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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 if you've been on social media lately and follow any of those pimple popper videos or whatever, you may have heard of a ganglion cyst. It is a small bump that usually shows up on the hands or the joints. And online, they'll tell you to pierce it with a needle or hit it with a big old book. We're going to find out if that's the right way to treat these big old cysts.

Joining us today is Dr. Brad Rockwell. He is a professor of plastic surgery and he works with hands.

Now, Dr. Rockwell, when it comes to a ganglion cyst, what is it?

Dr. Rockwell: All of our joints have fluid inside that's somewhat similar to oil to keep the bones moving freely. And around the joint, there's a skin layer that keeps the fluid inside the joint. If that skin layer gets a little weak spot, it can form a bubble and the normal fluid that's in the joint can enter that bubble. It stretches out that skin lining and then the bubble can get bigger and bigger. And eventually, that bubble can work its way up to be visible beneath the skin. And that's a ganglion.

Interviewer: So it's not just when you see pimple popper videos or whatever online it's oil or it's trapped dermatological fluid. This is something that your joints need to function correctly.

Dr. Rockwell: Yes. It's just normal structures that have moved outside of the joint and usually form under the skin. But they still have an attachment to the joint.

Interviewer: Oh, wow. Okay. And do they only show up on the hands, or can they show up in any joint?

Dr. Rockwell: They can show up in any joint. There are some that are more common. Palm side of the wrist, the back of the wrist, or the end joint in the finger are common spots. But the back of the knee is another common spot where orthopedists would treat ganglions.

Interviewer: Now, is there anything in particular that causes them? Any cofactors or anything, or are some people just more predisposed to having these, some activities that they do?

Dr. Rockwell: Most of the joints, we don't know. They may, to some degree, be arthritis-related, but most of the ones in the hand at the wrist don't have a specific arthritic etiology. At the end joint on the finger, there's a definite arthritic etiology. There's, in general, a bone spur that's there. The bone spur rubs on that skin inside joint layer and weakens it and allows the bubble to form, which becomes the ganglion.

Interviewer: Now, is there a way to, say, identify that it is a kind of ganglion cyst or it's one of these joint fluids, not something else that you should probably not be popping anyway?

Dr. Rockwell: Most times a doctor could look and tell. In general, where a ganglion is there is not something else comparable that would be in the same spot.

For a patient, they may notice that it increases and decreases in size. It is normal joint fluid that's beneath a stretched-out joint lining skin layer. Occasionally, that lining that contains the fluid can weaken and develop a little hole and the fluid may escape from the ganglion, and then the fullness will go away. The fluid escapes under the skin and gets resorbed. There are no symptoms associated with that.

So if someone notices a mass over the joint that gets bigger and then gets smaller and gets bigger, that's going to be a ganglion.

Interviewer: All right. So we now know what these things are, where they come from. Now, I've seen some pretty gnarly videos on the internet. Why or why not should someone pop them or hit them with a book?

Dr. Rockwell: Well, deflating a ganglion in the end is a good treatment. There's a medically appropriate way to do it. Popping it at home or hitting it with a book to try to rupture that skin layer may accomplish the same endpoint, but the body won't necessarily see it as a friendly way to treat the ganglion.

So, in the office, rather than popping it, we will put a little needle into it and drain the fluid. So put some lidocaine in the skin to numb the skin, clean the skin well, and then put a needle in and drain the fluid out. And about 20% of the time, that will be successful in treating the ganglion.

Eighty percent of the time, unfortunately, the fluid will recur. And then it can be drained again, although most likely if it recurred once, it will recur again. If it recurs once, surgery is the best option to resect the ganglion down to the level of the joint.

Interviewer: What are some of the potential dangers of, say, doing it at home by yourself? It's not just a big pimple on the back. This is something that's connected to your joints.

Dr. Rockwell: Yes, exactly. It's a fluid-filled cavity that has a connection to the joint. So if it's popped at home and an infection develops in the ganglion, the infection has a very short direct route into the joint. And an infected joint would be a horrible outcome from ganglion treatment.

Interviewer: Geez. So say someone finds themselves with a ganglion cyst. They now know, "Hey, don't treat it at home." What kind of doctor should they be going to? Is this something that you go to a primary care physician, an InstaCare, a dermatologist?

Dr. Rockwell: So if it's in the hand, it should be a hand surgeon, and hand surgeons are either orthopedic-trained or plastic surgery-trained. If they're in other joints, most likely it would be an orthopedist.

