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Scot: Troy, I've got a question for you. I'm going to say a word, and I want you to tell me the first thing that comes to mind. Botox.

Troy: Crow's feet.

Scot: Okay. Mitch, Botox.

Mitch: Wrinkles.

Scot: All right. That's the same for me, crow's feet and wrinkles. Today, on "Who Cares About Men's Health," we're going to talk about Botox, not only for a more youthful appearance, but also some other things that it can treat that men might find useful. And also, we're going to answer the question "Is it safe?"

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. I'm curious if you might have a different opinion about Botox by the end of this episode. We're going to find that out. My name is Scot Singpiel. I bring the BS. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. I'm excited to learn about Botox for something besides my wrinkles.

Scot: All right. A guy who's working on his health and always has a unique perspective, Mitch Sears is on the show.

Mitch: I'm curious because TikTok keeps telling me in my 30s, I should start preventative Botox, and that worries me. Am I doing something wrong?

Scot: And Dr. Sarah Akkina, director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at University of Utah Health. Welcome to the show.

Dr. Akkina: Thanks so much for having me. I'm very excited to blow your minds about the other uses of Botox, botulinum toxin.

Troy: This is great.

Scot: I actually looked it up and it was really shocking some of the other things that Botox can do, because at the beginning of the show, as we all said, we tend to think about crow's feet or wrinkles, using it to get a more youthful appearance, right? And a lot of times, guys hear that word, too, and we have that misconception that maybe it's not for us, right?

Mitch, you had a similar experience. Tell us about how you reacted when you heard that you needed Botox for another reason.

Mitch: Oh, frustrating. So I had Bell's palsy, right? We've talked about it. It's another episode. We can direct you towards it. But one of the weird after effects was that I have a thing called crocodile tear syndrome, which means when I eat, my eye will sometimes tear up. Big tears sometimes, whatever, it depends on what I'm eating, etc. It just is a nerve that didn't quite match up right.

And so I went to the ophthalmologist and they looked at it, and the potential treatment was Botox in that area to see if we couldn't numb up the nerve that was misconnected.

And unfortunately, I immediately just said, "Nah, I don't do Botox." I don't even know where that comes from, this idea, "Yeah, I hear what you're saying, but no, that's not for me. I'm a man." How dumb is that?

But then afterwards, I thought about it and whatever, and there were some other things that I wasn't quite super excited about. But yeah, the second that word Botox came out, I shut down very quickly.

Troy: Oh, I think I would do the same thing, Mitch, if I had to tell people, "I'm going in for my Botox injections." Number one, I wouldn't tell people that, but if I had to admit it, I would be embarrassed.

Scot: Yeah. You would rather cry when you eat, huh?

Troy: I'd just rather tear up.

Mitch: Yeah, I would apparently.

Scot: Than tell somebody you were . . . Yeah. Dr. Akkina, is this how guys typically respond when they hear Botox, that word?

Dr. Akkina: Yeah, absolutely. And I think it's funny because in the zeitgeist in our society, it's become so synonymous with cosmetics and appearance, and then people think, "Oh, it's mostly for women." But there are so many different ways that we can use it.

So stepping back, Botox is a brand, first of all. So it's a type of botulinum toxin. If we want to be more cool, if you want, we can say the toxin.

Scot: Yeah, you're getting the toxin.

Dr. Akkina: So you can say you're going in for your toxin treatment.

Troy: I'm getting my toxin.

Mitch: Rad. I love that.

Dr. Akkina: That's right. So, heretofore, we'll say toxin. So your toxin treatments, the best way to think about it is it's this really cool drug that we can use that basically shuts off muscles right at the junction that the nerve is giving them input.

So when you think about it like that, this toxin can be used to basically shut down any muscle that we feel like is not working well. In Mitch's case, one of the kind of muscles that I think you're talking about treating for the crocodile tears, it's basically things around the lacrimal gland. So we can use it to stop that gland from secreting things because you're affecting that muscle function.

And another way that we can do that in a similar case, which probably a lot of people don't know, is you can actually use toxin to treat over sweating. So actually there are especially a lot of men who use it. Actually, we can use it in your armpits or other areas that you feel like you're sweating a ton and it's embarrassing or you're just not into it. We can treat that with Botox, or toxin, as we're saying.

But that does require a little bit of higher doses than we're typically talking about versus things like wrinkles. So that's one option that we can do.

Another really great use of toxin is in your masseter muscles to stop teeth grinding. Do any of you guys teeth grind?

Scot: Yeah.

Dr. Akkina: Fancy word, bruxism So that masseter muscle is often the culprit in what's really causing that grinding.

And fun side note, my husband was very much like you guys and was very anti all sorts of toxin treatment. But when I told him about this and he had been having a lot of struggle with teeth grinding and stress, things like that, he actually let me attempt to treat his masseters and his teeth grinding stopped. It was amazing. And to this day, this is actually two years later, he's still not grinding his teeth. I think because his body just learned to adapt without it a little bit.

Troy: After one injection, one treatment?

Dr. Akkina: Yeah, after one series of treatment.

Important things to just remember for toxin treatment, it does take about a week to bring into effect. And then it only lasts three to four months. So you do have to know that. So typically that effect wears off. Some people are able to use that for teeth grinding, for instance, just to kind of rewire their body a little bit. Other people certainly need treatment still every three to four months.

But it's a great way to, like I said, selectively stop these muscles from over-activating and to help you in whatever that means for you for that muscle.

Troy: And what about things like facial twitches? If someone notices their face gets kind of twitchy when they get anxious or something like that, have you used it for that?

Dr. Akkina: Yeah. So blepharospasm, or that twitching around the eyes that can happen when people are stressed, tired, things like that, super common indication, and actually one of the first indications for using Botox, or toxin.

So toxin initially was actually developed and promoted in the '80s by ophthalmologists who were treating something called strabismus or basically crossed eyes where your eyes are misaligning. And that was one of the first uses in humans. And then quickly after that, they realized they could use it for blepharospasm or the spasms around the eyes. And then that led to saying, "Hey, we don't have crow feet anymore. How exciting."

Scot: That was the side effect, huh?

Dr. Akkina: That's right. So that was a side effect of all the initial use of toxin. So that's how we started to develop in the market.

And all jokes aside, there are some very serious other medical conditions that we can treat with toxin. One of the other things in my field of otolaryngology is for people who have spasms in their larynx. So you can have these spasms that really prevent you from having normal speech and normal talking patterns. And our laryngologists, or throat specialists, are able to basically direct toxin to those specific muscles and help shut that down so people can talk normally.

Another really common indication, probably more than that, is things like migraines, or anything that you can think of that's a muscle chronically or misfiring where we can kind of gently turn that off.

Now, it's a little tough because the dosages are obviously all different for different areas. So, depending on what you want to treat and what the indication is, insurance can cover some.

So, Mitch, if you'd gone forward with your crocodile tears, it's likely that insurance would cover that because that's a medical disease and illness that you're treating with it. Certainly, for cosmetic things like the crow's feet and forehead wrinkles, things like that, that is out of pocket.

Troy: And where would you do an injection for a migraine?

Dr. Akkina: Yeah. So you can inject things like the temporalis muscles and sometimes even behind. Our neurology colleagues do treatments for that typically. But yeah, there are different things that we can work.

For me, I used to get a lot of tension headaches, and when I started getting toxin for my forehead wrinkles, actually my tension headaches went away because I think I wasn't contracting or squeezing my brow angrily all the time.

Troy: Wow.

Dr. Akkina: I don't actually do that, for the record, but . . .

Scot: You don't sound like an angry person, so I can't imagine that.

Dr. Akkina: Well, I can't contract my brow right now.

Scot: Because the toxin shut that muscle down.

