, I see the sequelae of them in the OR weekly.

So what to do we do? Good posture, stretching and avoidance of triggering activities seem to make common sense. In addition, as many of you know and as intimated in the article, steroids seem to be the mainstay of treatment amongst some practitioners, but as also stated, the effects are often not permanent. The reason is obvious - the compressive forces remain, even if inflammation is temporarily suppressed. Therefore, I continue to believe that decompression (or neurectomy & implantation for permanently injured nerves) are reasonable options as they are safe and effective. Moreover, they address the underlying problem, the mechanical compression of these poor nerves caused by our ever more technologically demanding lifestyles. So next time you pick up your smartphone, remember to pick up your head as well.

For more information, read and visit for information on how to reduce your migraines and nerve pain.

Continue reading
1751 Hits

Dr. Peled Co-author On New Paper

The paper, 'Supraorbital Neuroma: A Rare and Unreported Complication Following Blepharoplasty' co-authored by Giorgio Pietramaggiori, MD, PhD, Sandra Saja Scherer, MD, Ziv M. Peled MD and Raffoul Wassim, MD has been accepted for publication by the Journal of Reconstructive Microsurgery (Theime Medical Publishers, Inc). This manuscript describes a novel approach for managing a supraorbital branch neuroma following blepharoplasty - a very popular aesthetic procedure. A short excerpt from this article is shown below with the full text to be published soon.  


Supraorbital 1


Supraorbital 2

Continue reading
1510 Hits

Dr Ziv M Peled Wins Most Outstanding Paper award at CSPS

Dr. Ziv M. Peled's paper entitled, "A Novel Surgical Approach to Chronic Temopral Headaches" won the 'Most Outstanding Paper Award' at the 2015 California Society of Plastic Surgeons annual meeting this past weekend in Monterey, CA! The paper was presented by Dr. Peled during the 4-day event that featured the top plastic surgeons in California giving presentations on their areas of expertise. Dr. Peled's paper was chosen from dozens of nominees as the top paper overall.


Dr Peled's Latest Award


CSPS Title


Ziv Presents

Continue reading
1426 Hits

To Decompress Or Transect: That Is The Question

There continue to be questions raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

Continue reading
1655 Hits

The Bionic Arm

I recently read with interest the work of Dr. Oskar Aszmann and colleagues in Vienna, Austria regarding bionic reconstruction of the hand (The Lancet , February 2015). I have been listening to Oskar speak about this work for the past several years at our annual meetings and it is great to finally see it in publication. My hope is that this research will raise awareness of the possibilities for nerve reconstruction in the near future as well as what we are capable of doing today.


For those that haven’t seen or heard about this paper, it describes three patients who had severe brachial plexus injuries. The brachial plexus is the network of nerves in the neck and shoulder regions that mediate all of our upper extremity function and sensation. All three patients had failed traditional reconstruction methods and the patients were left with minimally functioning upper extremities. Something else had to be done. To simplify it, the wiring of the remaining upper extremity was reconfigured using a combination of nerve transfers and bringing in muscles from other parts of the body along with their nerves so that the remaining, functional nerves could intuitively and predictably innervate the upper extremity muscles. Then, by following a specific rehabilitation protocol, the patients re-learned how to use this re-wired musculature. This protocol included the use of a hybrid myoelectric (i.e. robotic) prosthetic which was attached to the native, non-functional hand so that the patients could appreciate how much additional function they had with the robotic hand as compared with their native hand which was often minimally functional and insensate. After adequately learning how to control this myoelectric (i.e. robotic) hand, each patient underwent elective amputation of the native hand and permanent fitting of the same myoelectric prosthetic which they had been learning to use. Post-operatively all three patients demonstrated significantly improved upper extremity function, decreased pain as well as improvements in quality of life according to well established measures.


Oskar’s work is exciting for a number of reasons. First of all, it wonderfully demonstrates the degree to which we are able to restore function in the upper extremity for those with previously devastating injuries that were once thought to be irreparable. Secondly, while these surgical procedures are not for everyone and can be complex, the technical challenges that we face in the operating room are being greatly aided by improvements in electronic prosthetic development. Already in the works are myoelectric prosthetics with vastly more degrees of freedom (i.e. independently moveable joints) and signal processing capabilities which will ultimately allow a very precise level of function at the wrist, hand and finger levels beyond those which are available today. Third, I believe that in the not too distant future, we will see prosthetics that can actually be surgically implanted and will not need to be taken on and off as we have today, thereby removing a psychological downside to prostheses in general. Fourth, such procedures and prosthetics may ultimately provide us with a level of functionality that even a “normal person” doesn’t have. While there are certainly moral and ethical implications to consider with these possibilities, the concepts and potential are exciting indeed.