Most of the other bigger joints in our body, the ganglion would be deeper under the skin or the patient may not actually know there is a ganglion there. But if they have arthritic trouble and are seeing a rheumatologist or an orthopedic surgeon for the arthritis, the doctor would recognize that the ganglion is there and then suggest appropriate treatment.

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.

Interviewer: Three types of surgery can be used to treat craniosynostosis, which one depends on a few different factors. If the synostosis is caught early enough, the newer endoscopic procedure can be used.

Pediatric plastic surgeon Dr. Faizi Siddiqi and pediatric neurosurgeon Dr. John Kestle are here to discuss the three different types of surgery for a synostosis and why they would consider one over the other. So, first of all, how early does a child need to see you for the less invasive endoscopic procedure to be an option?

Dr. Kestle: So the endoscopic method we've been doing since '07, and we've found that the best time to do it is usually between two and three months of age. So we have to see the patient before that and the earlier the better. The surgery is done under a general anesthetic, and the surgery typically lasts about two hours, and most of them spend one night and can go home the next day. Occasionally, they need two nights. It's done with, for example, sagittal synostosis with two incisions -- one just behind the soft spot and one toward the back of the head. And then we work under the skin to remove the fused bone.

Removing the fused bone doesn't really change the shape much at all immediately. It just releases the bone. And then about two weeks after the surgery, they start wearing a special helmet that's designed for surgical patients, that is a little snug front to back and a little loose on the sides, and it just guides the growth so that as the baby's head growing, it's taking on a more normal shape. They wear the helmet for about six months, some shorter, some longer, and we just monitor the growth pattern and make that decision. And they'll go through several custom-made helmets over the course of the treatment as they grow.

Interviewer: Generally, I'd imagine a less invasive procedure is always better. Why is this procedure better than say the traditional treatments?

Dr. Kestle: Well, it's got a shorter hospital stay, a much lower rate of blood transfusion. It's a lot less swelling associated with the surgery. It's easier on the babies, and the results are at least as good.

Interviewer: Is there a reason, other than age, why a child would not be eligible for the endoscopic surgery?

Dr. Kestle: We don't often do it in children that have syndromes where they might have multiple malformations in other parts of the body, such as Crouzon syndrome or Apert syndrome. And in addition to those other malformations, they have synostosis. Those children usually need the more traditional, bigger surgery. But any child that has one suture fused is a great candidate for the smaller surgery.

Interviewer: Dr. Kestle, you're a neurosurgeon. So you handle that part of the procedure?

Dr. Kestle: Yes.

Interviewer: Okay. And then Dr. Siddiqi, you're a pediatric plastic surgeon. With the endoscopic procedure, both of you are in the operating room at the same time. Just kind of walk me through how the surgery goes. Dr. Siddiqi, you start the surgery.

Dr. Siddiqi: So we're in the OR together. It's a team approach. So once the anesthesia team have completed their part, which is getting the baby asleep and making sure the IVs are put in and everything is safe to proceed, that's when we position the baby for surgery. I would make the initial incisions. For example, for sagittal synostosis, we make two incisions on the top of the scalp. Again, that's one of the advantages of doing it this way versus the bigger procedure because you have two small incisions. Through those incisions, we expose the area that we want to operate on, which is that fused sagittal suture. And once everything's exposed and visible, then Dr. Kestle would take over.

Dr. Kestle: What we do is remove a little bit of bone under each incision. And that allows us to get underneath the bone. Underneath the bone is a layer called the dura, which is a covering layer over the brain. It's kind of like leather, like a thin leather. And we use the endoscope to separate that layer from the bone, and that allows us to safely cut the bone and remove it. Once the bone is removed, we look at the dura and make sure it's okay. We stop any little bits of bleeding, but there usually isn't much. And we check the bone edges, which sometimes ooze, and make sure that any bleeding is stopped. And then at that point, Dr. Siddiqi and his team continue working.

Dr. Siddiqi: Yeah. So we take out or remove additional segments of bone. There are these little triangles we take out, about four them. Again, afterwards, we make sure that the bone edges are, you know, clean. They're not bleeding. Again, that's one of the other advantages to doing it this way. The blood loss is quite small, minimal compared to the traditional way. Most of the time, it's maybe 10 or 15 milliliters of blood. So once those triangles are removed, then we close the incisions. Then the anesthesia team takes over, and the baby's, you know, woken up and then taken to the recovery room.

Interviewer: What does the recovery look like then for a child? And, you know, what kind of outcomes can parents expect?