Dr. Akkina: Because of the toxin, yes. Very smooth and content all the time now.

Scot: So what is the actual name of it, not the brand name?

Dr. Akkina: So botulinum toxin, that's the actual name.

Scot: I don't know. That doesn't sound too good to me. On one hand, it sounds cool because, "Oh, I'm tough, I'm taking my toxin," but on the other hand, is that safe?

Dr. Akkina: Yeah, there are very little side effects. So a few important things is that whenever that toxin is injected, it can diffuse to other things in the area. And this is a little dependent, of course, on where it's injected, what the concentration it's injected at, things like that.

So you do have to be careful, and that's why I always recommend going to someone who knows what they're doing and is very familiar in the anatomy and structures in whatever area that they're injecting.

But it's relatively safe. The nice thing, again, is that while it takes often five to seven days to act, it goes away in three to four months. So if you don't like whatever the action is, it will wash out eventually.

Very few people do have allergies to toxin. If you have egg allergies, actually the botulinum toxin A in Botox, for instance, is formulated with egg proteins, albumin, so you have to be a little bit careful to just think about that.

And if you have other things like neuromuscular diseases or disorders, yes, you definitely have to be very careful about the effects of it.

Also, certain antibiotics, like aminoglycosides, botulinum toxin can potentiate some of the effects of that.

But outside of those pretty specific circumstances, it's got a really safe profile for use in a lot of different ways.

Scot: I've heard of something else called botulism. Is it related to that?

Dr. Akkina: Yeah, the toxin is the same, believe it or not. So that is how they initially learned about it. And yes, that's a serious disease. That is more if you have canned food, like cans that are crushed or look funny or things like that, those can harbor botulinum toxin. Honey can actually technically have some relation to that too, but not in the ways . . . mostly just serious for babies and infants, things like that.

Scot: Sure. But the way you're using, it's . . .

Dr. Akkina: Yeah, very different.

Scot: It's safe. I'm not getting any of that illness.

Dr. Akkina: Correct. Yes, you're not getting any of that illness from an injection of the toxin.

Troy: My one piece of advice, Scot, would be to avoid botulism. Don't drink pruno. It's a prison wine. We had a big case series we published. A bunch of prisoners who unfortunately drank that, and they had a potato in it, which was the source of the botulism. But it was a big CDC report that we published with multiple prisoners. So yeah, if you want to avoid botulism . . . But this is not botulism. I think that's the point here. You're not putting yourself at risk of botulism.

Dr. Akkina: Yes, correct.

Scot: So it has a lot of really, really cool uses. The sweating thing, I bet you, for some guys could really be a game changer. We talk about the Core Fore, and emotional and mental health is one of them, and if it makes you self-conscious or anything like that . . . Lazy eyes, I think you mentioned that as well. Any sort of spasm disorder. To remove that from your life, I would imagine, can be a great thing.

Do you have any guys that have ever used it for those purposes and how did it change their lives?

Dr. Akkina: Yeah. I think the sweating thing in particular, I remember a patient a few years ago who came in, it was a gift from his mom for his 19th or maybe his 18th birthday, because he was going to be taking prom pictures soon and he didn't want to sweat through his shirt during prom, which is actually a really sweet gift I thought from his mom. So small things like that, I mean, they can make a big difference in people's lives.

Troy: Sweaty palms, people use it for that?

Dr. Akkina: I've not personally done that, but I think in theory you could. When you're treating large areas like that, again, you do have to be a little bit careful because it's probably just going to be a high dose. So it might just be a little bit dose-limited in terms of having to inject all these little areas there. The other tough part there is you wouldn't want to turn off the muscles in your hand.

Troy: Right. That could get awkward.

Dr. Akkina: It's always a balance. You can inject it in glands and things like that, but yeah, if you're injecting around muscles, you have to be prepared that it might diffuse a little bit.

Scot: So it can do a lot of really cool things. And since you're here, let's talk about using it to remove wrinkles. I'm just gathering information. I'm not saying it's for me.

Troy: Asking for a friend.

Dr. Akkina: For a friend, yeah.

Scot: I'm just asking for Troy.

Troy: I was curious. Yeah.

Scot: So, actually, I want to throw that out. Mitch, you had mentioned that it had been recommended that maybe . . . well, on the internet . . . that you start doing some preemptive Botox.

Mitch: Oh, no. I have a friend in my life who has also said it's not that big of a deal and if you start now, you'll never have wrinkles. I don't know if that's true or not, but . . .

Scot: Have you considered ever using Botox for a more youthful appearance?

Mitch: See, I have a pretty youthful appearance anyway, and the rule I've always told me is as long as I could play a high schooler on a CW original, I am okay. But there is a part of me that does wonder . . . I don't know. I don't particularly love the idea of becoming super duper wrinkly. Maybe. I'm open to it, but I'm not super excited about it.

Scot: What would your dad have to say about all this?

Mitch: I don't know. He's probably listening right now. I'm sure I'll get an email.

Scot: Troy, is this anything you've ever considered?

Troy: Botox? I haven't seriously considered it. No. It's probably crossed my mind because I'm at a point in life where I do see more wrinkles appearing, but I can't say I've ever really looked into it beyond thinking, "Huh, maybe."

Dr. Akkina: Well, fair enough. I think a lot of patients, and especially men, are in that boat. But it is nice because from that . . . Mitch, you asked earlier I think about the preventative part. So Botox or toxin can't take away wrinkles that are already formed.

So when I think of wrinkles, there are both static wrinkles and dynamic wrinkles. So when we're young, if I raise my eyebrows, you can see typical areas where my muscle is causing contraction of the skin. That's causing temporary wrinkles. But when I relax, you can't see any of those wrinkles. Versus in another 20 years, unless I keep my toxin up, then those wrinkles are kind of permanently etched in the skin.

So important distinction. Toxin can't take the permanent wrinkles away because that's just part of your skin at that point. But it can always, as we said, inactivate the muscle under it.

So for forehead wrinkles, for instance, that's the frontalis muscle. We can make that muscle calm down, be much less active with the toxin, and then you're not actively working to keep forming those wrinkles. So that's why it can still help even if you have static wrinkles that are there.

Scot: What are other wrinkle locations it could help? So crow's feet, if I already have them, that's not going to help that, right?

Dr. Akkina: It still will make I think the appearance of the deep wrinkles less, right? If you have the crow's feet, yes, they're there, but if you're not activating the muscle all around it, it can still look a little bit softer, a little bit less aged overall.

For other areas . . . So we talked about the forehead. The between-the-eyes area, that brow, that's another super common one. And especially for men, right? It's that kind of furrowed, angry brow look. We call those the 11 lines because it leads to those two often horizontal lines in the very middle of your forehead. Those can respond really well to Botox.

And again, if you have permanent wrinkles there or static wrinkles, it's not going to take them away, but it does soften the overall appearance of your brow. It can help you look a little bit less angry or things like that.

Scot: How many men do you see in your office that actually come in and get treatment? And what are their reasons? Because I had read somewhere that Botox has just exploded among men. I think a 400% increase in treatment since 2000, so a lot more men are getting it nowadays. Why are they doing that?

Dr. Akkina: And most of it is for appearance. Yes, overall, for my patients coming in for toxin treatments, less than maybe . . . It's certainly a minority. I would say probably at this point, maybe 5% to 10%. But among those men, certainly things like the forehead wrinkles, but the masseters is also another really common indication for people who want to try to stop grinding their teeth.

That's another actually great thing that I'm getting more folks coming in for. I'm glad that it's getting out there that's something that we can use toxin for.

Scot: Yeah. I Googled a couple things because I was curious. I was like, "Gosh, is it vain that I want to get rid of my wrinkles?" For me, it's not actually wrinkles. I don't think Botox is the solution to my problem. I have these bags under my eyes. I look like I'm constantly fatigued. Botox isn't going to help that.