In many ways, this type of work represents the ultimate melding of computer science/engineering and modern medicine/surgery. Dr. Darrell Brooks and I have performed several similar procedures, so far with very encouraging results. We sincerely hope that the publication of this paper and hopefully soon others like it will encourage peripheral nerve surgeons to pursue even greater achievements. I believe that in time and in collaboration with our engineering/biomedical colleagues, devastating injuries suffered by those returning from war or after accidents will no longer mean a lifetime of dysfunction.

Continue reading
1451 Hits


This post will be a relatively short one, but this question is very important. I have been queried about this phenomenon numerous times. Peripheral compression of the occipital nerves can come from muscles in the neck, scar, fascia (a tough type of connective tissue) and blood vessels, specifically branches of the occipital artery. When the latter are involved, the pathology to the nerve is much like that of an anaconda strangling its prey if the blood vessel is wrapped around the nerve or alternatively that of a jackhammer if the artery lies next to the nerve in a small and fixed space. In both cases, when the blood pumps through the artery with greater force, the pulsations will pound the nerve with greater force. Hence, when blood pressure increases, so does the pulsatile force against the nerve and hence the pain.

What types of things can cause blood pressure to rise? Not surprisingly these forces are many of the same triggers that people report all the time: stress, exercise, caffeine ingestion, pain, etc. To illustrate the point, take a look at my recent post with a picture and a video of a greater occipital nerve in the process of being decompressed. During the dissection, I was able to demonstrate a pulsatile occipital artery branch passing right over the greater occipital nerve. In addition, once someone experiences pain, their blood pressure rises which in turn causes the arteries to pump harder thus causing more pain, which causes a further rise in blood pressure and setting in motion a terrible positive feedback loop. For these reasons, when we see vascular compression of the occipital nerves in the OR, we tie off and/or cauterize those vessels so that they no longer impact the nerves.

For more information on how nerve decompression can help solve your occipital neuralgia issues, visit and call 415-751-0583 for an appointment.

Continue reading
2462 Hits

Phantom Pain or How Come It Hurts When It's Numb?

This post has been a long time coming.  It seems that almost daily, I get a question from some patient somewhere wondering why their (insert body part here) hurts when they’ve had a nerve injury despite the fact that the area feels numb to the touch.  This phenomenon can be seen in patients suffering from diabetic neuropathy (most commonly noted in the lower extremities), amputees with phantom limb pain and anyone with a sensory nerve injury anywhere else (e.g. the head/neck region).  I will qualify my remarks below by saying that this topic is a huge one and cannot be covered in its entirety in a brief post or even a book chapter.  There are whole journals published monthly devoted to the study of such clinical dilemmas.  The goal here however is to provide a general understanding of why one might have these types of sensations and as a launch point for discussion with your treating physician about what can be done. I will also use phantom limb pain as the template for understanding this problem as it is one of the most common manifestations of this problem and the one most conceptually accessible to a non-physician.

First of all, what is phantom limb pain?  Simply put, it is the sensation of pain from a body part that no longer exists.  For example, a right below-knee amputee feels as if the right foot is being squeezed and is painful, even though that very foot was removed a long time ago.  But how is this possible?  Phantom limb pain has traditionally been hypothesized to occur as a consequence of abnormal mutability of signals within the brain (specifically the cerebral cortex) as a result of lost input from a limb.  Translating from medicalese, since the sensory input from a limb no longer exists, the neurons within the brain that used to map to that part of the body re-organize themselves in an abnormal way thus leading to the perception of pain.  Another potential mechanism is that the nerve ends from those nerves that used to go to the foot and now reside in the amputation stump are irritated in some way, but still go to that part of the brain which mediated right foot sensation.  Therefore, again, when those peripheral nerves fire, the patient perceives that they have right-sided foot pain even though there is no right foot because those signals ultimately still end up in the right-foot-part of the brain (which of course still exists). This situation might occur if you strike the nerves within the stump (e.g. while wearing an ill-fitting prosthesis) of if they are neuromatous.  It might also occur if a nerve end that has been implanted into a muscle in the neck is “tweaked” by that muscle.  There are other theories as well which state that nerves within the spinal cord that receive sensory input from an absent limb fire abnormally, thus ultimately sending messages to the brain that one is experiencing pain.  So which theory is correct?