Dr. Kestle: With the small surgery, they don't need to go to the intensive care unit. They stay in the hospital in a regular room, and the parents can stay with them. The vast majority of those children are here for one night. Occasionally, they need two nights. The criteria for going home are pain control and feeding. They get some swelling toward the back of the head, that gradually goes down over the first week at home. Stitches dissolve on their own. And within a day or two, they're back to their usual self as far as feeding and behavior goes.

Interviewer: And Dr. Siddiqi, how long does it take for the head then to regain more of what would be considered a normal shape?

Dr. Siddiqi: Yeah. So as Dr. Kestle mentioned earlier on, the shape doesn't change after the surgery, right after. It's once they're in the helmet. The helmet is critical for reshaping the head. And typically, they're in the helmet usually two to three weeks after the surgery. It's a custom helmet. You know, it just guides the growth of the head, and over the ensuing, you know, three to six months, we have a more normal head shape. And hopefully, after six months of helmeting, that's all they need.

Interviewer: And the incisions that were talked about out in the endoscopic surgery, are those visible or are those in the hairline?

Dr. Siddiqi: You know, they're in the hairline. And again, another advantage to doing it this way is the incisions are on the top of the scalp, the head, and those scars heal very nicely. They're quite thin and they're barely perceptible. You only notice them when the hair gets wet. Again, with the bigger procedure, you have a much bigger incision from ear to ear, which is much more noticeable.

Interviewer: Let's talk about the more traditional procedures in the event that a parent is in a situation where their child is older than six months old or there's other reasons why they might have to have that. What are the two procedures, and can you explain those a little bit?

Dr. Siddiqi: Yeah. So sometimes, you know, we do see kids who are, you know, two, three months old and they're eligible for the smaller procedure, but for various reasons, let's say they live out of state or they don't want to do the helmeting, they would like to do the traditional, what's called cranial vault reconstruction with orbital advancement. So then we would wait until they're 10 to 12 months of age to do that procedure. Essentially, that's a much more involved procedure, but it's a procedure that's, you know, well described. People have been doing it for, you know, 30, 40 years. You know, the results that you get are comparable to the endoscopic procedure, but, again, it's how you get there.

So with this procedure, you have to expose the entire skull. So that means an ear-to-ear incision through the top of the scalp. I would expose that, mark out where I want Dr. Kestle to make the cuts and remove the segments of bone that we want to reconstruct and reshape. Then Dr. Kestle would remove those pieces of bone, make sure that the lining of the brain is okay, make sure everything is okay. Then I would reshape all those bones and reconstruct the skull in a more normal configuration, and everything is stabilized with plates and screws. And these are resorbable plates and screws. They dissolve in about a years' time. So we put everything back together and close the scalp. That's a four or five-hour process. Much more blood loss than with the endoscopic procedure.

They typically would go to the intensive care unit for one night, and they typically would be in the hospital three or four nights. Oftentimes there's quite a bit of swelling. The eyes can get swollen shut, and it would take maybe 10 days to 2 weeks for that swelling to go down.

Again, the advantage is you don't need a helmet. It's all done in one stage. You know, the compromise is that it's a much bigger operation.

Interviewer: If parents are evaluating a center or physicians to do this procedure, what advice would you give to them to, you know, pick out the best place for them?

Dr. Kestle: I think it's a procedure that is usually done very safely, and children do very well and go home quickly. We are exposing the layer over the brain, and there is a potential for bleeding. And so I think that experience matters. And I think that you do want to be treated by people who do this a lot and people who can handle problems, which are rare, but if they arise, they need to be dealt with appropriately. So I think it's a big advantage to being treated by people who have experience with this, who are in a children's hospital with pediatric-trained specialists, including anesthesia and a pediatric intensive care unit if they need that.

Interviewer: And you mentioned a third procedure, a cranial vault distraction, when might that be used?

Dr. Kestle: So there are some children where their brain is in trouble or potentially in trouble because they have presented very late or they have multiple sutures that are closed. And in that situation, we want to make the skull bigger to give the brain room to grow. Probably the best way to do that these days is a procedure called distraction, where some implants are inserted and then the skull is gradually expanded over time.

Dr. Siddiqi: You know, with cranial vault distraction, again, the idea is to give the brain as much room as we can because of the fact that more than one suture is fused. And the way that's done is I would ask Dr. Kestle to make some cuts on the bones. And then I would put these little devices, they're called distractors, on either side of the cuts. And then three days after surgery, we would have the family start turning those distractor devices. Typically, it would be total of one millimeter a day. So over the ensuing three to four or five or six weeks, the bones are slowly being separated. And what happens is that, as they're separated, there's new bone being formed in the gap. And over time, that new bone will solidify. So we're not only expanding the volume for the brain, we're also creating new bone. This is really the only way we can expand the brain to this degree using these devices. We couldn't do it as a single-stage procedure.

