*Starting the conversation about sex with your patients–in order to grow your sexual medicine practice *How to choose between radiofrequency and lasers for vaginal therapies *Research about using PRP to help post-menopausal women to conceive *Research about using PRP to help with Asherman’s syndrome *How and why your aesthetic practice can thrive and grow in times of disaster *C.S. Lewis on Functioning During Times of Disaster
Video/Recording of CMA Journal Club, Pearl Exchange, & Marketing Tips
C.S. Lews on Thriving During Times of Disaster In one way we think a great deal too much of the atomic bomb. “How are we to live in an atomic age?” I am tempted to reply: “Why, as you would have lived in the sixteenth century when the plague visited London almost every year, or as you would have lived in a Viking age when raiders from Scandinavia might land and cut your throat any night; or indeed, as you are already living in an age of cancer, an age of syphilis, an age of paralysis, an age of air raids, an age of railway accidents, an age of motor accidents.”
In other words, do not let us begin by exaggerating the novelty of our situation. Believe me, dear sir or madam, you and all whom you love were already sentenced to death before the atomic bomb was invented: and quite a high percentage of us were going to die in unpleasant ways. We had, indeed, one very great advantage over our ancestors—anesthetics; but we have that still. It is perfectly ridiculous to go about whimpering and drawing long faces because the scientists have added one more chance of painful and premature death to a world which already bristled with such chances and in which death itself was not a chance at all, but a certainty.
This is the first point to be made: and the first action to be taken is to pull ourselves together. If we are all going to be destroyed by an atomic bomb, let that bomb when it comes find us doing sensible and human things—praying, working, teaching, reading, listening to music, bathing the children, playing tennis, chatting to our friends over a pint and a game of darts—not huddled together like frightened sheep and thinking about bombs. They may break our bodies (a microbe can do that) but they need not dominate our minds.
*Vampire Facial® techniques reviewed in Facial Plastic Surgery Clinics of North America, August 2019 *When to activate PRP with Calcium (chloride or gluconate) *Tear Troughs & Bags Under the Eyes *PRP with or without Amnion in the Neck *Dr. ‘Tangchitnob’s Pearls About Doing the Vampire Facelift® Procedure *Selecting the Best Patients for the O-Shot® Procedure *Dr. Tangchitnob’s Pearls for Doing the O-Shot® Procedure *2 Guiding Principles That Bring More Patients and Provide Better Care *Dyspareunia after radiation–Can/How improved with the O-Shot® Procedure *Pelvic Floor Spasm *A Nine Minute Cram Course on Marketiing Your Mecial Practice, Timeless Intimacy™, and Virtual Assistants from an Engineer/Physician’s Perspective
Video/Recording of CMA Journal Club, Pearl Exchange, & Marketing Tips
Vampire Facial® Procedure in Facial Plastic Surgery Clinics of North America
Dr. Runels: This should be a really wonderful meeting tonight. We’ve got new research, and we have the amazing Dr. Edward Tangchitnob who is out in California, award winning for his practice, and brilliant gynecologist, and surgeon, and teacher of our procedure. This should be an interesting call. We have some new research I want to just bring up very quickly. First, let me bring Dr. Edward onto the call. Let’s see, hold on just a second. I’m going to unmute you here. There’s a couple of research things that are out that I think are really nice. Hold on just a second. Let’s see.
Edward, I’m not sure what’s going on with your mic. I don’t know if you will need to call. It looks like your audio might be turned off or something. Let me go ahead and bring up the research and as soon as I see your mic light up I’ll unmute you. Let’s see if there is something here. Anyway, so I’ll be watching for that. I can see Dr. Tangchitnob on the call but I don’t … Okay, there it is. There’s your microphone. Here we go. Beautiful. There you are. Can you hear me.
Dr. Edward T: I can.
Dr. Runels: Beautiful. Look at this. Just a review article but it came out in here it is, in Facial Plastic Surgery Clinics of North America, August 2019. I don’t think you could see a better endorsement. I mean, there’s the abstract. “Platelet rich plasma has gained popularity in facial plastic surgery because of it’s healing and growth factors.” But then this is the part I love, “One of the most popular uses facial skin rejuvenation in the form of injections and topical application during microneedling …” That would be in for a facelift and facial, “… and the promising nature makes using it for injection or conjunction with microneedling a good addition.” Beautiful. That sounds like a pretty strong endorsement in that journal, or in that periodical. This is the article I wanted you, and I put a link to that. Actually, I didn’t yet, but let me put a link to that into the chat box, you guys.
Using Scientific Research to Educate and Market To Your Patients
That’s a good one to take … If you just take this link ( https://www.sciencedirect.com/science/article/abs/pii/S1064740619300331?via%3Dihub) and you put it in an email or a Facebook post and you shoot that out to your people and say, “Hey, here’s some research that came out this month.” Here’s a little trick about … It’s just commonsense, actually, for how to talk with your patients, is make, when you have this this counts as news. We’ve all heard on CNN or whatever news channel you listen to where they talk about something, they usually report it out of the New England Journal, because the guy on the street knows that’s a reputable journal. But, often it’s the news reporting on the news. This is news, and you could call up your news channel and say, “This is what I do.” You could also just post this to your social media, or an email to your people and say, “Hey, look what came out this month, more nod of approval from the the powers that be, that this is something that’s useful, and this is what I do.”
I want to shoot over … Any comments about how you’ve been doing that, Edward? I know you’ve had some success with your marketing. Talk to us about how you’ve done things like this.
Dr. Edward T: I think that there’s a lot of information out there at the fingertips of all the patients. They’re getting bombarded constantly from their Twitter feeds, their Instagrams, their Facebook. I think everyone, and anyone, really can be the so-called expert on a particular topic. When I’m emailing my patients, and I make a habit of it every two weeks using Ontraport email client,
I think that we have a very captive audience, because the patients already know and trust us, and the open or the click rate is a lot higher, especially when it comes from us. I’ve also played around a few times with the subject line. I’ve done split testing to kind of see what kind of topics and what kind of tone of the subject, or the copy, can resonate with my patients. I’ve been actually surprised a few times in the split testing. That was something I kind of picked up along the way.
Just to kind of give you an idea, a year ago I didn’t even know what Ontraport was, or an email client was, let alone what split AB testing was. But, as I’ve come along on this journey I’m finding that my ability to communicate to my patients in sophisticated ways is being appreciated. The way I’m measuring it is that I’m able to see that the number of conversations, booked appointments, and paid procedures is going up. Just as you’ve said before, the more we seem to email and communicate the more the patients are aware of the procedures that we’re performing, and the more that they’re aware that their procedures are available from the physician, or the practice they’ve trusted all these years, the conversion rate, I think, is a lot higher.
Dr. Runels: Yeah, let me expand on a couple of important points you made that I failed to make. One is that people are bombarded, but for your patients, you being whomever is on this call, and for my patients, and Edward for his patients, they are more interested in … Because they’re bombarded it’s confusing to them. As you just said, Edward, they want us to curate that and point out to them what’s important and occasionally, I think the ratio should be mostly what’s good, but occasionally point out to them something that may be popular that you don’t think is as useful. As a general rule that’s more of a waste of our energy to talk about what’s not good, but being the curator I think we tend to think, “Why do they care about what we think since they’ve got CNN, and the Mayo Clinic Newsletter, and the Cleveland Clinic Newsletter?” I actually talked to a man today that helped the Cleveland Clinic start their newsletter. They’re doing exactly what you just said, for people who wind up going to the Cleveland Clinic they want to know what the Cleveland Clinic thinks.
My patients, and Edward’s patients, and everybody else on this call, they’re more interested in what we think than what the Cleveland Clinic thinks. So, sending that out every couple of weeks, and making it something that reports, this is your perfect … This is what you wait for, and you don’t have to wait long on their procedures because we’re in the news so much. But, you shoot this out and now you’re not spamming people, you’re reporting on the news just like CNN does.