Dr. Akkina: No.

Scot: And I never thought I would think about getting any sort of cosmetic anything until we came into this world of Zoom. I'm looking at my face all the freaking time and I just look so run down and so tired, and I'm afraid people in the office are going to think, "Does he ever sleep? He looks sleepy."

So social media was one of the reasons why. And I thought, "Well, again, that's kind of vain." But then it said online dating. Well, okay. We're representing ourselves in a completely different way than we've ever had to, our dads or grandfathers have ever had to, in high resolution. So do you guys come in for those reasons and . . .

Dr. Akkina: Yes, absolutely. I had a patient the other day who was telling me that he's a little bit upper level in his company now, but he feels like some of the other people in the company are much younger than him and seem more youthful. And he gets embarrassed on these Zoom calls where he feels like he's the old person in the group, and he just wanted to feel more youthful.

So talked to him about things like facelifts, blepharoplasty. That's the under-eye or over-eye surgery where we try to help reduce that evidence of the extra skin and the bags, things like that. And he's really excited to get a little bit more of a youthful appearance just so he feels like he can stand up with the younger folks at his company.

Troy: I was going to say what about . . . The big thing I've heard with Botox is kind of the mask face where you get to where you always look like . . . Your expression doesn't change.

Mitch: You're a Barbie?

Troy: Yeah, exactly. Is that common, or are people just overdoing it when that sort of thing happens?

Dr. Akkina: Yeah, I call that a frozen face or freezing someone out. I don't like to do that. And when you have an injector that you're going to, I think talking about what your expectations and what your goals are is super important. And then having your injector listen to you and make sure they're not overdosing things to freeze things out is important.

So when folks come to see me, I talk through exactly what they're interested in getting. We talk through wrinkles often. And then I discuss my normal dosages.

And usually, I like to err on the lower side, right? I never want to free someone out. That's just my preference. So starting on lower ends of dosages, and then always coming to back for touchups, things like that. Super easy to do.

In general, when we go through the process of injecting Botox or Dysport or Xeomin, it's a very tiny needle. It's a couple little sticks. Yes, there is a risk of just a little pinpoint bleeding, things like that, or just a tiny bit of bruising. But overall, it's a pretty short and sweet procedure.

So we can start at low doses. I can have people come back and we can kind of keep augmenting until we find a regimen that they like in terms of its outcome.

Mitch: Now, I've heard about Botox parties. I've heard about going to a "spa." Is there a benefit? I mean, it sounds like this drug is pretty safe. Is there a reason that we should maybe err towards going to a medical person rather than some of these other things?

Dr. Akkina: Yes, absolutely. So we talked a little bit about some of the risks. I just mentioned injection risks certainly are something to always think about. But making sure that whoever is injecting your face is intimately familiar with those muscles and the other things in the area that could get affected by your injection is so important.

So one of the other common things that can happen if you're injecting around the eye, and especially if you're injecting in certain areas, is that toxin can diffuse and affect one of the upper muscles in your eyelid and basically give you a droopy eyelid. So that's something called ptosis.

And especially for cosmetic things, it's a little bit less common, but you want to make sure that your injector is injecting in places where that's a much lower risk. Certainly, we can treat that with eyedrops, and often it only acts for a few weeks even.

But yeah, that's a small example of you want to make sure you're going to someone who knows what they're doing and can provide the treatment in the places that you want it, giving you the effect that you want, and the dosage that you want.

So yeah, Botox injectors come in all sorts of varieties. I've even seen dentist office offering Botox. Have you guys seen that?

Mitch: What? No.

Scot: No.

Dr. Akkina: I mean, I think if you're well trained and have good results, okay, for sure. But yeah, you just never know and I think it's safer to make sure you're going to a place where the person knows the face, knows the muscles, knows what they're doing.

While it's safe in general, you can have unwanted consequences. You can freeze out a face. You can cause droopy eyelids. You can affect things like the smile overall. If you're doing masseter Botox, sometimes that can diffuse in different places. So you just want to make sure someone's really knowledgeable when they're doing it.

Scot: Those are some really good tips on how to look for a professional. And also, I love the fact that you said you should have a conversation and make sure that you feel comfortable with the person . . .

Dr. Akkina: Yes, absolutely.

Scot: . . . that's going to do it for you.

So I'm not going to pass judgment, I guess. I think the Scot of 10 years ago, and certainly the Scot that is the son of a South Dakota Rancher would. But we're in a different world, right? Botox is super useful for a lot of reasons beyond just appearance. If you want to get it for appearance too, and I've considered it, so I would completely understand.

So I want to find out where we are after our conversation. We started out with the association game. Troy, Botox.

Troy: Teeth grinding.

Scot: Okay. Wow. So we did change perception there.

Troy: That was my takeaway. And as we talked about it, I was grinding my teeth and I thought, "Maybe I need this."

Mitch: Oh, my. I've been struggling with this forever. I have a little mouth guard thing that I wear most nights, and I've still got sore muscles. It's like, "No duh, we have something out there that can turn those muscles off for a bit."

Scot: All right. Mitch, Botox.

Mitch: Toxin, my eyes. I don't know. What I'm thinking now is just, "Maybe I . . ." If it's for the most part relatively short term, maybe I could try it and see if it's worthwhile to have those muscles near my eye frozen. I didn't fully realize that it was kind of a temporary thing. So I don't know. I feel very different about it.

Scot: You're more open to it now?

Mitch: Oh, very much so.

Scot: All right. Very good.

Well, thank you very much, Dr. Akkina. We appreciate having you on the show.

And if you're listening, where are you about Botox after this episode? Have you ever used it for other procedures, for your appearance, or any of the conditions we talked about? And how did it work for you? Then finally, is it legit for a man to care about their appearance and want to use Botox?

If you have thoughts on any of those topics, you can email us at hello@thescoperadio.com.

Thank you for listening, and thank you for caring about men's health.
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Interviewer: As patients and loved ones of patients who have suffered from Bell's palsy know, the loss of one's ability to move one's face can be really serious and impact their lives. And if it's lasted for longer than six months or so, a surgical option may be available to give back a loved one's smile and ability to move their face.

We're joined by Dr. Sarah Akkina. She is the Assistant Professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology and Director of the Facial Nerve Center at University of Utah Health.

Now, Dr. Akkina, briefly, what is Bell's palsy and why is facial paralysis so potentially life impacting?
What is Bell's Palsy?

Dr. Akkina: Bell's palsy is a rapid, or less than 72 hours, one-sided facial nerve weakness of unknown cause, meaning we don't have an alternative reason for a patient to have it.

It's really important to know that recovery from Bell's palsy should start two to three weeks after. So that as an entire category really classifies Bell's palsy.

There are other conditions that can cause facial weakness, and that includes stroke, brain tumors, salivary gland tumors, cancers, and infectious diseases, including things like Lyme disease or a tick-borne disease.

Overall, we suspect that Bell's palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear, and taste to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth, a change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye, trouble keeping food and liquid in their mouth, nasal obstruction, and overall difficulty expressing emotions. So they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.
Treatment Options for Bell's Palsy

Interviewer: Wow. And so for patients who are maybe suffering from these different symptoms, whether it be facial paralysis, or inability to tear, or asymmetry, etc., what options are available for patients who are still experiencing those types of symptoms longer than is typically expected for healing, say, six months or so?

Dr. Akkina: For overall treatment of patients who have Bell's palsy with incomplete recovery, meaning they still have some muscle weakness, some asymmetry of their facial movements, or some major functional issues like being able to keep food or liquid in the mouth or nasal obstruction, we have a series of treatments that we can provide for those patients.