Interviewer: Between the two procedures, the endoscopic procedure, the less invasive, and the cranial vault reconstruction, are there any tangible differences and outcomes or how the head is going to look or anything like that?

Dr. Siddiqi: I would say like the overall head shape is probably going to be comparable, just the head shape itself. But again, as I said, it's how do you get there? You know, how long does it take? What are the risks involved? In terms of the shape itself, with the endoscopic procedure, overall the head feels and looks quite smooth at the end of the day when everything is healed. Whereas with the bigger procedure, you know, we're taking all the bones out or in multiple pieces, putting it back together. So when everything is healed in a year, two, three years' time, you do feel some irregularities over where the bones are joined together. But overall, the head shape is probably comparable. But, you know, I think you get an overall smoother head shape. And I think it probably looks a little bit better as well.

Dr. Kestle: And obviously, the scar is different as well. In the endoscopic, there's two scars on the top of the head that hide really well. And the bigger surgery has an ear-to-ear incision, which also usually heals really well. But as people age and start to lose hair, it's a lot more obvious.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Interviewer: Craniosynostosis. It's a condition that causes a newborn's head to be misshapen. And it should be treated. To learn more about the condition, how to identify it, and why it needs to be treated, we've got Dr. John Kestle, he's a pediatric neurosurgeon, and Dr. Faizi Siddiqi, he's a pediatric plastic surgeon. And they are experts. They do the surgery that actually treats craniosynostosis.

So let's start with the first question, which is very basic. Dr. Kestle, what is craniosynostosis?

Dr. Kestle: So it's a condition where the bones that are normally separate are fused. And it restricts growth and creates abnormal head shapes. The pattern is usually present at birth or very soon after birth. That's different from the benign conditions where the head shape gets distorted because the baby is laying on one side. Those babies have a normal shape in the beginning and their head shape gets distorted over the first couple of months of life because they're lying on one side.

Interviewer: How does a parent generally find out that their child has craniosynostosis or synostosis?

Dr. Siddiqi: When they're born, they're usually told that after delivery, as Dr. Kestle mentioned, the head is going to be a little misshapen from the birthing process. And that usually corrects within two to three weeks. If that doesn't correct, then they're kind of suspicious and they visit their pediatrician. And then hopefully that's when they're referred for further evaluation by us.

Interviewer: And then what does that head shape look like? We do have a link to a pamphlet that you have that can help a parent. But just describe it briefly.

Dr. Kestle: So the typical head shapes, number one, most common is sagittal synostosis. It makes the head long and narrow, and the forehead and the back of the head kind of stick out. And the back of the head is narrower than the middle of the head. You can see those features when you look down from above.

Probably the second most common type is metopic synostosis. And that's when the suture down the forehead closes early and the forehead looks like the bow of a boat, or a triangle.

The other two types are less common. One is coronal synostosis, and that misshapes one side of the forehead so the forehead is pulled back, and the nose is sometimes crooked, and the eye socket on that side is usually a little bit elevated. And then the very rare one is the lambdoid synostosis, where the back of the head is flat on one side and the ear tends to be pulled back toward the flat side.

Interviewer: So how is it diagnosed then? So a parent recognizes that their child might have a misshapen head, they're concerned, they would go to a pediatrician first?

Dr. Siddiqi: Certainly they visit with their pediatrician and then they're referred to our synostosis clinic for further evaluation.

Interviewer: Okay. The pediatrician doesn't do any sort of imaging or anything like that generally?

Dr. Siddiqi: Sometimes they do. Oftentimes they don't because they don't want to subject the child to a CT scan unless they've seen a specialist and they're confident of the diagnosis. So we would see those kids in the clinic. Most of the time, it's a clinical diagnosis.

Interviewer: Meaning it's just visual, you're visually confirming it?

Dr. Siddiqi: Yeah. But once we decide it is and we talk about surgery, then we would want to get a CT scan, generally speaking, to be definitive about the diagnosis. And the scan also gives us information about the brain, which is helpful as well.

Interviewer: Why do you choose a CT scan over, say, an X-ray or some other sort of imaging?

Dr. Siddiqi: A CT scan gives much more detail of not only the bones, but, as I said, also the brain as well.