The second thing you said is that just the general idea that when I said expand on this, the idea that email still is the powerful way. Even when you post to Facebook it doesn’t get shown to all of your friends, and they’re so bombarded, and it’s limiting the conversation. Sometimes it gets banned if it’s some picture about, or something about, sex. The old email to your patients is still, in my opinion, the most powerful way to get things done.
When to activate PRP with Calcium (chloride or gluconate)
Okay, let me pull up this other … You know, I think I’ll hold off on the other research. There’s something here about … I just wanted, since you’re an expert surgeon I wanted to talk some about how PRP’s been used in surgery. Let’s skip over that and maybe do a question. This one comes up occasionally about calcium chloride. “I used to use calcium chloride. I started with Selphyl,” so the short answer to this is if you Selphyl it comes with a kit. With the others you can either order it as, it’s the same calcium chloride that’s in your crash cart or, and here’s … I’m on the O-Shot website. The reason I’m not pointing it out to the Vampire Facelift website is I quit using calcium in the face. It makes it hurt more. If I have a Selphyl kit I just leave it out.
But, you can use the same calcium that comes in a crash cart and mix it in with … So, I took it off the Facelift site, but you can mix it with the PRP. This is a video showing you how to do it, so you can take that ampule, mix it in to just a 10 cc syringe and then use that syringe as a dispensing vial into an empty syringe and then put your PRP into that, obviously not cross-contaminating that. You can make this into a multi-dose vial.
There’s a source of it at mrcrashcart.com. It’s where you get your calcium chloride. That’s 10% calcium chloride. Also, you can get it at McGuff, which is the same place where we get our syringes, and it’s on this supply list that sits up here. There’s your supplies in the PDF file right there, and where I get some of it. There’s the phone number, there’s the email for McGuff, and that’s basically if you order everything on that you can do pretty much all of our procedures if you have a PRP kit.
What’s your … Edward, I know I really stress using calcium chloride for the O-Shot® and the P-Shot®, and if you’re trying to grow nerves. Say you lost the sensation in the breast. I’ve quit stressing it. I don’t see people talking about it much with hair anymore, or with the face. Is that still what you’re doing, or have you altered that in any way? What are you doing when it comes to calcium chloride, or calcium?
Dr. Edward T: No. I still follow the teaching that I was given originally, which is exactly what you had mentioned. I’m finding, particularly, with the Vampire Facelift®, for example, the ability to kind of spread over the cheeks and in the nasolabial folds, as well as run down very finely in the tear trough, I don’t use calcium chloride to activate. It would be a little bit to viscous, in my opinion.
Tear Troughs & Bags Under the Eyes
Dr. Runels: And there is that idea that, which you just mentioned, is that with the O-Shot® you want it to gel quickly and stay in a pretty small area, relatively speaking, where with the scalp and the face you want a more diffuse spread. This right here, I think, is a really important point. Dr. Hamilton has someone who has some bags under the eyes after injecting. I recommend, and the question is, “What do you do?” Absolutely I’ve treated a lot of people who came in with … The tear troughs, not so much in the lower lid, but in the tear trough area if it is convex I can almost guarantee you there’s filler in there. I’m seeing people say, “No, it’s not filler,” and then I put a hyaluronic base in it, just a little dot, and it goes away. When I say a dot I mean one unit on a 30-unit insulin syringe is what I do with a 31 gauge insulin syringe and just put 0.01 mL in there, or one unit on that insulin syringe, and it goes away.
But, if you don’t have a lot of experience with using fillers I just wouldn’t use. I would use PRP as a stand-alone in the tear troughs, or do a mixture of one part JUVÉDERM® and nine parts PRP, so 0.1 of JUVÉDERM® and 0.9 of PRP in a 1 cc syringe, swished around, and use that and this is less likely to happen. But, it is fixable. I know you sent me some amazing pictures, Edward. Do you have any of those handy that you could show us? And, you can talk about what you’re doing, because I know you’ve developed some pearls around the face. Do you have any of those handy that I could just hand you the screen and you could talk to us about what you’re doing?
Dr. Edward T: Sure. Give me one second here.
PRP with or without Amnion in the Neck
Dr. Runels: Yeah, that’s cool. I’ll talk about this next question while you’re pulling that up. “Any protocol for injecting PRP with or without Amnion into the neck?” I think we covered this, actually, on the last call, but just to review. I think if you’re working with the neck I’d do three things. Again, if it’s a turkey neck they need a surgeon. I send lots of people for blephs, and for neck lifts, and facelifts. If it’s just necklace lines, or if there’s some platysma looseness that I can fix with Botox® then I go for it, and people love it. I charge for the PRP part of it 600 bucks. What I’ll do is … I treat it like a scar, basically. So, in the necklace lines I’ll put 27 gauge needle into the necklace line and inject intradermally and subdermally with PRP, and then microneedle PRP on top of that.
Then, if you’re going to mix Amnion with it, I just use one of those half cc Vampire Amnion. You know we have our own brand now that’s about one-fifth the price of what most people charge and it’s good stuff. You put a 0.5 cc of that, or a half a cc of that to 5 cc of PRP and mix it up and then inject it. Then, Botox® 2 units along the line about every inch or so apart, and then put them on a good cream, put them on our Altar® Cream. If you want to go all out, put them on Retin-A 0.1% cream at night and our Altar® Cream in the morning and they get amazing results. You found some pictures for us, Edward?
Dr. Edward T: I did.
Dr. Runels: Okay.
Dr. Edward T: Let me see if they-
Dr. Runels: Yeah, I’m going to hand you the … By the way, you guys, Edward teaches a great class where … Actually, let me just give you the screen. I want you to show us your pictures and then we can talk about your class. Let’s see.
Dr. Edward T: I’ve got a great story about this first case, if I have control of the screen here.
Dr. Runels: All right. It should be offering it to you right now.
Dr. Edward T: Do you see what I see here?
Dr. ‘Tangchitnob’s Pearls About Doing the Vampire Facelift® Procedure
Dr. Runels: Yep? I got you. She’s 55-60 year old woman treated with Vampire Facelift®.
Dr. Edward T: Originally, to take us back, this patient found me. She had actually moved, her and her husband from Tennessee and found me for an O-Shot®.
Dr. Runels: Beautiful.
Dr. Edward T: We ended up doing an O-Shot® on her and there’s so much crossover with the PRP procedures that she asked about the Vampire Facelift®. Naturally, we ended up doing a facelift on her. Now, this was one of my great kind of before and afters, because she had such a great result both from kind of the textural component as well as the shape. Staying with the classic form here I ended up … I just used one syringe. I used [inaudible 00:16:07]. I did some [inaudible 00:16:08] around her PRP, and that’s the result she got. My pearl is with this particular case I remember … I think that I was able to achieve the lift I did really by pulling, doing a pulling technique. When I first started doing these injections I would go right on the periosteum, right where the zygomatic arch is.
I still do that, but now I pull up very aggressively, and I draw Dr. Hinderer’s lines, which you can see here kind of mid [inaudible 00:16:41] down to the lateral aspect of the nose, and the lateral canthus down to the mouth. See where my finger is, this pointing arrow what I do is I lift and pull up really, really high on the skin and you can actually see where that line used to be, the one I drew when you kind of pull the skin up taut. I inject where the line used to be. What I mean by that is that for patients who are over the age of 40 who have a little bit more heaviness and need more lift I’m really kind of pulling up and I’m using the filler as a tack.
Dr. Runels: Interesting.
Dr. Edward T: I think before I was, basically, just filling down to the level of the bone hoping that it would just raise the skin. But with this technique when I’m drawing Dr. Hinderer’s lines I’m pulling the skin as high as I can. I inject with my right hand, so I pull with my left hand, and then I kind of see where that line used to be and I inject there. Obviously, when you pull the skin up with your left hand here, the line you drew goes up. So, the line you can imagine that used to be there is where I inject. That’s kind of the after that I get here. There’s a lot more kind of superolateral projection doing this pull and lift technique. I started developing this because as I’m getting into the more longer-lasting fillers such as Voluma®, that’s actually how Allergan teaches it. Now, I’m combining this lift and pull technique with the Vampire Facelift®, which was my introduction to facial aesthetics when I first learned this from you, Charles.