We provide treatments that are focused on both moving, or dynamic, and non-moving, or static, facial reanimation. Static procedures are focused on improving the overall symmetry of the face at rest, and that includes procedures focused on the brow, the eyes, the nose, the mouth, and the cheek.

Dynamic procedures can bring back facial movement itself, and that includes surgeries that connect working nerves to non-working nerves, as well as surgeries that transplant nerves or muscles from nearby or separate areas of the body.

For patients that have developed abnormal facial movement after facial paralysis called synkinesis, we offer procedures to reduce that abnormal movement, including chemodenervation, or using botulinum toxin injections, or Botox/Dysport/Xeomin, as well as selective neurectomy. And this is cutting nerves that lead to the abnormal movements. We can also cut selective muscles that are moving abnormally.

So there's a variety of ways that we can really delve into exactly what is abnormal for a patient and help them in these matters.

Interviewer: Wow. So you just described quite a few procedures. These are all under the umbrella of facial reanimation?

Dr. Akkina: Correct. Yeah.
What is Facial Reanimation for Bell's Palsy?

Interviewer: Wow. So what kinds of patients are, say, eligible for these types of procedures? Is there anyone that for one reason or another would not be eligible for something like this.

Dr. Akkina: So by group, I'll say, for things like nerve transfers, it's important to know . . . For Bell's palsy, we don't assume that there are other nerves that are affected. But for patients who may have the facial paralysis because of other skull-based tumors or other pathologies that may then affect other nerves, we have to make sure that the nerve we connect to the non-working nerve is going to work, if that makes sense.

Interviewer: Sure. Okay.

Dr. Akkina: For muscle therapies, a lot of patients will qualify for different work such as cutting muscles that are abnormally moving. But for moving muscles, so sometimes if a patient has permanent, abnormal movement of their smile, we can transplant a muscle from their leg into their face to basically recreate their smile muscle movement.

That, of course, does require that that patient's a good candidate to be able to undergo a long surgery where we transplant that muscle. They have good arteries and veins in their face that we can connect it to and are otherwise healthy from other standpoints too.

So, as you can tell, it is pretty individual-based, and that's why it's so important to be able to see a specialist who can talk you through all these different options.

Interviewer: And the specialist that they're looking for is a facial nerve specialist in surgery?

Dr. Akkina: Correct.

Interviewer: I guess this might be a strange question, but considering how tailored and kind of unique it is per patient, what kind of success rates do you see with your patients?

Dr. Akkina: We can get great success rates, especially with nerve transfers. One critical part is that timing is super important. So we talked about for things like Bell's palsy, if you have abnormal movement after three months, you should get immediately referred to a facial nerve specialist. Because overall, for some of these nerve transfers to work, we only have 12 to 18 months before that facial nerve itself may not work very well even if we connect it to a better nerve that can give it more input.

So overall, for the nerve therapies, we really need to see patients, again, ideally within 12 months so we can start planning for whether they may be a candidate for the nerve surgeries.

That muscle transfer surgery can be done essentially at any time. That one we like to wait a little bit longer to know that they won't recover from the other standpoints and that they may not recover from things like the nerve transfers. But that is a really great option for patients who don't qualify for the nerve transfers themselves.

Interviewer: And for the static procedures, it's mostly for cosmetic, mostly for that kind of situation, or . . .?

Dr. Akkina: Both cosmetic and function. So the static procedures, they can really help with, for instance, for the eye work, again, closing the eye. So being able to maybe not necessarily use as many eye drops or have to tape the eye at night, things like that, our eye procedures can give that function back.

Another really great thing is . . . Outside of the symmetry, the nose can be droopy, so a lot of patients have nasal obstruction. And some of our static procedures, one called a static sling where I take fascia from the leg and reattach it to parts of the face, bring back basically support of the nasal valve and support of the mouth, so it's not drooping so much.

So it helps both the appearance of the face and the function in terms of that droopiness, which is why a lot of patients have difficulties with chewing food or keeping food and liquids in their mouth. So the static procedures can help both of those aspects.

Interviewer: We're just not necessarily replacing muscles or reconnecting nerves.

Dr. Akkina: Exactly.

Interviewer: We're doing structural things. Okay. Interesting. So what are some of the potential complications that come with these types of surgeries?

Dr. Akkina: Yeah, one of the main complications is sometimes for the nerve transfers, the nerves unfortunately don't connect as we like or don't eventually function as we like. But we do like to work with our physical therapists very intimately for those procedures as well, to teach patients how to use those new nerve connections.

One example is that we can connect a nerve that controls one of the muscles of mastication, or one of the muscles that's responsible for us closing the jaw, back to the facial nerve. But that does mean that a patient essentially has to clench their jaw to activate their smile. So there are different physical therapy things to learn about that, to teach a patient how to use their new nerves correctly.

Some of the complications that always exist for surgeries are things like bleeding, infection of the site, sometimes failure of the static sling procedures where we don't get as much of a lift of the face as we want, as well as ultimately relaxing of the face again.

Gravity wins always at the end, so even if we do these procedures when a patient is, say, in their 30s or 40s, over time the face will continue to droop and may need additional procedures in the future.
The Cost of Facial Reanimation for Bell's Palsy

Interviewer: Well, this is kind of really exciting to hear about all the potential ways that we can work on this, but what does this kind of procedure cost and is this something that is covered by insurance?

Dr. Akkina: Great question. So this procedure is typically covered by insurance. That's the number one thing, especially for things related to overall facial paralysis. Typically, insurance will cover any procedure related to that facial nerve motor dysfunction.

There are insurances that won't cover some smaller procedures. Sometimes things like the brow lift on that side of the face, because it is very focused on the symmetry and appearance of the face, has difficulty getting covered by insurance. But for the most part, a lot of these advanced procedures we've discussed will be covered.
How to Choose a Facial Nerve Specialist

Interviewer: So we've got a patient, and they're dealing with this kind of long-term facial paralysis. What should they be looking for in a doctor? If they want to explore some of these potential facial reanimation options, what kind of doctor are they looking for, and are there any particular trainings or certifications or something that they should be searching for?

Dr. Akkina: Absolutely. The first thing I'll note is that taking care of facial nerve disorders is a team sport. So we have, in our facial nerve center, multiple specialists from different aspects that all come together to collaborate and care for our facial nerve patients.

So our team includes experts in facial plastic surgery, neurotology, otolaryngology, head and neck surgery, oncology, ophthalmology, facial nerve rehabilitation. So you can get a sense that there are so many different aspects that we can come together to treat for patients.

And each specialist focuses on their area, but certainly in a facial nerve center setting, we can all basically collaborate on our individual aspects.

Initially, I think it is important to see a specialist who's at least aware of many of the procedures and treatments that we can offer. So, typically, facial plastic surgeons or even some neurosurgeons are focusing their practice on these areas.

This is an exciting field where we do have development of new techniques and new practices that are coming out each year. So being at an academic center can also really help because specialists in these centers are usually up to date on the latest knowledge, if not performing some of these trials and experiments ourselves. So going to folks who are most up to date on what's going on, I think, is also important.

For facial plastics, there are board-certified surgeons who have additional training and are, again, certified on a particular level with that training. So I would recommend always seeking a board-certified surgeon, especially moving forward with the surgical treatments.

Interviewer: So I guess look for a board-certified surgeon maybe at an academic center, or just look for that doctor that will be able to help you get the type of treatment that you need.

Now, as a patient who might be first starting out onto this, first looking into potential options, or a loved one of a patient, what is the message that you have for them in kind of starting this journey towards facial reanimation?

Dr. Akkina: Yeah, my main message is that, one, you're not alone, and two, there are ways that we can help. Even if that's mainly connecting a patient with a therapist to work on facial retraining or discussing some of these more advanced, both surgical and injection options, there is likely a way that we can help. And we want to work with you and evaluate all these aspects that you're going through.