Dr. Kestle: The X-ray is very unreliable in making the diagnosis. And the CT scan has been changed over the years so the dose of radiation that's received is lower and lower. So now it's a very reasonable thing to do. It gives excellent anatomy, helps us with planning a surgery, makes the surgery safer.

Interviewer: And, Dr. Siddiqi, when do you generally like to treat a synostosis then?

Dr. Siddiqi: So if we see a baby with, let's say, sagittal synostosis that comes in at 2 to 3 weeks of age, then we've seen that the optimal time for surgery would be somewhere around 3 months of age. Between 2 and 4 months of age. That's why we stress the importance of early referral.

And the reason for that is if we can get the kids in by that time, we can get the surgery done, and then we can get them in the helmet and the duration of a helmeting would be as short as six months. So if we see these kids later on, the helmeting duration is much longer.

Interviewer: And, Dr. Kestle, if a child doesn't receive treatment for a synostosis, what could be the potential outcome then?

Dr. Kestle: So the natural history is that the shape will stay the same or get progressively worse because everything is growing except the fused suture. So number one, it's an issue of shape and appearance.

Number two, there are potential effects on the brain if it's left untreated. There's an incidence around 15%, maybe 20%, in the kids with sagittal synostosis that the brain growth will be restricted. And that can lead to brain problems, chronic headache, possibly visual problems.

With the other types of synostoses, that number is a little higher. And so it's nearly impossible to predict which baby with synostosis is going to get into those brain problems later. But that incidence of raised pressure is enough that we worry about leaving it alone.

Occasionally, we'll see an older child who had a CT scan for another reason, like maybe a concussion, and we identify a fused suture. But their shape is normal, and they're healthy, and their brain is developing normally. That's the situation where we might just follow them. But the baby that has the abnormal shape soon after birth is the ones where we recommend treatment.

Dr. Siddiqi: I would just add that . . . echo what Dr. Kestle said. The two indications are the shape and the risk of pressure on the brain. But the shape is important. A lot of families ask, or even other providers say, "Is this cosmetic?" It's not cosmetic. Cosmetic means, by definition, it's normal and you're making it better. It's not normal to have craniosynostosis. I just wanted to make that clear.

Dr. Kestle: I just want to really emphasize that it's visual. It's the shape that makes the diagnosis. So much so that what we do for almost every patient is have the family send photos. And we can pretty much make the diagnosis from the photographs and then decide if they need additional testing, how quickly we need to see them, and so on. But it's really a visual inspection of the head shape that tells you the diagnosis 90-plus percent of the time.

Interviewer: So really at 3 weeks, if a parent suspects that their child might have a synostosis, they should get in contact with a couple of specialists or a specialty center such as yourselves. You would encourage them to do that as quickly as possible. Is time really of the essence?

Dr. Kestle: For sure. And we can make plans based on photos, and we can see them in the clinic and talk about it, and then targeting between 2 and 3 months for corrective surgery.

Interviewer: So you or a loved one have opted to have endoscopic spinal surgery rather than one of the more traditional methods. What can you expect on the day of the procedure and afterwards?

We're here with Dr. Mark Mahan. He's an associate professor of neurosurgery at the University of Utah Health. Now, Dr. Mahan, when it comes to endoscopic spinal surgery, what can someone expect, you know, leading up to the procedure, the day after? Where do they start? And what should they be expecting?

Dr. Mahan: The wonderful thing about endoscopic spine surgery is that in, I would say, 99% of the cases, it's outpatient surgery. So that is a little bit of a reframing of what an individual will be expecting, because it's not a traditional come to the hospital, stay there for several days, eat wonderful hospital food, stay in wonderful hospital beds. This is something that you would anticipate going to one of our outpatient locations. A patient would expect to arrive that day. Typical requirements are for, you know, for any surgery are, you know, no eating from the night before, coming in, unfortunately, you know, sort of extra early because we all like to end our days early, and so we try to get started early.

And then you would expect that you're going to be meeting a whole host of new individuals that are going to come in and take care of you. And meaning that we're going to have nurses and others that will come in and check-in and make sure that you're ready. We'll go through a surgical consent. That's an important part for me personally because I want to make sure that everybody understands, ahead of time, both what the surgery entails, what the risks are, what your expectations will be both in recovery as well as long term. And so that we all can meet in a common understanding about what our goals are and what you'd be facing. And then through also about, you know, how to best optimize your recovery long term.