Dr. Runels: Beautiful. So, can we go through that again? So, you draw the lines and then you pull-
Dr. Edward T: What I do is … Right. So, I draw the lines and then I pull up on the lateral aspect of the cheek just as high as I can with my non-injection hand. Where the line used to be, now that it’s been moved up, that’s where I inject.
Dr. Runels: While you’re holding it up?
Dr. Edward T: While I’m holding it up.
Dr. Runels: Okay, beautiful. You’re directing all along the lateral zygomatic arch there. Is that what you’re … Okay.
Dr. Edward T: I’m doing the 0.15 and the 0.5 is classically descried by the Vampire Facelift®. I think I’m getting more bang for my buck when I’m thinking about using it as a tack rather than as a fill, and then I put the PRP over it and it seems to work really well with that lateral superolateral projection.
Dr. Runels: That’s some beautiful photographs. What are you doing around the tear trough area? I hear lots of different techniques for the tear trough. I like that technique where you’ve taken the best of Allergan’s teachings and then one upped it with your Vampire ideas. Talk to me about … By the way, if I were defining the Vampire Facelift® it would be like this. Take a syringe of filler, do your best work with it, polish it off and think of that as reshaping the mattress, keeping in mind the ideas that you just mentioned about shaping the, restoring the youthful shape of around the eye and the mid cheek area especially, because that’s where research shows that we first get an idea about our perception of how old someone is. So, that’s where you start and then you think about the other things that are described on the website based on your understanding of the face and your understanding of your best technique.
I never expect everybody to do it exactly the same way. We all have different eyes on different days and with different people. As long as those techniques are used then they’re going to have the best result possible. It’s just what’s going to happen. So, that’s the Vampire Facelift®. Around the tear trough, and we all have a different way of seeing it, but we’re all following that basic principle, using HA, make your best useful shape, polish it off with PRP, and then if you need more HA that’s fine go for it, but let that be additional cost to the patient since it’s additional cost to us, and that way we’re all going about the same guidelines as far as our pricing, as well. The tear trough, though, is where I see the most variability, so talk to us about what you’re doing since that was one of the questions tonight.
Dr. Edward T: Absolutely. I get very, very medial all the way up almost to the nose, and then I inject and I’d watch the PRP fall backwards. I don’t activate, by the way. One of the risks that I … Actually, one of the side effects of this particular technique is I almost always get a little bit of bruising, and so they get kind of that darkened shadowing after I do a Vampire Facelift®. It goes away and I assure them of that, but I’ve been getting really great outcomes with it. I also get better outcomes I’m finding when they come back four to six weeks later, and I only inject their tear trough with PRP. I think sometimes the first PRP injection might not be enough, particularly if they are almost on that borderline of needing a lower bleph. I also finish it with Lytera®, which is a skin cream made by SkinMedica® that helps with pigment. I learned that one from an oculoplastic colleague of mine who gave me that pro tip.
Dr. Runels: Beautiful. Thanks for the pearl. That’s why we do this at night. Let me ask you for a little bit more clarification, though. You started that explanation by talking about doing something more medially. Can you talk more about what you meant by that.
Dr. Edward T: Absolutely. If I may use my … If you can still see my screen here, I’ll use this picture. My needle originates or goes in here and goes all the way to the most medial aspect of the eye near the nose here. I’m going to zoom in here slightly. To me I see this triangular shape here that I want to fill, because when I go through this crepey, or there’s almost always kind of crepeness here of the skin. The bag, or the space here, is so thin here it fills so well with that unactivated PRP that it filled all the way up to here and comes back. I don’t know if that was by design or not. I suppose to try to get rid of your tears as you kind of tear, but it’s natures way of very efficiently kind of whisking away excess fluid there. I’m just kind of leveraging that shape.
Dr. Runels: Interesting. Would you say the name of that cream again that you’re using, and you’re using it for the crepe papering in the lower eye area? Is that right?
Dr. Edward T: Correct. It’s actually Lytera® 2.0. It works great because it works well for the color. In those patients who have an ethnic predisposition to bags under their eyes this alone works fantastic. That’s where I got the idea to begin pairing this with that part of the Vampire Facelift® that involves injection of PRP under the bags of the eyes.
Dr. Runels: Just so you guys know. You may have picked up already, Edward has a strong background in mathematics as an engineer and then is a world-class and award-winning robotic surgeon and gynecologist there in Southern California, and does a really beautiful job of teaching combination therapies, teaches BioTE®, so he teaches hormones and he teaches lots of ways of thinking about how these procedures can be combined with energy sources and surgical techniques. With that introduction, can you pull us up some pictures and talk to us some about your ideas about the O-Shot®, starting with maybe, if it’s handy, maybe that picture you have of the urethra, which I think is amazing. But, talk to us more … I want to get back to marketing, because you’ve been really successful with the marketing.
Selecting the Best Patients for the O-Shot® Procedure
First, talk to us some about your ideas about patient selection. I never want to get away from the idea that the better we are about patient selection, that’s the first step to having great results. All of us want to have wonderful results and be paid appropriately for doing, basically, miracles with our patients. Can you first start with explaining this picture and then some patient selection pearls?
Dr. Edward T: Absolutely. To kind of go a step back, as an engineer I think that it’s very important to define and measure all the activities we do. As a physician I try to look for those tools in our clinical toolbox to measure these outcomes. When I had done my fellowship in robotic and urogynecologic surgery at Scripps Clinic in San Diego, one of the kind of key aspects of my training, even before I started doing pelvic surgery, was urodynamics. Urodynamics to me is the gold standard for actually assessing the different kinds of urinary incontinence. Does the patient come with a pure stress urinary incontinence? Do they come with a overactive bladder picture? Or, is it more commonly the most common kind, which is mixed, which is actually the most difficult to treat. So, when I do my assessment of the patients for their candidacy I think it’s ideal when you do the full work up, although it doesn’t happen every single time, to have some kind of urodynamic evaluation.
The area that I look at, and I’m most interested in … Actually, I’m going to scroll down here, is the intrinsic sphincter deficiency assessment, or the urethral closing pressure, because I really want to know at the urethra what the degree of damage or the degree of strength that resides. To me at one end of the spectrum you have a very healthy urethra that upon closure can actually withstand the increased pressures that are created when the patient laughs, coughs, or is a little bit heavier. That’s a young patient, maybe they’ve not had kids before. They cough real hard they’re not going to leak, because the urethral pressures and that intrinsic urethral strength is quite strong.
On the very other end of the spectrum, you have a patient who has intrinsic sphincter deficiency in which the urethra takes on more of a complete pipe shape and function. In the case of the patient with intrinsic sphincter deficiency, when you perform urodynamics on them you will see that their urethral closing pressures are way less than 50 mmHg. They’re actually quite low. In my opinion, the patient who is healthy, who can be continent when they cough really hard, versus the patient who has intrinsic sphincter deficiency, somewhere lies in between the ideal patient for doing an O-Shot® for urinary incontinence.
I’m thinking, in my mind, Charles, that the patient who doesn’t have a lot of tone to begin with … You could probably do four or five O-Shots® on them, several lasers, even putting a sling on them, and it may not work. Why? Well, I think by nature that urethra it’s too damaged or it’s not functional. Many of our procedures that are noninvasive, such as doing an O-Shot®, or doing two, or even giving them testosterone in the form of a pellet that causes hypertrophy of the muscles that surround the urethra, may not work. In fact, when you kind of do the literature search, one of the gold standards for performing a treatment on someone with intrinsic sphincter deficiency is to do a TVT, or perform a TVT, a transvaginal tape, in which it’s a lot of back support against that urethra does not work that well.
If you look at … I’m a big fan of the mini-sling, the Solyx. For those of you who are on the call right now, mini-sling is a very small sling that’s usually called the minimally-invasive sling, because it’s so small and doesn’t pierce through any of the spaces, may or may not give as much of that backstop support for someone with ISD.