Places like a facial nerve center will have multiple specialists who are all geared towards helping this very special patient population. So we want to help you. Please come find us.

Interviewer: You've already tried mood-balancing medications such as SSRIs and cognitive behavioral therapy to treat obsessive-compulsive disorder or major depressive disorder, and those treatments aren't working. You're not alone. Treatment-resistant OCD and depression isn't uncommon.

Matter of fact, it's estimated 40% to 50% of OCD patients are considered treatment resistant. And when those first-line treatments don't work, many explore surgical options.

Dr. Ben Shofty is a neurosurgeon from the Clinical Neurosciences Center at the University of Utah Health and is an expert in surgical treatments for OCD and MDD.

And today, we're going to learn about common surgical treatment options that are providing hope to those with treatment-resistant OCD and depression.

Dr. Shofty, how long does a patient need to be on standard treatments until they're considered treatment resistant?

Dr. Shofty: For a patient to be even considered for therapy, they have to have availed all other therapeutic options, especially the non-invasive ones, which mainly consist of drug therapies, SSRIs, SNRIs, and tricyclic antidepressants, and behavioral therapies like psychotherapy, exposure and response prevention, and cognitive behavioral therapies.

Interviewer: And how long does somebody have to be on the non-invasive types of treatments before they can be considered nonresponsive? Is that a year or longer than that?

Dr. Shofty: Usually, we are looking at patients that have been suffering from the disease at least five years.

Interviewer: Before we head to some of the specifics about the three different treatments, some common questions that might come to mind when treating OCD and MDD with surgical procedures. First of all, in general, are the treatments effective?

Dr. Shofty: The treatments are super effective. Considering the fact that these patients are usually patients that have failed everything else, I think the treatments are life-changing.

Surgical treatment for OCD has been approved by the FDA for more than 10 years, and recently we had a lot of good high-quality data from around the world, in the United States, Europe, and even Australia, that show about 60% to 70% of patients respond to treatment and their disease improves by roughly 40% to 50%, which is a huge change. I mean, these patients can actually go back to living a relatively normal life.

Interviewer: So, I hear those numbers, and in the real world, that is a significant difference.

Dr. Shofty: That's a huge difference, yeah. That's a life-changing difference. Even some of the patients that we do not classify as responders because they only had 30% improvement in their disease metrics, this is a huge improvement even if they're not officially defined as responders.

Interviewer: And surgery can be kind of scary. Do you find that the patients that come in tend to be a little apprehensive about getting surgery for their condition or are they at a point where not so much because they're just looking for any sort of help?

Dr. Shofty: These patients are usually desperate. I mean, they've exhausted every other therapeutic option out there, including a lot of well-based therapies and some experimental therapies, and this is pretty much their last resort.

I also think over the last 10 to 15 years, there has been such a technological improvement in our ability to perform these surgeries safely. And these are quality-of-life surgeries, right? We're trying to improve these patients' quality of life.

So, these are super safe surgeries. Usually, there's a day of recovery inside the hospital, and then the patients go home the following day and go back to their normal lives pretty soon after the surgery.

Interviewer: Then after the procedures, and I realize that for each one it might differ and for each person it probably differs as well, but how long until patients start kind of seeing results?

Dr. Shofty: These are chronic diseases. Patients have been living with them for many years, usually anywhere between 5 and 30, and it takes time for the effect to sort of fully manifest itself. We don't talk about success of therapy at least until six months have gone by. Usually, the maximal effect is witnessed within a year.

Interviewer: When treating OCD and MDD with surgery, generally how do these surgical treatments work?

Dr. Shofty: Our main advancement and the main reason that these therapies are becoming so efficient these days is that we finally understood that it's not a single area of the brain that's not working well, but it's a network, which means that a few, two or maybe more, different areas of the brain are not talking to each other in the way that they should.

And once we've understood that, we can look into a specific patient's disease and the way his brain networks are sort of modulated or altered or working differently, and we can try and target that specific area and that specific place in the brain which is causing this miscommunication.

Once we do that, once we figure that out, the tool that we use doesn't really matter. I mean, we can choose from our sort of toolbox the perfect or the best treatment and sort of tailor the therapy to that individual patient.

Interviewer: That's incredible that you're able to trigger . . . you're able to pinpoint exactly where you need to go and what you need to do in each area.

Dr. Shofty: Yeah. And I think that's the main reason why these therapies are becoming better and better, because our ability to understand the specific patient and the specific patient's disease is becoming better.

Interviewer: And what are some other of the new developments that have allowed this treatment to be so successful?

Dr. Shofty: So, we have a bunch of tools that have become better and better over the last years. One of them is DBS, Deep Brain Stimulation, in which we have newer electrodes and newer devices that can provide smarter and more sophisticated stimulation to the area of the brain that we want to affect.

Interviewer: And Deep Brain Stimulation, I've heard of that before for other conditions.

Dr. Shofty: Yes, it's been around for almost 30 years. It's been used widely for movement disorders such as Parkinson's disease and essential tremor and others, and it's been FDA approved for OCD for more than 10 years.

Interviewer: So, Deep Brain Stimulation might be a procedure that would work for one particular patient. What are other options that are in your toolbox that might work for somebody else?

Dr. Shofty: One of them is creating a lesion or severing a specific bundle of fibers that sometimes causes severe OCD. We can do that today in a minimally invasive approach using laser fibers and under MRI guidance so we know exactly what we're burning and we are just damaging that specific fiber bundle inside the brain.

Interviewer: And with a tool like that, when you're damaging that specific fiber bundle, are there other side effects that might arise out of that?

Dr. Shofty: The reason that this approach was developed is to minimize the side effects, because you are only hitting the sort of damaged part of the brain that you want to affect. And when people used to do that 20 or 30 years ago, they didn't have all these sophisticated tools and they caused more damage than was probably needed. So, today we actually err on the safer side and do less damage.

And then if we have to enlarge the treatment, we can go back in and do it again. It's minimally invasive. Patients go home the next day. There are barely any incisions, so the recovery is super quick.

Interviewer: The third option is Vagus Nerve Stimulation or VNS. How does that work?

Dr. Shofty: So, VNS is an approved therapy for patients with the treatment-resistant depression. It is a peripheral neurostimulator. It connects to the vagus nerve, which then carries the electrical stimulation to the brain.

Interviewer: What is the biggest barrier or reason why somebody doesn't pursue a surgical treatment for their OCD or MDD?

Dr. Shofty: So, I think that there's a knowledge gap with our sort of community providers and community psychiatrists who are not always aware of the modern sort of surgeries and therapies that we can offer these patients. They're also not always aware of the recent advances and publications that have shown that these treatments are safe and highly effective for these specific patients.

Interviewer: Yeah. Somebody like you, this is all you pay attention to, so of course you would know about it.

Dr. Shofty: Yeah, exactly. I mean, medicine is so subspecialized today that it's hard to keep track with all the recent advances. But I think there are a lot of recent advances that have been published that show and support these approaches for these patients.

Interviewer: How should a patient bring this up with their primary physician that they're working with for their OCD or MDD if they're interested in a surgical option and it hasn't been offered?

Dr. Shofty: I think that if you've exhausted all other treatment options, you should bring it up just like that. "I've heard that there's a new psychiatric neurosurgery center at The U and I wanted to consult with them. Is there a chance you can refer me there?"

And we have a quick screening process that allows us to sort of say if the patient is a possible candidate. And for possible candidates, we have a very fast-track assessment process.

The second barrier is to be insurance. I think over the last four or five years, insurance companies have started understanding it's actually cost-effective to approve these surgeries for these patients. And Anthem has actually made a significant policy change and have added DBS for OCD as a medical necessity in their guidelines. So, I think it's easier today to get insurance approval for these procedures.