And then after surgery, obviously, these are generally performed under general anesthesia, which is the type of anesthesia where you would have a breathing tube. And so waking up, coming around is usually a time when most people don't remember, fortunately, and then just recovery, make sure that you've, you know, that you're ready to go, you're steady on your feet, that you're eating, you're feeling well, and then we get you back to your car and you can go home.

Interviewer: So how long are you actually in the operating room for a procedure like this?

Dr. Mahan: Typically, it really depends on what the problem is we're seeking to treat. Some of the disc surgeries go really, really quick, like on the order of about half an hour.

Interviewer: Oh, wow.

Dr. Mahan: Now some of the more complex narrowing can be two hours. It really truly depends on what the work that needs to be done.

Interviewer: Now, after the patient is home, what can they expect? We're dealing with pain control, recovery. How long until they're back on their feet, etc.?

Dr. Mahan: Yeah, now, pain control is a particular focus of mine because I really want every individual to really have that smooth glide path because, you know, even though that the endoscopic technique is meant to minimize tissue trauma, it is still a spine surgery. It is still the goal of removing something from your spine. I don't want to make that sound scary, but I don't want to make other people feel like, oh, it's a magical procedure, right? It's not. There's a reality here that we're removing something that's pressing on the nerves and causing pain and discomfort.

And so that you would expect to have some irritation or some discomfort from having something removed from your spine. And so what I do is I do everything I can to possibly minimize it. Number one, endoscopic techniques, minimal incisions, minimal approaches. Number two, often using a lot of numbing medication can really make the recovery much more straightforward. So we'll use a long-acting anesthetic into the muscles of the spine to make them comfortable and relaxed even before we even start doing surgery.

So the first step, block the muscles. Make it comfortable. It also leads to some numbness of the skin where the skin incision is so that that is not too much discomfort. But the block will wear off. So the things that we do is try to, obviously, avoid a lot of powerful pain medications because powerful pain medications can have their side effects and consequences. So we're using things like ice, heat, anti-inflammatories, and then we talk about milder pain medications so that you don't get into the complications associated with strong pain medications.

Interviewer: Now other than the pain management that happens afterwards, when they go home, are they up for a day or two? Are they on their back for a day or two? On their belly? Like, what are you having a patient do to heal up from a procedure like this?

Dr. Mahan: In the majority of the cases, you're doing exactly what you want to do.

Interviewer: Oh wow.

Dr. Mahan: Yeah, the limitations really come down to if somebody has had a disc herniation, we want to minimize the risk of re-herniation, meaning that another part of the disc fractures out and presses against the nerve roots, which can occur. Other than the disc herniations, I want the individual doing as much as they feel comfortable doing. Oftentimes that sometimes means tempering people. I had one patient the day after surgery he asked if he could go on a snow bike up the mountain. And I was like, it was one of those moments where you have that sort of, you know, common sense questions, like, well, just tell me what would happen if you got halfway up there and you had a back spasm? You had difficulty coming back?

Interviewer: Right?

Dr. Mahan: And, you know, he's like, well, maybe that's not the greatest thing to do today. And you're, like, yeah, the day after surgery may not be the greatest day to go nuts. But people will be walking more. People will be doing more activities. And we want that. We want them to go back to the way that they will choose to live their life.

Interviewer: Now, it's impressive that they are kind of up the next day, or a day or two after their procedure. Maybe a little bit tempered from what they were normally doing. But, you know, not going back up and doing crazy mountain biking, or that snowmobile trip, like you mentioned. But how long until a patient is, you know, all the way healed and sees the most benefit from the procedure, and they're back to normal?

Dr. Mahan: That is an excellent question. And it really is patient-specific. So if somebody had a more profound nerve pressure or nerve injury, and it's been there for a long period of time, meaning that it's going to take longer for their recovery, right? So if you've had a problem that is minor in nature, and it's a short duration, your recovery is going to be quick. If you have a very profound problem that is of long duration, you know, there may be a new normal, even with spine surgery. We can't always erase everything that occurs in time, but you know, we're going to try.

Interviewer: If your loved one is experiencing some sort of serious spine issue, perhaps stenosis or herniated disc, you may be looking into spinal surgery. Now, typically you might be imagining your back being opened up for major surgery, but there's another option that is available.

We're here with Dr. Mark Mahan. He is an associate professor of neurosurgery at University of Utah Health. Now, Dr. Mahan, we're talking today about endoscopic surgery for the spine. Why don't you kind of talk me through exactly what happens with an endoscopic procedure like this and how it differs from say what I as a layperson think when I think about back surgery?