What does that mean for all of us performing and looking for the ideal O-Shot® patient. Well, I would actually really use the history to try to guide us. How long has the incontinence been going on? Are there things that you can do, or things that you’ve tried? Some patients have been very good about doing Kegel’s muscles and Kegel training. They get some improvement upon doing these Kegel muscles. They just can’t get to it every day. I mean, we have such busy days. To do Kegel muscles with intent it’s just so difficult. That patient is a good O-Shot® patient, because they can demonstrate that with some exercising they could bring back that tone.
Someone who has had … I actually saw a patient today. She had had two C-sections. I’m about to do an O-Shot® on her next week. I think she’s a good candidate. We just did her urodynamics. We’ve proven that her urethral closing pressures are well above 50 mmHg. It makes sense in her history that probably with time, age, and the decrease of hormones that that tone or incontinence is changed. I think she’s going to be a fantastic candidate for an O-Shot®. These very soft findings in the history, not all of us have urodynamics ready to do in the office, I think really guide our ability to find that O-Shot® patient. Sometimes it might take another O-Shot®, for example.
Dr. Runels: Can I ask you two quick questions? First, for the person who doesn’t have the ability to make those measurements could you elaborate more on what clinical history or physical findings they might use that you’re correlating with those measurements? Second, do you have the beginnings of a data bank measurements before and after an O-Shot® that we could publish somewhere?
Dr. Edward T: I’m beginning to collect that score, because very early on, which is why I’m referencing this picture, I wanted to find a way to measure, if not visually, at least quantify the difference in the closing pressures after doing an O-Shot®. Now, this particular publication, or this article submission, was a case report of a 48-year-old gravida 5 para 2 … Actually, wow, last year. Almost by design a year ago that I had published, and this was after we did an O-Shot® in the operating room for a patient we did robotic surgery on. You can see here before the O-Shot® I put the cystoscope in. This was a 30-degree Stryker cystoscope, and you can see what the urethra looks like before the O-Shot®, and this is immediately after. I can imagine with time that the O-Shot®, the effects of the O-Shot® platelet rich plasma probably would just improve the tone of the urethra.
I actually don’t have, and I wish I did, pictures in a series of what happens at 30, 60, and 90 days, because I don’t know how I would consent a patient to do cystoscopy just to see how the O-Shot® is doing. More rather, bringing the patient in and just kind of asking what their incontinence level is.
The second part I think you were asking is, looking at a questionnaire, which is what we did, I’d be happy to share with the group, too. There’s a great one developed by LABORIE who makes my urodynamics equipment. It’s a checklist of about ten questions that, basically, look to see, Do you feel like you have to pee as soon as you put the key in the door? We call latch-key urinary incontinence, which really speaks more towards overactive bladder. Or, Do you leak when you cough? How many pads are you using a day? You could almost get a gestalt on whether they have stress urinary incontinence or overactive bladder, for which the two treatments are different. I am seeing almost in colloquial, or kind of informally, that the patients with overactive bladder are needing to use less Detrol, something about their O-Shot® and rejuvenating some of the vaginal mucosa immediately underneath the bladder helps with overactive bladder.
Dr. Runels: Anecdotally we’ve had some people with very severe cases that have made remarkable changes, so hopefully you can get us some objective numbers that we can publish somewhere. Can you give us your pearls about actually doing the procedure, and thank you for showing those pictures and, yes, we would like to see that survey you’re using for measurements.
Dr. Edward T: I’ll get that to you and maybe you could distribute it out to-
Dr. Runels: I’ll just post it on the web … Is it copyrighted? Is it something we can post?
Dr. Edward T: It’s pretty general.
Dr. Runels: Okay, I’ll post it to the membership site for people to download. Would you talk to us about your pearls about how you think, what you’re thinking, when you actually do an O-Shot®?
Dr. Tangchitnob’s Pearls for Doing the O-Shot® Procedure
Dr. Edward T: Absolutely. So, when I talk about … I’ve experienced in two realms and I’m very fortunate because, I think I’ve told you this before, my hospital system has been extremely supportive with regenerative medical techniques that I’m doing in the OR. My story in terms of the OR, versus doing it in the office, which I’ll talk about in a second, really stem from a product made by Stryker. Stryker made a product called Vetigel® and Vetigel® is a combination of autologous PRP in which the scrub tech or the nurse that would have to draw the patient’s blood and then mix it human thrombin and that’s what our GYN oncologists and I were using to put on the vaginal cuff before I even took your class, Charles. This is …
Dr. Runels: Interesting.
Dr. Edward T: … before I took your class. We were finding that the rate of vaginal cuff dehiscence and post-robotic hysterectomy spotting went to nil. One of the most frequent calls that we get as a gyne robotic, or any kind of gyne surgeon, is post-hysterectomy spotting, because the cuff has little pores through it. We were just plugging the Stryker Vetigel®, which is really just PRP plus thrombin, over the cuff and the patients had less pain. They were not spotting. We had less calls. We were happy.
Then about three months later it made me so sad because Stryker pulled the product off the shelf. In my very engineer mind I said, “You know what, this is just too good of a product to not have on the shelf,” so I started looking at other companies. We use Regen. We were able to replace a pre-existing product in our hospital OR with a similar product. I think I found a very pleasant loophole, right, because I had to have something to replace it, so we found something to replace it that ended up being a lot cheaper.
Dr. Runels: You’re referring to Regen when you say there’s something to replace it? Regen Therapy?
Dr. Edward T: When I do it with my hysterectomy, I do make it with a gel, and I [inaudible 00:36:47] calcium chloride, and I add about 0.1 of thrombin, that is autologous thrombin.
Dr. Runels: Yes, and Regen, just so you guys know, Regen has a kit that comes with thrombin …
Dr. Edward T: Exactly.
Dr. Runels: … or a way to make thrombin, and they also have a setting on their centrifuge to make a gel. Am I understanding properly? Is that what you’re doing? Are you using that thrombin kit?
Dr. Edward T: That’s exactly what I’m doing, but I’m doing that above the vaginal cuff. When I undock the robot and I’m done with the … Actually, I did the same exact same for a stage IV endometriosis patient today. She’s on the floor. She’s doing great, and after I undocked the robot then I used my PRP kit, and I do a classic O-Shot®, and that’s it.
Dr. Runels: Interesting. Beautiful. That’s pretty amazing combination therapy. Do the people that are getting hysterectomies from you, do they realize what a higher standard that you’re taking this procedure to? I guess they do. Tell it to me more about, do they find that out when they show up for surgery? Are you advertising this combination or way of doing hysterectomy, because it sounds like what I would want my loved one to have?
Dr. Edward T: I think that at the end of the day I’m guided by the same principle that my father, who I operate with still today, actually we just did the case together, has always taught me, which is be very patient centric. I just want to take care of my patients. The money part, and the finances, and the marketing sometimes, as you know, Charles, can get in the way of that.
Dr. Runels: Yes.
2 Guiding Principles That Bring More Patients and Provide Better Care
Dr. Edward T: It’s kind of a very means to an end, I suppose. But, when I start counseling the patients about what we do I start out by saying that we want you to recover as quickly as possible. So, when I lead with that, and I also followup with the fact that we utilize the newest and latest technology in regenerative medicine, the patients begin to understand that their body actually does have a natural mechanism to heal itself. If not using parts of their own body, why would I reach for something on the shelf if I didn’t have to, if I could use their own PRP, and their own thrombin, autologous, to help them heal? I think when it’s set up like that it’s an easy sell.
Dr. Runels: Well, and part of the reason I brought it up was that I feel like, as your father said, Part A is that the want to be patient centric and make sure that we’re always doing the best with the least amount of risk. Then, Part B is that, I think, it’s our responsibility to make sure that our patients know what we’re capable of doing. I think that’s a different way of thinking about it than the way, and I know that’s the way you think, as well, but some people think, “Oh I just want to do it but I don’t want to have to sell it,” but if you use a different way, and it has to be sincere, of course, but if your way is not trying to get people to do things, but your way is taking responsibility for educating people in what you’re able to offer them as an option, and then they decide what they want based on a fully-informed description of the possibilities.