Interviewer: Well, I'd imagine that there's somebody listening that is very interested in a surgical option at this point given the success rate and given the change in somebody's life. Tell me a brief story as we wrap this up of somebody who came in, had the procedure, what they were like, and then . . . what their life was like, and then had the procedure, and then what their life was like after.

Dr. Shofty: So, we've had an OCD patient who was basically house-ridden for more than three years. Every time he needed to go out of his house and come back, it used to take anywhere between four and six hours going back from the front door to the living room because he had to do so many rituals and so many compulsions. We've operated on him successfully, and six months later, he's back to work. He still has OCD, but he manages it.

One of the good things about these therapies is that they allow patients to respond to medical treatment and to psychological treatments such as exposure and response prevention, which they did not respond to before surgery. So, it's not only the effect of surgery, but it's the effect that it enables them to respond to other types of therapies.

And a lot of our patients have a similar story. They just went back to living a normal life with the disease and not living just under the disease.

Interviewer: After a person has experienced major weight loss, either through lifestyle changes or something like a bariatric surgery, you may be left with a bit of excess skin that just won't seem to go away. And there are a few surgical options available to help remove that skin. Dr. Brad Rockwell is a professor of plastic surgery at University of Utah Health.

Now, Dr. Rockwell, when it comes to the excess skin from weight loss, how common is it for someone to have excess skin that just won't seem to go away?

Dr. Rockwell: Oh, virtually 100%. Unfortunately, as we get older, our skin loses some of its collagen, loses some of its elasticity, and the skin will become loose. So, even at certain ages of maturity, even if someone is not overweight, they will still have some lax skin in their abdomen. For everyone that's lost weight, virtually 100% will have some extra skin that could be improved with abdominal surgery.

Interviewer: So the surgery is an abdominoplasty, correct?

Dr. Rockwell: Correct.

Interviewer: And it's my understanding that there's a gradation of how much skin, and that kind of relates to what kind of surgery that you as a plastic surgeon would perform. Why don't you walk me through some of these treatments and kind of walk me through how they work and what a patient could expect?

Dr. Rockwell: There's the standard abdominoplasty. The non-medical term for that is tummy tuck. That's also essentially one of the main components of a Mommy Makeover. But it's just loose skin in the abdomen. In addition to the loose skin, usually the muscles beneath. If it's in a female who's had a pregnancy, the muscles will be a little loose. The skin may have some redundancy.

And the standard abdominoplasty or tummy tuck will remove skin in the lower portion of the abdomen. The skin that is higher on the abdomen is stretched to close where the skin was removed. And in addition, the six-pack muscles or rectus muscles are tightened and that will narrow the waist.

Interviewer: Okay. So it's not just the skin that you're operating on. It's also the muscles underneath?

Dr. Rockwell: Right, by tightening the underlying muscles. No muscle is cut. No muscle is thrown away. The muscle is still fully functional. There's some experimental evidence that actually shows the tone in the muscle is increased and athletic performance may be boosted a little by tightening the muscles. But the muscle is tightened. That will narrow the waist and that actually allows more skin to be removed because the inside becomes a little smaller.

Interviewer: Ah, got you. So what's the next stage of treatment?

Dr. Rockwell: So the standard abdominoplasty that we just talked about will pull the skin from the upper portion of the abdomen down lower and remove skin in the lower abdomen. Some people who have lost more weight will have a vertical skin redundancy and also a transverse skin redundancy. So the skin can be tightened by pulling it down, and the skin could also be tightened by pulling each side towards the middle of the abdomen.

The standard abdominoplasty leaves a longer scar in the lower abdomen. It goes from one hipbone to the other hipbone. The second stage does everything that a standard abdominoplasty would do, but in addition tightens skin from side to side, and that leaves an additional scar along the vertical midline of the abdomen. It goes from the bottom of the breastbone down to the pubic bone.

Interviewer: Okay. And so that's for, say, someone who has additional excess skin on the sides, love handle area, or . . .

Dr. Rockwell: It would be someone who's probably lost 50 pounds or 100 pounds. Standard abdominoplasty, maybe the people haven't lost weight. Maybe they've actually gained a little bit of weight from their younger days.

So this second stage, which is also called a fleur-de-lis, which is a French term, that will tighten side to side. And most of those people have lost probably 50 to 100 pounds.

Interviewer: And so as we go onto the last stage, this is for people who have lost a lot of weight. Tell me a little bit about this Stage 3. And I hear that it was a procedure that was developed by someone from the University of Utah?

Dr. Rockwell: Yeah. So the third stage is called a corset abdominoplasty. Dr. Alex Moya, who was a plastic surgery resident at the University of Utah in the early 2000s, now practices in Pennsylvania, and he developed this surgery.

So it incorporates everything that a standard abdominoplasty would do and everything that a fleur-de-lis abdominoplasty would do. And in addition, he pulls skin from the upper portion of the abdomen up towards the chest. The downside of it is it adds a scar right under the chest, or in women right under the bottom of the breast. But it allows even more skin to be removed compared to the other two options.

Interviewer: When it comes to deciding which surgery to do . . . I've heard you kind of discuss it depends on how much weight has been lost, how much excess skin. How much does the scarring come into that decision-making?

Dr. Rockwell: For most of these people, scarring is a secondary concern. Removing the extra skin is more of a concern. Obviously, if someone is in clothing, the scars are not visible at all.

And the majority of people who have the fleur-de-lis abdominoplasty or the corset abdominoplasty may not be on a beach exposing their abdomen. They may have little more modest clothing to cover it up, and then the scars would not be visible at all. But even if they're in that clothing and had not had surgery, the redundant skin and the rolls of extra skin would show through their clothing.

So, for most of these people, the priority is removing as much skin as possible, and the secondary concern would be the scarring.

Interviewer: So, for patients that are choosing to have this procedure done, is it an outpatient procedure? Are they in the hospital for a few days? And how long does it take to get back to your day-to-day life?

Dr. Rockwell: So just about everyone that has any of the three versions of a tummy tuck that we have discussed, it would be performed as an outpatient. The reasons to stay overnight would usually not be specifically related to the involvement of the surgery, but would depend on pre-existing medical conditions.

So if someone had lung trouble or heart trouble and their lung doctor or heart doctor might say, "You need to be monitored overnight in the hospital after that surgery," that would be the reason to stay. But most of them, it's an outpatient operation.

Interviewer: After they get home, what is the recovery time, and what are the steps of recovery, and how long will they expect to be recovering for?

Dr. Rockwell: So if someone has a desk job, they would probably be able to return to a desk job after two weeks. If they have a job that's a little more physically demanding, maybe three weeks.

In tightening the muscle, there's a six-week recovery period to resume exercise. Where the muscle is tightened, it takes six weeks for the muscle to heal where someone could attempt to do a sit up. So the long point of recovery would be six weeks to resume exercise or six weeks to lift more than 10 to 15 pounds.

Interviewer: So, for patients that might be interested in a procedure like this, what should they be looking for when it comes to choosing a good surgeon who will be able to give them the best results possible?

Dr. Rockwell: So none of these options of an abdominoplasty are small operations. They usually require between three and maybe six or seven hours in the operating room. So you want to make sure you have a qualified surgeon.

The best level of qualification that the public could find out about a surgeon is to make sure the surgeon is board certified. And for this type of surgery, make sure they're board certified by the American Board of Plastic Surgery. There are non-plastic surgeons who offer this surgery, but their background training would not be as rigorous as a board-certified plastic surgeon.

Interviewer: And I guess the last question is what are some of the positive results that people see? Are most people happy with the procedure? What can a patient expect after they're all healed up and back to their lives?