Dr. Mahan: Endoscopic spine surgery is very similar to what people would refer to as traditional spine surgery, meaning that we're the same goals. We're there to decompress the nerves and in doing so with either removing disc fragments or treating narrowing that presses on the nerve roots, but doing it in a much smaller, much less traumatic fashion than previously accessed.

For most of us, the spine is really kind of in the center of the body, so getting there is always an art, to put it mildly. The older techniques, they work great for treating their intended targets, but the problem is, is there's a fair amount of tissue trauma involved with getting there.

And I've been intrigued for quite some time of finding a way of doing that same surgery, but in a way that does not cause the same tissue disruption, tissue trauma, and as a consequence, the same sort of pain or disability and recovery.

Like for so many things in medicine, we stand on the shoulders of others. Other pioneers had really developed using endoscopes previously, starting in about the 1980s, to create the same surgical corridor but through a much smaller opening. So now with the modern surgical endoscopes, we get beautiful illumination. We get beautiful magnification. We get beautiful video representation of the soft tissues in a way that we're able to perform those same delicate procedures, but through oftentimes really small, like 7 millimeters size skin incisions. That's, you know, 7 millimeters means it's less than your nail width depending on your fingers, but somewhere between your index finger. That's how big the skin incision is.

So that also means that that translates it's not just the skin incision size, it's because now you're going to go down with a very narrow caliber set of tools. So the things that you're going to be doing is that you're not going to be opening up as widely. You're not going to be disrupting joints. You're not going to be getting as much bleeding because we're constantly irrigating.

In fact, the operative field never actually gets to see air. There's none of the circulating air even in an ultra sterile OR environment that actually makes contact with the tissue. We're using constant irrigation with sealing. And so, again, it provides beauty and clarity to the surgeon but also minimizes any risk of infection or other bleeding type complication with regard to the surgery itself.

Interviewer: And again, as someone who's a layperson who might be kind of curious about this, how long have surgeons in the medical field been doing this kind of procedure? It seems kind of new I guess to me.

Dr. Mahan: I'd say it hasn't been done at a large volume for quite some time. There were some initial pioneers who were in the 1980s when they were coming out with the initial endoscopes who were starting it and trying it.

And you can imagine what using 1980s technology meant kind of dark kind of grainy, not necessarily with the same precision. Things really got a boost I would say in the, you know, the 2010s with the introduction of more modern, you know, high-definition televisions, easier access to those techniques, and then just greater popularity.

So we started seeing that the endoscopic technique was really taking off in Germany, and there there's a couple of key innovations that allowed it to be safe for the spine. So whereas you can think of joints having arthroscopes, those are endoscopes specific for joints, those were a little earlier take on, but they were using really high-pressure pumps and those high-pressure pumps would be dangerous if not lethal in the spine. So we had to really develop lower pressure technologies. You had to develop specific tools sets that were able to do the same sort of meticulous and very detailed work we do with the spine.

We saw that those tools and techniques and instrumentation sets really start about 2010-ish, and so there's a very small fraction of spine surgeons in the United States who are trained to do this, unfortunately, because I think it's the technique that should really predominate. And I do, you know, have the good fortune of being able to go train other spine surgeons on how to do this and adopt this technique, which I really enjoy teaching the other spine surgeons how to do it because hopefully it will become the dominant technique and it's not just a single or specialty practice.

Interviewer: It sounds like this procedure has been getting more and more popular over the last two decades, and you sound confident that it could be the next standard practice for a procedure like this. What is it that you see in this particular type of procedures and what are some of the pros and cons of it that make you think that this is going to be the way that surgery is going to be going?

Dr. Mahan: I really like the fact that it has minimal tissue trauma, which means that it has quicker recoveries. So when you ask about the pros and cons, the certain positive that I particularly love and I particularly enjoy about the surgery is that it provides rapid recovery for my patients. That the next day when I talk to my patients or find out how they're doing, they're describing that they're already back to more activities oftentimes than they were before surgery, which is relatively rare.

When we think about surgery, where most people are like, "Yeah, I've got a down period," and I don't have patients coming back to me with like down periods. They're like, "I'm out walking." I hear reports over and over again. They're like, "I am walking now more like the day after surgery than I was in like the several months leading up to surgery." It is that dramatic as far as differences in outcomes. So that's the most certain person and positive note.