That, I think, is really what we’re supposed to be doing anyway, whether we’re taking insurance or not. If it happens to be something that somebody could pay you for, well that’s wonderful, but it’s kind of what we’re supposed to do anyway, and that is the best way to “sell stuff.” As you know, I never script these conversations with our teachers, because I like the serendipity of discovering along with the people on the call what might be possible. Have you had any of the gynecologists reach out to you, or do they even know it’s a possibility the ones who come to your class for you showing them this way that you’re doing a hysterectomy, or is your description you just gave enough for them to take it and run with it?
Dr. Edward T: Well, I think that they understand it. I always get a very academic nod to what I’m doing but to your point, Charles, some of the GYNs that I train, they’re my colleagues, they’re a little bit slower to adopt, because we’ve been kind of put into a corner with our Board certifications, and you’re supposed to do it this way. I’ll be honest with you, if that’s how we did hormones then we wouldn’t have any progress.
Dr. Runels: Yes.
Dr. Edward T: If all we did was treat to the exact specifications of what [inaudible 00:41:25] put in brackets, none of our patients would feel better. We would still have all these issues.
Dr. Runels: Is there something you can measure, for example, that postop spotting that you were talking about? Is there something you could measure where you could do the next 40 patients, 20 with and 20 without that? It would the great to have some sort of paper where we could let people know what you’re doing. You know, I just put a link in PubMed where there is some discussion already. I couldn’t find the one … There’s one out there somewhere about using PRP as part of the hysterectomy process. I guess it came out of the people who did the research for the last product you mentioned, but I can’t find that paper right now. Anyway, I won’t dwell on it too much, just to let you know it’s something else that would help the whole group, because there’s lots of GYNs and urologists in our group.
Dyspareunia after radiation–Can/How improved with the O-Shot® Procedure
Okay, we’ve got a couple of questions, and I’m going to unmute Stephen Carp who has a question for you. Let’s see if I can unmute him here. Let’s see. I’m just going to let you ask him instead of me trying to slow down the mail. All right. Dr. Carp, you’re unmuted. Go for it.
Dr. Stephen C.: How are you? Good evening.
Dr. Edward T: Hi.
Dr. Stephen C.: I’ve got a patient that came in, been a long-time patient, who came in just looking for a potential solution. Had endometrial cancer. Had a hysterectomy with radiation and has some scarring that’s tender, and discomfort, a few cm proximal to the introitus that’s probably from about 5 to 8 o’clock or so. She came in because she’s actually a physician and wondering if PRP might be something that could help soften that, might help with that area. Have you had any experience with any PRP in post-radiation in the pelvis?
Dr. Edward T: I have not, but when I think about the three or four cases of patients who have had traumatic vaginal deliveries, they create quite a bit of scar tissue in that fourchette. The success cases I’ve had for those particular ones required more than one O-Shot®, and by O-Shot® I mean doing the classic O-Shot®, but then also doing focal 1-2 cc of activated PRP right into that area of the scar tissue to soften it up. I would also go so far as to maybe use vaginal dilators and, depending on the comfort level of the oncologist, there’s a great product that has compounded DHEA that could definitely soften that fourchette. DHEA with history of gynecologic malignancy is still kind of up in the air, but I have a lot of breast cancer survivors. We’re right next to City of Hope, my practice, and we were using a lot of these nontraditional therapies to help these patients out. I can imagine the irradiated tissue is very similar.
Dr. Stephen C.: Yeah, I would think so.
Dr. Runels: Let me add to that in that my position that I am grateful every day is now becoming described in the Earpiece for lots of brilliant people like you guys. I’ve had quite a number of people, probably a dozen different providers, call me and tell me about similar cases, several cases of dyspareunia post radiation. One case in particular comes to mind where a woman had repeated tearing and pain in an old episiotomy scar, and just like you just said, Edward, it took three treatments with injecting, basically infiltrating the areas if you’re getting ready to suture it intra and subdermally with PRP, and then waiting four to six weeks and doing it again, and doing that three times, and then the woman was without pain and without bleeding. It was something that was a nuisance for quite a number of years. Another case of radiation that had some scarring and pain around the anus, as well. Yeah, so it’s been done and it’s been helpful, and hopefully some of you guys will publish a case report.
I had a case ... While we are talking about dyspareunia, I had a case of scleroderma that got well, but just one. These are … No one person has enough to do a series, but maybe we should some case reports, or try to pool it. What else? Anything else, Dr. Carp?
Pelvic Floor Spasm
Dr. Stephen C.: I’ll just as an addition to that, have you had any experience, especially with urogynecologic, with Botox® for the spasms that they get in the pelvic floor?
Dr. Edward T: I have not done that, although many of my colleagues have. One of the risks of doing that is if you do it too much they go into retention. I have not done that particular method. I have used CO2 fractionated laser. I’m a big FemiLift physician. I use FemiLift quite a bit for overactive bladder, as well as the compounded vaginal estrogens work very well. I think there is a great deal of dysfunction at the level of the vaginal epithelium, that thin layer that separates the bladder from the vaginal canal that needs to be addressed. It gets irritated in these patients with overactive bladder.
It’s really interesting, because one of the gold standards that the insurance covers is the administration of Detrol, or an anticholinergic, which many of my patients within about 30-60 days will self-discontinue due to the side effects, the dry mouth, the dry eyes. They might have less overactive bladder but [crosstalk 00:47:28]. There’s some brain slowing, especially in the older population.
Dr. Runels: Yeah, there was actually a paper out about six months ago that was pretty compelling that there really is an increased risk of dementia long term, as well.
Dr. Edward T: I can see why. You, basically, create that parasympathetic overabundance or push the parasympathetic system to try to dry everything out, well it’s probably going to slow your brain function down, as well. The patients are getting forget. I think it’s very high risk in the older population due to polypharmacy.
Dr. Runels: Anything else, Dr. Carp?
Dr. Stephen C.: No. Thank you.
Dr. Runels: Thank you for the excellent question. There was quick question from Dr. Vora about Emsella, and the answer is, “yes,” some of us are combining Emsella with results. Some are using the intensity vibrator that has contraction component to it. Are you doing any of that, Edward?
Dr. Edward T: So, I was using the [Visa 00:48:30] Plus for a while. I don’t know if you’ve seen that as a at-home device.
Dr. Runels: Yes, talk to us about it.
Dr. Edward T: So the Visa Plus is something that the patients were using. They would take home, use as a light therapy that helps with collagen generation and urovascularization. There’s two versions of it. There’s a version that’s available in the United States, and then a stronger version which I think is only available in Canada, is one of the examples of, I think, an at-home treatment that the patients can use.
Patients always want one and done. From the very beginning I try to tell them, especially when it comes to some of the dyspareunia associated with the menopause state, once estrogen runs out and the vaginal epithelium begins to change it takes a variety of different approaches that begins in the office and really continues with the patient at home. I might do an O-Shot® on them and have them go home with something called … There’s a commercially available medication called Intrarosa®, which is compounded DHEA, or I would use vaginal estrogen. They’re going to work on that at home for the next 30 days. They may come back. I do another pelvic exam. Maybe the grade of the atrophy changes, or improves, or they could have one more sexual encounter that month. To me that’s a win. Then we will add a vaginal laser.
The in between treatments, whether it’s a device such as the Visa Plus or these creams are very, very important, whether you’re talking about vaginal health or you’re talking about aesthetics in the face. I think really beginning to set that as a proposition to the patient, “You’re going to be doing things at home, that are going to help.” Certainly having multi-modality.
I have colleagues of mine in Southern California having great success with the Emsella®, to strengthen the pelvic floor, as well as doing an O-Shot®, looking back at our … We have about 300 patients on pellet treatment right now. Many patients will cite that their urinary continence has gotten better within the first treatment of testosterone. How do I know that? It’s because they won’t show up to their urodynamics test, and so I know something is there. Having that multi-modality approach for urinary incontinence, intimacy, even aesthetics I think is going to be key.