Well, as with many things in life this problem is not a zero-sum game.  In other words it’s not that one theory is absolutely right and the others are all wrong.  The overall pain sensations are likely due to a combination of factors.  In fact, I was just reviewing an article in a prominent pain journal in which they demonstrate that blocking a peripheral nerve in an amputation stump leads to some persistence of phantom limb pain, whereas blocking nerves in the spinal cord leading to that limb resulted in temporary, but complete cessation of said pain. This result would suggest that it is these spinal nerves that mediate this pain. However, the authors then go on to admit that electric charges emanating from peripheral nerves within a stump are likely responsible for the sensation of phantom pain when a person bears weight, such as while wearing their prosthesis.  My take home message from this paper is therefore that there are several components to this phantom pain.  One component may occur at rest or at night when no pressure is placed on the stump.  This component of the phantom pain is important and may be treated by addressing those spinal nerves.  However, if you are an amputee, you’ll likely want to walk using a prosthesis at some point.  If so, those peripheral nerves at the stump also need to be addressed so that this component of phantom pain gets better allowing the patient to ambulate.  Indeed, this latter mechanism is the partial rationale behind targeted muscle re-innervation in the extremities.  Therefore, in any individual patient, the optimal pain relief will probably only be achieved by several specialties working together to attack the problem from a number of angles.

For more information, please visit today!

Continue reading
1607 Hits

Medication Overuse Headache (MOH) or ‘Rebound Headaches'

Medication Overuse Headache (MOH) or ‘Rebound Headaches'

I have been asked recently to write a little something about so-called “rebound headaches”. This topic can be quite confusing, and as you will read, is not very well understood. The precise medical term for this disorder is Medication Overuse Headache (MOH) or analgesic rebound headache. The prevalence of this problem is about 1% in the general population and as with many types of headaches, is higher in women than in men. The underlying mechanisms for MOH are unknown, but as with many medical problems, are oftentimes multifactorial. It is known that there can be a genetic predisposition to MOH. In addition, long-term exposure to opiates is known to cause changes in the nervous system through increased expression of specific cytokines (chemicals, e.g. Calcitonin Gene-Related Peptide) and increased activity of certain neural pathways felt to modulate the sensation of pain. Some people also feel that addictive personality disorders are associated with MOH. Interestingly, migraines are the thought to be the most common “primary headache disorder” that has been linked to MOH.

Continue reading
1816 Hits



I’ve noted that there has been some confusion lately over the roles of nerve blocks, nerve stimulators and nerve decompression in the treatment of chronic headaches. To be sure, there will be variations in how each clinician may use these modalities, if only because each patient presents a unique clinical dilemma.  While I certainly can't speak to the ways in which others utilize these modalities, I can offer general guidelines as to how I use them in my practice.  Hopefully this information will also provide some insight into the advantages and disadvantages of each.
To start with the most straightforward, nerve blocks in my hands are used as diagnostic, not treatment tools.  If, based upon your history and physical exam it is felt that nerve X may be contributing to your chronic headache symptoms, I would propose to block nerve X.  After a few minutes, if your headache symptoms are either gone or significantly improved, it strongly suggests that this nerve is somehow injured and would benefit from surgical treatment.  The local anesthetics used in nerve blocks only last a few hours. Therefore, it is fully expected that the headache symptoms will return after the block wears off.  However,  the results of the block help identify which nerve or nerves may be involved and give an approximation of the numbness that one might have permanently, if those nerves are removed.  The numbness should not be permanent if the nerves are simply decompressed and then recover as expected.

Continue reading
1859 Hits


  • Just wanted to let you know that you broke that episode of neuralgia with that local anesthetic Friday. After such a bad time all that night and morning, I have had not one zinger since then, was able to sleep days and work nights over the weekend without pain. I know this is such a low tech and possibly unimportant-seeming thing for a skilled surgeon to do, but it made an enormous difference in my life that day and I just want to thank you once again.

    S. P.

  • Cary Anne and Dr. Peled, I want to thank you both for all your help in making my life so much better! In SO many ways. Again thank you for making my life something I treasure and look forward to daily.


  • Dr. Peled is the real deal. His technical skills should be seen as elite. My headaches and neck pain are gone as a result of the surgery.

    PJHCali Mar 1st, 2013

  • Amber on Mar. 1st, 2013.

    I suffered from migraines for 2 years. I went to numerous doctors and was on a wide range of serious pain medications. No one could help me or diagnose me. After learning of Dr. Peled I made an appointment with his San Francisco office and within 20 minutes of meeting him he diagnosed me with Occipital Neuralgia and treated me with Botox. Within 3 weeks I had surgery and have been pain and migraine free since. It has been almost a year. Dr. Peled gave me back my life!!!! I would highly recommend him to anyone and will never go to another doctor again!!!! His office staff Cary-Anne and Aimee are the sweetest ladies you will ever meet and go above and beyond their job to help you with anything!!!!

  • Thank You so much Dr. Peled. You have returned to me a great pleasure... the ability to walk...and enjoy it. The time test was a walk from Bondi Beach to Coogee. I didn't walk the whole thing but the 6 miles over the day only required a few rests. The important part... no pain and no night-time burning. I couldn't have enjoyed my vacation nor would I be able to keep a positive outlook without your help. Thank you doesn't seem to be enough!

    R.R. A very appreciative patient!!






csps1  ww22011-Vertical-small 2 healthgrades vitals