Now, some of the other positives I particularly like, again, its lower blood loss. It has a substantially lower risk of infection. There's a substantially lower risk of a specific complication that occurs in spine surgery and that's spinal fluid in leaks or thecal sac injuries. And that's unique to the endoscopic technique is again, we're using sealing to put a little bit of pressure and create space and so the thecal sac is moved away and so you have less risk of that specific complication.

There are downsides, right? I tell all my patients almost repeatedly, you know, if it's powerful enough to help, it's powerful enough to harm. There are cases where people have injured, you know, individuals with using minimally invasive techniques. Endoscopic spine surgery is no stranger to that.

I would certainly say that I think, in my hands, the complication rate is lower, but it's not it's a freebie. It's not like there are no risks. Secondarily and I think the most of the negatives really accrue to the surgeon. You imagine like if you had to do the same work, let's say it's painting a wall, and you were given the choice of a big paintbrush or a tiny paintbrush, which do you think would lead to be faster endpoint?

Interviewer: It's the big brush, right?

Dr. Mahan: The big brush. It's the big brush. The big brush is going to do something quicker. And so, if you force the surgeon to do the same procedure with tinier tools, it's going to take longer. And the way that the insurance in the United States reimburses surgeons, it's on sort of work product. And so again, they pay you to paint the wall. If you can paint the wall faster, then it can be a choice.

Interviewer: What are the success rates like on a procedure like this?

Dr. Mahan: The success rate on anything in life really kind of depends on what your probabilities of success are. So if I take somebody who has relatively straightforward problem and has a very focal problem that's apparent on MRI and is clear on their physical exam and their description of their symptoms, we're going to have a good success rate whether it's an open technique or an endoscopic procedure.

If it's something that's a little bit more challenging, somebody has multiple problems, multiple medical issues, other interdependencies, you know, things that are going on in their lives that are either participating or motivating the pain, then we're going to be less successful. But so for that, let's take the good situation which is for most people where they are.

This is, you know, somebody who has singular problems, relatively identifiable things that could fix their problem, and they're going to have an 80% to 90% success rate with a surgical treatment and it's going to be durable. We want to do a simple procedure that doesn't necessarily create problems that need treatment later.

There are some spine procedures out there that cause further problems down the road. This is one of the ones that leaves a person essentially with more or less their native anatomy, their normal anatomy. And so the goal there is that the only thing that contributes to future problems is really, you know, the nature of time and body's ability to resist time but not the surgery itself.

Interviewer: Say that a patient has now received their diagnosis, they know they have one of these spine issues like we've talked about earlier. What is their first step? Say they're listening to this right now and they're intrigued about this procedure, what is their very first step to get more information and maybe even meeting up with someone like you or another trained professional?

Dr. Mahan: One of the things that we want oftentimes in medical practice, and this applies to a lot of things, is that we want somebody to ideally for somebody to come to me or to come to one of another trained practitioners. If they've had a degree of workup, meaning that they've been evaluated, they've been seen by somebody, and that the process has already been started.

For example, a classic thing is that sometimes you have back pain that can be treated with physical therapy, some exercises, some stretching, maybe some modest medications, right? We're talking about like anti-inflammatories and other things that can get you back to recovery that you don't need surgery for. And so both insurance and the surgeons really want to have that evaluated ahead of time so that when you're coming to somebody, it's meaningful. It's a meaningful use of the patient's time. That you're not coming to see somebody who's going to talk about surgery when you don't need it.

And so it's not a waste of the patient's time. It's not a waste of, you know, of resources or other things. So an initial evaluation, maybe some time with the physical therapist, trial of medications. And then if those aren't working and the MRI, which is a critical component of all of our evaluations, because that's where we can come back to saying is an anatomical surgery going to fix your problem.

And so we need a view of that anatomy, and fortunately, MRIs just do such a beautiful job of doing that is that. If an MRI shows that there's a problem, then clearly there's something that we may be able to intervene on and achieve a good outcome.

Interviewer: Wow. So it sounds like it's a kind of newer procedure and you've got to find the right doctor to do it, the right surgeon and you got to make sure that you have done your homework, gotten your imaging and your workups and everything but maybe they're curious about this type of procedure and treatment, where is somewhere where they can get more information?

Dr. Mahan: Well, one place to start would be the University of Utah website. We have a lot of wonderful information there that can give you the breadth because no patient has the same and what no problem is the same either. So there's oftentimes very distinct treatments that endoscopic spine surgery may not be for you. I would love to think that it is, but at the same time, realistically, there are plenty of things that may need to be done and it may not be endoscopic spine surgery and so that's a great resource to go to.