A Nine Minute Cram Course on Marketiing Your Mecial Practice, Timeless Intimacy™, and Virtual Assistants from an Engineer/Physician’s Perspective
Dr. Runels: Beautiful. We’re going to talk … We have about nine minutes left and Edward has some interesting ideas about when it comes to marketing with trademarking and not just our procedures but you as a provider and expanding upon that idea. So, we have about eight minutes left, Edward. Before you do that, though, I just want to tell you guys that Edward is, obviously, brilliant and excellent teacher, and excellent as a provider for our procedure, so highly recommend his classes. He’s got one coming up July 27, which is pretty close, but I don’t know if he’s got slots left, but I’ve put a link to that. If he doesn’t have slots in that one I’m sure he has another one coming up soon. With that, Edward, if you don’t mind, talk to us some about, I know you’ve thought a lot about that idea. Can you expand on that some and then we’ll close it down for the night?
Dr. Edward T: Absolutely. So, as I’m going through the mental exercise and thinking about how to combine all the different procedures and finding that a combination of different approaches that hit different aspects of what I’m doing is the best, I really did a deep dive and found that my main focus is intimacy, how to restore it, how to improve it, how to educate patients on it. I was very happy when my trademark, actually I have a copy of it here, by the U.S. Patent Attorney Office was accepted now with for the second year in a row. I’m ready to defend it, because I came up with this idea of Timeless Intimacy. You can see here, this was actually from my-
Dr. Runels: One second. I took the screen back. I’m going to give it back to you. Now you can show us. Go for it.
Dr. Edward T: I applied for a Trademark. It was actually more of an activity than anything else, and it was successfully accepted by the U.S. Patent Attorney Office. This was a recent email, actually July, by my attorney and I was able to submit it again for the second year in a row. The Timeless Intimacy trademark basically encapsulates performing a minimally invasive vaginoplasty, performing an O-Shot® and followed by a laser, in this case a CO2 FemiLift at a particular setting to help heal and to help reconfigure the vaginal vault to take on a more youthful function. I would always tell the patients, if you want a certain tightness or a certain kind of friction coefficient in terms of the sexual intimacy that you were at 21 we’re not going to go past that, right. We want you to be in a place I would say, ideally, between 20 and 30, in a place before you had children, in a place before you entered menopause, such that you could resume intimacy again comfortably and pleasurably with your partner.
As a part of that I then went on to develop Timeless Health Solutions, Inc, which is my Med-Spa or my functional wellness practice. That’s now being developed as its own entity. It has its own collateral. There’s a voice that’s being developed in which the girls in my office are trained to pick up and talk to the patients with a particular voice.
I’m finding who I am as I’m going along in this journey, that originally I started as an engineer. I think I have a very compelling story to use technology and, basically, give that technology and distribute it in such a way to help patients. I’ve become a surgeon in the last few years, a robotic surgeon in the community, helping women have surgery in a minimally invasive way and get back to life sooner, and putting it all together. I think that’s really what the Timeless Experience is. I think it’s really garnered a lot of attention in our community. I know it’s being recognized at the level of [inaudible 00:54:48] hospital systems. I’ve been recently kind of given this idea, this honor, of being a social media expert in women’s health. Now I have this wonderful platform to get all these ideas of regenerative medicine, minimally-invasive surgery, and to be able to talk about intimacy in a way that’s never been done before in my community.
I’ve been very kind of passionate. This was actually what I was going to talk to you about tonight, and I’m going to highly the second point here. I would say, Charles, right now in the last few minutes that I’m in lean startup mode, and I looked at my colleagues, my engineer friends up in Silicon Valley, and there’s this wonderful book by Eric Reese called The Lean Startup. What that means is creating these very small … Let’s see if I have a picture of it. … MVP, that is a minimum viable product, and really getting it out there to see if the population, or the market, is interested in it. What that means for us as busy physicians is before we buy that next laser, or before we buy that next cool sculpting machine, can we create these minimum viable products and test our market, and how convenient is it that our market are the patients who have been following us all this time.
Dr. Runels: Yes. Yes, we already have an audience.
Dr. Edward T: We have a captive audience. In this world of marketing you actually have to pay for these focus groups.
Dr. Runels: Yes, and let me emphasize that real quick. I don’t want to slow down your momentum, but everyone needs to remember, you are marketing to your people. If you [want to 00:56:27] market to the whole world that’s fine, but you need to start with your people. If you don’t have a group of people that you call your people, in my opinion, it’s difficult to have a steady flow. You start by building a fan base of people who love you, because you’ve done good things for you. Now you can do what you’re talking about. Okay, keep going.
Dr. Edward T: I think every once in a while when I get stuck, Charles, I put my engineering hat on and I think about what an engineer would do, because if I think about what a doctor would do, I would probably take on another [inaudible 00:56:58] contract and working harder and I’d probably be- [crosstalk 00:56:59] Just being honest with you. I’ve already seen this. I saw what happened to my father, right? I think desperate times call for desperate innovative measures, and I put my engineering hat on and I found this, and I’m just sharing this with our group, lean startup. In the last minute here I encourage …
Dr. Runels: You know what. Keep going, go a little over. That’s fine. I think this is good stuff.
Dr. Edward T: … and want all of us in the call, the physicians, to really become lean again. I think that all of us as physicians need to find a way that we retract because the environment right not conducive to us expanding aggressively. We must all come together and retract and regroup, much in the way that Sun Tzu says in The Art of War about looking at our enemy and knowing that we are not ready, and we are not powerful enough to be out there and fight. So, we have to retract, and in this very lean startup manner regroup and see what anchors us.
Dr. Runels: Yes.
Dr. Edward T: It’s very easy because all of us in quarter four … I know I’m speaking to everyone on the call right now when the tax comes all of us who are on the call most of us are in private practice, and we are lured by the laser companies, and by a big company to do that capital investment just to decrease our taxable income. Really understand what it is that our market is demanding. We can do that by creating these very small value propositions and testing it. That’s why doing a class on injectables, or learning how to do an O-Shot® is so valuable, because it may be caused that initial fee, the tuition, and that’s it. That fee is the minimal [crosstalk 00:58:47]
Dr. Runels: Then you take the money from that and do the next thing, yes.
Dr. Edward T: You got it, because what makes you think, and forgive me for saying this, that you’re going to be able to make a vaginal laser which can cost up to $100,000 work if the patients in your group don’t even want an O-Shot®? To that same degree, what makes you think buying the newest fractional CO2 facial laser is going to be appropriate when the patients don’t even want you to do a Vampire Facelift® on them?
Dr. Runels: That’s right. The guy who taught me Botox® was doing … He was the top Allergan account in the world, we talked about this before, and he always said, “Get your Botox® practice going then buy the facial laser.” So, exactly that’s the right strategy. When you get to where you’re one or two O-Shots® a week now you can take the money and take the flow, and you know that your laser’s not going to gather dust, or you’re radiofrequency. I’m loving this. Tell us about the next thing on that list.
Dr. Edward T: I guess the next thing, …. Forgive if I’m going over here but-
Dr. Runels: No go for it. We like it.
Dr. Edward T: In addition to retracting … This is what I’ve been doing. I’ve been retracting, rebuilding, regrouping, and creating my brand. The brand tells a strong story that I’m infusing technology with medicine. I actually had a doctor friend of mine, Charles, reach out to me, and she asked me how I’m seven places at once? I said, “What do you mean?” She’s like, “I’m watching your Instagram, man, and you’re like seven places at once. I’m like, “Thank you, I’m not.” I have virtual assistants. I try to automate and eliminate, and I’m doing this because I have a virtual architecture and I check in with this lovely girl in the Philippines. I give her a list of things to do and in the morning it’s all done because of the time zone difference. It could be something as simple as arranging for my dry cleaning, or figuring out a logistical issue for a seminar that I’m going to be teaching out.