Dr. Rockwell: Yes, I think universally the patients are happy. The extra skin is gone. The satisfaction is largely patient-derived where the abdomen is closed. There's not a lot of positive reinforcement from other people because other people aren't seeing it.

But the patient himself or herself just feels much better. Their confidence increases. They find clothing will fit differently. They can buy clothing more easily because they're more a standard size. And if exercise is an option, that extra skin, extra fat is not there, and just normal everyday moving around is easier and exercise is easier.

Interviewer: You don't realize how much you really use and depend on your thumb until you can't use it anymore because it hurts so badly. And if you're suffering from thumb pain, it can have a drastic impact on your quality of life. Luckily, if you have thumb pain from thumb arthritis, there are some excellent nonsurgical and also surgical options to relieve the pain and get functionality back.

Dr. Brittany Garcia is a hand surgeon and an expert on thumb arthritis. And today, she's going to talk us through both the nonsurgical options to give you some relief from your thumb arthritis and also the surgical options and their effectiveness.

So let's start out here. If somebody has thumb pain, is it a good idea to go see their family doctor or a general practitioner first, or go to a specialist like yourself?

Dr. Garcia: First up is primary care physician because they have a lot of non-operative options that they can offer patients. So, usually, when you present to your primary care, most people will take some X-rays and then they'll be able to parse out, "Are there arthritic changes on your X-rays that we think are probably causing your pain? Or is this something else like the trigger finger, or carpal tunnel, or things like that?"

And then primary care can start with some of the non-operative options, such as splinting, activity modifications, referring to a hand therapist who can work on a home exercise program to strengthen the muscles around the joint.

I like to think of strengthening, which is a really good option, similar to an ACL. So if you've got weak quads and hamstrings and calf, you're probably more at risk of developing ACL tear. Well, similar to the base of the thumb. It seems silly, but you've got lots of small little muscles that attach around the base of the thumb, and strengthening those muscles likely offloads the forces and supports the joint in general.

Interviewer: Let's talk about some of those non-operative treatments first. So are there any downsides to any of those, or is it always kind of a best practice to start with the non-operative stuff first?

Dr. Garcia: Definitely best practice to start with non-operative treatment. And by doing non-operative therapies and trying those first, you don't necessarily drastically change what we're going to do surgically. So it's not like you're losing time or making the surgery much more complicated for us by trying these things first.

And certainly, for some people, while non-operative options don't necessarily take away the arthritis, and we know that, many of them can help quiet the arthritis.

And so the things that come to mind that are most common that we do is bracing, where we do a hand-based brace for the thumb to kind of support it from loading consistently in those types of movements that cause it to be painful. It's basically a rest thing. So if it hurts, then you rest it.

The other things that are commonly used are anti-inflammatory medications, as long as you don't have any other medical problems that would prohibit you from having them, such as kidney disease or issues with your stomach. But anti-inflammatories can be really helpful, both those that you take by mouth, as well as some topical anti-inflammatories.

I like to sell it to you straight. I'm not going to say this is a magical topical cream that's going make you feel 100% better, or take away your arthritis, or anything like that. But the goal with non-operative therapy is really to try to make you more comfortable to be able to do your normal activities of daily living, as well as your hobbies and things that you want to do without having pain that's limiting you.

Interviewer: When you do splinting to help relieve the pain, I thought I had read somewhere that that could relieve pain, but it could also cause weakness, which would be a concern to somebody who does use their hands for a living. Is that true?

Dr. Garcia: That's always a catch-22. Usually, my prescription, when I'm doing splinting with a patient, is I will try to have them wear that splint full time for about six to eight weeks to see if we can calm it down. So that includes daytime and nighttime with the exceptions of taking it off for showering and washing hands and hygiene and things like that.

Theoretically, there's a risk that, because you're not using those muscles, you get some weakening of that muscle. But I think if you can calm down the pain, then you're probably going to increase your function and gain that use back and bulk, so to speak, those muscles back up.

And the other thing is when you're having so much pain, you're probably not using it normally anyway. So there's probably some degree of deconditioning that people get just by having the pain and doing the splinting. But I think if you can get the pain under control by immobilizing that joint, then likely you bounce that back quite well.

And then the other thing I didn't mention, which is a nice non-operative option, is corticosteroid injections or steroid injections, which is commonly used in musculoskeletal conditions to help calm down the inflammation around the joint. So I sort of think of those as you're taking a dose of . . . it's sort of like putting ibuprofen right inside the joint to calm down inflammation.

"Itis," which is the end part of arthritis, is inflammation, so really this is an inflammatory process that's caused by the joint being overworked or overloaded. So putting steroid in that area can help calm down that inflammation and give people some pretty good relief.

Interviewer: Are there any downsides to the steroid injections?

Dr. Garcia: I like to use steroid injections for people who respond well to them and get a fairly long-lasting effect. It's really hard to predict exactly who's going to respond to them or who's not. And even if you've had an injection in the knee or the shoulder and it hasn't worked as well, it doesn't necessarily mean that it's not going to work in your hand. I've definitely had patients who've had injections in other places that haven't worked that well, and it's worked really well in the hand.

Interviewer: For surgical treatments, talk me through what considerations you have there. I think there are two different types of surgery, or is there just really kind of one that you tend to use most of the time? Help me understand that.

Dr. Garcia: There have actually been lots of different ways described to take care of arthritis here. Basically, they all culminate on taking out the trapezium bone, which is a small, little bone in the wrist that makes up the joint at the base of the thumb. And this is where most of your arthritis at the base of your thumb typically goes. So regardless of which type of procedure people choose to do, usually it all begins with taking out the trapezium.

And then there are a number of things that can be done to sort of stabilize or support the base of the thumb after you've taken out that little bone. That bone typically supports your metacarpal bone, which is the longer finger bone. It sits on that little bone.

So most people will take out the trapezium and then you can do a number of tendon-type procedures to support the base of the thumb. I like to do something called the suture suspensionplasty, which is where you take two of the tendons that are nearby and you suture them together underneath the metacarpal bone, which sort of acts as a soft tissue hammock or supportive structure for the base of the thumb now that that little arthritic bone is out. But people do a number of different iterations of that particular procedure.

Interviewer: And then after you get that procedure done, the goal is to reduce pain and improve functionality. How successful is that procedure at doing those two things?

Dr. Garcia: This CMC arthroplasty, which is what we call our surgery for this condition, is something that takes a long time to recover from, but people typically are very happy once they get recovered. So usually it involves some sort of immobilization like casting or splinting for about three months, exercises with our hand-specific occupational therapist to get the thumb back in good working condition and strong and get the range of motion back.

So people are sore for three to six months, but once they . . . They're slowly getting better, and once they get to kind of their maximum, I guess, potential of recovery, people are typically really happy with this surgery.

Interviewer: And that treatment, that pain relief will last for a while? The mobility will last for a while?

Dr. Garcia: Yeah, the goal is for that to kind of be one and done for people, that they get the surgery and then most people don't need any sort of revision surgeries or other procedures down the line for it. It typically takes care of it for the duration of their life, which is the goal of it.

Interviewer: And you've removed a bone, so is there going to be from a mobility standpoint anything different? Or when you go in and you make the other adjustments, it usually takes care of that?

Dr. Garcia: When we put the sort of supporting stuff at the base of the thumb, typically, people have pretty good motion. Obviously, after you come out of your splint or your cast after surgery, everybody is stiff. And any surgery around an area will make you stiff, particularly in the hand. But it doesn't necessarily take away motion.

Certainly, we have other options for different types of arthritis in your hand where we're actually fusing joints, and those are types of procedures we're definitely . . . you're very clear preoperatively with patients that they're going to lose motion at the joint that you're operating on. This is not one of those where we're talking to them about drastically decreasing motion.

Usually, people are using their thumb better because it no longer hurts. And so once we get them through that initial therapy period of getting the swelling down and the stiffness from surgery down, people's motion comes back pretty good.

And then the other thing I wanted to bring up, because we see it not infrequently, is carpal tunnel. People who have arthritis at the base of the thumb, we see in about 30% of patients, they also have carpal tunnel symptoms when they present to clinic. So that's always something that we're looking for at the same time because we don't want to miss that and not release their carpal tunnel if it's surgically something that makes sense based on their exam.

So any time they're coming to clinic, we're always teasing out, "Is your pain due to arthritis at your thumb? Is it due to the carpal tunnel? Is it due to both? And how much is contributing to what's going on?"

Interviewer: Oh, so you can get both of those done kind of at the same time.

Dr. Garcia: Exactly.

Interviewer: Dr. Garcia, that is some great information. I hope that it helps some people find some relief from their thumb pain and thumb arthritis. Before we go, though, do you have a takeaway, something we should take away from the conversation today?

Dr. Garcia: The most important thing is to know that we've got lots of options, both non-operative stuff that works really well and can get many people through without needing surgery, and then we have a good surgical option. It's just important to know that with the surgical option, there's a reasonable amount of recovery that goes along with it.

Interviewer: So maybe you or a loved one has a bony protrusion on your foot. It's maybe painful, maybe not. It's a bunion. How exactly does one treat a bunion and what kind of results can one expect from the treatment options?

We're here with Dr. Devon Nixon. He is an orthopedic surgeon at University of Utah Health, with an emphasis on lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, before we kind of go into treatments, let's just start real basic. What is a bunion exactly?

Dr. Nixon: A bunion is an interesting thing that we see really commonly in clinic. It's more than just a bump that's forming on the inside part of the big toe. What's actually happening is there's a complex three-dimensional change that's occurring where one portion of the toe is beginning to move towards the inside, which then drives the big toe part towards the second and third toe. And it may begin to even cross over under those second and third toes.

Interviewer: And is there any way to, say, prevent them?

Dr. Nixon: I wish there was a way to prevent them. They're very common, and certainly not everyone with a bunion needs surgery. And so there are plenty of things to do to try to make them more comfortable, like modifying your shoes or adding a toe spacer. But unfortunately, those options don't necessarily change the long-term progression, which is that the bunion may slowly increase over time.

Interviewer: So let's go back a little bit with that. When you're talking about treatments, you said it's not necessarily surgery. If we're not doing surgery, what are the other options available, and what are you actually treating with those?

Dr. Nixon: Like most things in my practice and in most orthopedic practices, there are nonsurgical and surgical treatments. And the nonsurgical things that many patients choose to do are to add some modifications to their shoes. So they get them in wider forms to help reduce some of the irritation on the inside part of the big toe, which, for many patients, is one of their biggest pain drivers.

Another thing is they can add over-the-counter gel inserts that slide between the big toe and the second toe to help push the toe a little bit out of the way to make it more comfortable.

And those are all driven based on symptoms. So the choice of whether or not to move forward with surgery is a patient-driven choice. It's certainly not one that I will make for them. My goal is to help them have the information they need to make the right choice.

But the options after modifying your shoes and adding an insert, there's not a lot of in-between. So, unfortunately, the conversation may then move towards, "What are my surgical options?" which are to help get the toes straighter and to help remove the bump.

Interviewer: So let's move on to those surgical options. As an orthopedic surgeon, any time a patient hears the word "surgery," there's a little bit of anxiety. There's a little bit of weighing the risks and benefits. Kind of walk us through the surgery. Not necessarily the nuts and bolts of everything, but as a patient, is this an outpatient procedure? How long can I expect to recover, etc.?

Dr. Nixon: Absolutely. I mean, I'm a surgeon, but I'm extremely sensitive to the fact that no one wants to go through surgery. And my job will never be to sell anyone on the surgery. It's the patient coming in to tell me that this is what they think is the best option for them. They feel like they've tried these other things.

And then the different technical options for surgery vary from patient to patient. So it's driven by a lot of factors, some of them clinical, some of them on the X-ray, some of them very patient-specific.

But largely, what we're doing is we're trying to correct the bunion by straining the big toe. And you can do that by either cutting the bone and shifting it. We call that an osteotomy.

You can fuse certain joints around the big toe. So one of them is fusing a joint closer to the middle of the foot, and we call that a Lapidus procedure.

And then another procedure is, depending on the patient, if they have some arthritis that's developed, you can fuse the actual big toe joint itself.

But a lot of these decisions of what to do from a surgical perspective are not uniform to everyone. So that's a conversation that we all have in clinic. If patients feel like they're at a surgical level, I look at the X-rays, I talk to them, get a good history, understand their activity level, what are their goals, and if there's any arthritis present, and then we talk about, "What are these varying treatment options?"

Interviewer: So a surgery like this, how long can someone expect to be undergoing treatment? How long does the procedure last and how long is recovery?

Dr. Nixon: Yeah. The surgery is an outpatient procedure. You go home the same day. The main goal is that . . . Depending on which type of surgery to do, it doesn't really change the fact that for the first four to six weeks, we're going to be keeping you off of your foot in terms of full weight out at the big toe.

If we're cutting the bone, doing what we described as an osteotomy, we need that bone to heal. And if we're trying to get joints to fuse, then we need those bones to heal together too. And so there is a form of protected weight-bearing, which can be challenging if it's your right foot because it's going to limit your driving.

But the first two weeks, you have sutures in. They get removed at two weeks. And then between Weeks 2 to 6, you're kind of protecting your foot, and then usually get X-rays around the six-week mark. Depending on the type of surgery you had, we may begin to advance your weight-bearing so that you're putting more full weight on the big toe.

Interviewer: Now, is there much physical therapy or anything involved with this particular procedure?

Dr. Nixon: Physical therapy is certainly a very reasonable thing to consider. And for some patients, they think that it's helped them considerably. Some of that depends on the type of surgery and the surgeon's specific decision-making. Not all bunions need physical therapy afterwards, but certainly plenty of patients that I operate on benefit greatly from physical therapy.

Interviewer: And what is the success rate for a procedure like this?

Dr. Nixon: It depends a little bit on the operation you do. So one of the things that we're trying to address if you have both a bunion and arthritis, if you have the big toe joint fused, and if that goes on to fusion, which can occur in about 90% or so of patients, then those are some of our happiest patients. They do quite well. They can remain very active.

The downsides to a fusion are that it does limit the motion in the big toe. So getting back into high heels is challenging. Getting back into certain types of activities, like certain yoga poses, the toe just won't let you do that. So that is one of the downsides, but it certainly is a very powerful and successful operation.

If we are preserving the joint and we are cutting the bones, then patient satisfaction is usually in the 80% to 90% range. Patients do quite well from those operations.

Whichever one you choose, they do require some level of recovery. And I would be lying to you if I said that it's a fast recovery. Some patients recover faster than others, but the first couple of weeks, there's going to be some swelling involved, so it's really important to keep it elevated. But as you begin to progress your recovery, you'll begin to get that swelling down and hopefully be able to quickly transition back into regular shoes, as we allow you to, once we get X-rays that confirm that everything has healed up well.

Interviewer: What is something that you as a surgeon would tell to give that last bit of kind of confidence to someone who's considering bunion surgery?

Dr. Nixon: I think what's really important is that the decision-making is all by the patient. My job or any of my partners' jobs is just to make sure that you have the right information to make the decision.

And at the end of the day, patients can get a lot of good pain relief and a lot of satisfaction and a lot of improvement from having their bunion corrected, whichever method you choose.

And like most things in life and in medicine, they all have some form of a pro and con weighing, a pro and con assessment, but whichever one you choose, patients do quite well from these operations. There is a recovery involved, but ultimately, patients do quite well.