But, when I’m able to do that and create that virtual architecture she learns from me. We talk about, as engineers, machine learning, and we talk about artificial intelligence. You don’t really need that when you could actually have bonafide intelligence. These virtual assistants, it’s a skill and I’ll be honest with you, coming out of fellowship I didn’t really know how to manage people that well. I’ve learned more about managing people, and learning how to lead working with these virtual assistants than I have in all the time I’ve graduated, because you learn about time management, because now I know what the value of time is in a quantifiable way. I’ll give you an example.
I found out that it’s actually a lot easier to click with my thumb Expedia and book a flight, and look for a flight than it is to go in almost two hours back and forth in different time zones to get my virtual assistant to book it. That’s a great example, right? But, for something that takes a lot of different steps, like research, I’m trying to find a cheaper way to bring in needles or syringes to my office. That’s an hour affair. I’m putting that to my virtual assistant, so now she does my supply chain and I’m like, “Oh, there’s something called supply chain. Let me learn about how to do supply chain management.” It didn’t cost me that much, and so that becomes part of my virtual architecture. It becomes part of my virtual corporation, my virtual timeless structure, and that’s the virtual architecture that’s rising me, or raising me, to make me look like I’m in seven different places at once. It’s because my virtual architecture is raising me, it’s giving me more time.
Dr. Runels: Beautiful. Both the virtual assistant and someone in the office who functions like an executive assistant, not just doing the nursing work, but they are willing, and expecting to do things like drive your car, or go buy your groceries, that sort of thing, I think when you value your time at at least $1000 an hour, which everyone on this call should be doing, then that person if they save you an hour a day, you can pay them a reasonable rate and still do well. What’s next on that list?
Dr. Edward T: I suppose the last thing … Let me give you the website that I use, and I explore …
Dr. Runels: You can just throw it in chat box and everybody will have it.
Dr. Edward T: It’s onlinejobs.ph. You actually see it.
Dr. Runels: Okay, there you go. Onlinejobs.ph. I concur with you in that the people in the Philippines they like Americans and unless they’re having a typhoon where they lose their internet they are as a rule usually reliable, and they are grateful. You can pay them what for her is not so much, and you can be helping someone have a whole different lifestyle in the Philippines. I highly recommend what you’re doing.
Dr. Edward T: The last part of my pitfall, so I will try to wrap all this up, because between becoming lean, creating a virtual architecture, becoming proficient with all of these advanced regenerative medical procedures, and learning how to do aesthetics with an artful aye, I’ve also learned along the way. A lot of the pitfalls, I think, stem from paid advertising. I think in the group whoever is still listening left, all of us, I think, have all tried to pay-
Dr. Runels: By the way, it’s everybody. Nobody’s dropped off. They’re listening.
Dr. Edward T: Anyone who’s tried to pay for advertising finds it very difficult to measure a return on investment, because in my mind as a physician if I pay for advertising it means that there will a measurable return for a booked and paid patient. However, with marketers and paid advertisers out there, their metric is leads, or …
Dr. Runels: Yes.
Dr. Edward T: … clicker rate. Things that are not as relevant clinically to us and to our bottom line. I think there’s a big discord.
Dr. Runels: They don’t pay the groceries. Clicks don’t pay the groceries do they?
Dr. Edward T: It took me a long time to learn that at the very visceral level, that we have a disconnect here. That disconnect is what’s actually preventing, in my mind, marketers and physicians from really aligning together. I think that if there was a better, more kind of physician-centric way to create paid advertising … You know it’s good that all of us on the call know the basics of marketing and advertising, but the the end of the day we are doing all this to try to get back to what we signed up for, which is to help patients and do medicine.
Dr. Runels: Yes.
Dr. Edward T: As a pitfall I think what I’ve been guilty of is going down too far and kind of veering off course, and there’s so many tools, and so many virtual assistants, and so many Ontraports, and mail … I mean, there’s so many digital pools out there that I think every once in a while I have to pull myself back, not as an engineer now, because that’s all we do is create tools, right, for better solutions, but pull myself back to the medium, which is the physician in me and go back to doing medicine. I would say that’s a pitfall that I’ve realized that it’s very easy to go down that rabbit hole and find that next digital tool, that next widget, that next app, and forget what we kind of signed up for.
Dr. Runels: Just let me expand on that just a little bit and then let’s call it an night. All wonderful stuff, Edward, by the way. There are so many tools, and I’m literally at a class now in Cleveland that cost me 30 grand. I’m in a class today, earlier today, with a guy that made $900,000 in two weeks online. These are high-end people, high-end in that they know how to make money online. It’s interesting, what I’ve noticed is the people who are making 10 million or more on the internet, they’re still doing the basics, and it’s not just online. The other thing that these guys with real businesses with tell you is that you bring it offline as soon as you can. It’s handing out the brochures to your patients, or your just physical card and saying, “Hey, if you know somebody else I can help, would you give this to someone.”
Using the tools, just the basic tools of a video so you don’t have to keep explaining it, emails that you send to your patients every couple weeks so they know that you’re there, that are not fancy, that are messages that give them the things you would say to them if they were in your office anyway about what you want them to do to be healthy, and what you’re able to do for them with explanations and clicks to show them the research. So, a video, a web page that’s helping you let them know what you’re able to do, and then instead of doing all your time marketing you’re doing something, it’s a practice, and so you’re practicing it. But, here’s the fun part, you’re practice of marketing is actually making you a better physician, because you’re teaching your people how to be well leveraging digital tools.
I know if people are on the call that have done it on Instagram and Facebook and all the other tools, and I’m not saying you don’t do those things, but for these procedures what you just said is the formula that works, an email, a video, a web page. Deliver good messages and then while that’s doing you have more time and more money to go take care of your people, sometimes for free because the money’s flowing.
Edward, always a pleasure. I know people, I’m telling you the stick rate was amazing tonight. Everybody was listening, so I know they loved it. One last thing, guys. Edward does a mean class and you can tell he’s on top of all dimensions of this. So, have a great night, and I’m honored always to have your attention. Bye-bye.
Several of our Cellular Medicine Association members reported to me a spam email sent illegally to our members. Seems an attorney harvested names from our list and sent an email to solicit business and spreading falsehoods about me.
Since I’ve received quite a few emails wondering what’s going on, I’m writing this note to explain.
A few years ago, I mentored one of our members, Lisbeth Roy, in an way to bring her national attention. It was early in the rolling out of our procedures and I wanted a female physician to help spread the word. So…
(1) I taught her the procedures
(2) I taught her my best marketing techniques and spent time mentoring her in that direction.
(3) Then made her a teacher.
(4) I allowed her ghost writer to interview Me for Dr. Roy’s book.
(6) As a result, Dr. Roy developed a successful teaching program and I paid her to teach and I helped fill her classes.
Then things went sideways.
Dr. Roy asked me to make her choice of centrifuge (Emcyte) the only centrifuge we use. And she wanted me to send all of our members to her to purchase the centrifuge so that she could profit from the machine. It bothered me that teaching off label (the centrifuge is only approved to make PRP) and then profiting from the device (Emcyte) seemed to be against FDA policy. It’s exactly like an Allergan rep teaching you off label uses of Juvederm—in the US, they can’t because of a conflict of interest. But I tolerated her behavior for a short time.
Then her classes became more about selling the device and some of her students started coming to my class to learn the procedures and complaining to me about the quality of Dr. Roy’s classes.
She also built her own directory that started to draw traffic away from our directory.
After several warnings from me about my concerns, I cancelled her rights to teach the class and I quit helping fill her classes.
After this happened, she approached the US Patent & Trademark office and made blatantly false accusations against me in an effort to cancel our marks and make them generic.
Now she has sent an email full of lies to our members who have invested time and some of their best efforts into helping find ways to use these procedures and the ideas and research from these procedures to help others-and so discouraging them with lies.
Should Dr. Roy win based on her false complaints to the US Patent & Trademark office, it’s true that you’d no longer pay monthly membership fees. It’s also true there would be no-one to spend the $800,000 the Cellular Medicine Association spent in 2018 to try and keep the imposters who do substandard medicine beat back from using our names to advertise anything at all.
But, Roy would be able to sell any PRP kit using our names to profit from the device.
Our policing takes time and is not perfect but has been largely effective at helping protect our reputation and our ability to profit enough to use quality supplies and still pay our staff and ourselves.
In fact, without the trademark intact, anyone could use the “Vampire” name to advertise anything as a “Vampire Facial.” A make-up artist could advertise a red mud mask as a Vampire Facial.
The same thing would happen with O-Shot® and with P-Shot® and anyone could use the names to mean anything…even non medical procedures done in anyway at all.
As a result, the names would become as valuable as “liquid facelift”—essentially becoming of no value to help communicate any degree of what will be done or with what degree of quality of care. Anyone will be able to teach any procedure (even things not related to PRP) at any price and call it a class about the Vampire Facial.
We will lose the source of the millions in advertising and research that our group has done thus far.There would also no longer be the CMA to issue certificates to help with securing reasonable rates on our malpractice insurance (our group has gained a reputation that helps with rates for many of our members).
Also, one of our members was successfully defended in court because he was following our accepted protocols…this protection would go away.
In summary, should Roy’s false accusations prevail at the US Patent & Trademark office prevail, then our investment in these names will become close to worthless in the US.
If justice rules, we will win this case. In the mean time, if you receive or have received a letter from Dr. Roy’s attorney (will be from a mail chimp address)…
Mark the email as spam (since Roy’s attorney illegally harvested your name from our directory and emailed you by mass email without your permission).
I believe we will win, but courts can sometimes make unexpected rulings (it’s just a 3 person board, not a jury).
Again, I believe we will win and I will continue to spend money on marketing and research and on lawyering ($40,000 this month so far) to create better ways to help our patients and to bring a better life to us and our staff.
I continue to be honored by the quality of provider in our group and by our esteemed teachers. I’ll continue to fight for our reputation and to find better ways to help our patients without going broke from device manufacturers and insurance carriers who would take advantage of us.
P.S. This is the first time I’ve ever made a post with anything negative about another doctor. I’m sad to have needed to do so to protect our work and the further helping and protection of those who need our services.
Topics Discussed in Journal Club with Pearls & Marketing (JCPM2018Nov28)
*Treating scars, new research *Leveraging national press to help with your local marketing for free *How to talk with patients in the office about the P-Shot® (from a very successful provider) *How to choose your patients (and when to choose to not see a man for the P-Shot®) *Marketing practices of one of our star physicians *Marketing tips from a 30 year breast surgeon *Creams that help scars
This episodes includes comments from Dr. Vernon Williams
Video and complete transcript available on membership sites (for members only).
Where to log in to see the webinar (choose the membership site you frequent most)…
We very much want to see the financial success of your practice and the healing of your patients to improve because of your membership in the Cellular Medicine Association & its provider group(s).
Please, always quickly contact us if you have questions about the material or if you want to see better results or more phone calls from people who need you. You should receive prompt and cheerful help (if you expected more than you received, please contact me).
The most dangerous thing may be not criticism but applause. If you love the applause, you start to freeze for fear that the next thing you do will not bring applause … CONTINUE READING
Why You Should Use Altar™ After Every Vampire Procedure
The active ingredient in Altar™ is SBD-4. SBD-4 is a patented extract from the root of the plant Angelica sinensis, which grows in the high altitudes of China, Japan, and Korea. SBD-4 has been demonstrated to do some rather remarkable things … CONTINUE READING
Possible Treatment of Erectile Dysfunction Post Bicycle Injury
*** The following is a transcript of a webinar for the Cellular Medicine Association from Sept.12, 2018, with Dr. George Ibrahim. The full transcript can be read and heard by logging into the membership sites.
Typically, this (erectile dysfunction from a bicycle injury) happens oftentimes in younger guys where erectile dysfunction would never even be thought of. They are, by definition, usually very active, because they’re riding a bike … CONTINUE READING
Charles Runels: Let’s talk about something that I hate, I really hate, it’s dyspareunia or pain with sexual intercourse in women who are already suffered from breast cancer. Imagine the loneliness of having already gone through all the treatments for breast cancer, and now that you’ve survived, and you’ve lived through radiation, perhaps chemotherapy, perhaps surgery, and now you’re left with the inability to use estrogens that are needed to maintain the lubrication that’s involved with comfortable, sexual, intercourse.
Unlike decreased arousal, where a woman who loves her husband can accommodate, or decreased orgasm, where a woman can still enjoy sexual intercourse without orgasm, dyspareunia makes a woman actually avoid her husband. Her fear is often that if she arouses the husband, then the husband becomes more frustrated. I hear of women who will even avoid touching or holding their husband’s hand, even though she loves him, because of fear of arousing him, and then causing frustration because they can’t have sex. The things that have been tried for this … The thing is, it separates lovers.
Now, who am I? My name is Charles Runels; I’m the inventor of the O-Shot® Procedure, so I’ll just tell you right now, we’re coming to talking about how that might be a solution to this problem. I’ve been treating women for sexual dysfunction for the past 18 years. I’ve been a physician for 20 plus years, and I’ve done research in the area and I think we have something to help maybe.
But let’s go ahead and talk more about what’s been tried, and we’ll get to what’s new. If you look at a search on PubMed, which is the main way for finding research that physicians use worldwide. If you look at the different solutions that come up, not a lot of research in general, when you search dyspareunia and breast cancer, but if you look at the answers, it’s really very frustrating.
The conclusion of this one is, “Breast cancer survivors with menopausal dyspareunia …” In other words, they cannot use estrogens for fear of recurrence of the breast cancer … “can have comfortable intercourse after applying liquid lidocaine.” So, she’s back to accommodating, but not necessarily enjoying, and I’m not saying this is a horrible thing, it doesn’t mean it’s not something that can be used. But, if you look at the research that’s shown here, it involves basically, numbing things. It can get on her lover, and so they both can now put their genitals together which allow some closeness, but it really doesn’t allow the pleasure of sex, like it could be if you just made the pain go away instead of numbing it down.
So you look at this other one. Look at what they’re recommending here … Aqueous lidocaine. Not so good. These are the most relevant searches for this problem. If you look at this one, “Olive oil, exercises, and moisturizers.” So, when it comes right down to it, it’s a long way of saying that the current best practices are a combination of lubricating, numbing, and some sort of counseling. Counseling as in learning how to stay close without the pleasure of sexual intercourse.
My hats off to all the research that’s gone into finding a solution. I’m not angry at the solutions or the people that have tried to find these solutions. I’m very angry that this is the best we have. Starting about eight years ago, I started using Platelet Rich Plasma (PRP), first to inject Platelet Rich Plasma into the genital-urinary space, and we published some research about that, which you can find if you go to O-Shot®.info or O-Shot®.com, it wants … Puts you on the same web page, and then click on research. When you click on the research, you’ll see a list of various things that can be done to help with sexual dysfunction, and other problems secondary to that effect … Wait a minute … Then, at the top of that, you’ll see a paper that we publish, this is me, and we talk about all the reasoning why using Platelet Rich Plasma maybe of help, and we showed that we were able to decrease female sexual distress significantly, extremely significantly by using Platelet Rich Plasma to cause rejuvenation of the tissue. Platelet Rich Plasma has been demonstrated in multiple studies. Look at how many studies you have with Platelet Rich Plasma. Over 10,000 the last time I looked.
Yeah, there you go. 9,987 papers about Platelet Rich Plasma. This is not some new thing, and they go back over 20 years. It’s been known to help with healing of hard-to-heal tissue. The dentists have used it quite a bit. Orthopedic surgeons are trying to heal. Both of those specialties have to heal bone and cartilage, with not a good blood supply. And so it’s been used in that arena, and in 2010 I started using it for the vaginal periurethral space, and we published this study soon after that.
Now, there’s a new … We’ve been seeing this help for the past eight years, but a new study came out supporting it, and I want to get to demonstrate and talk more about what they did with this study, where they used Platelet Rich Plasma combined with hyaluronic acid for the treatment of vulva vaginal atrophy in post-menopausal women. You can see here they did not …. It wasn’t just about the atrophy. They followed dyspareunia, and saw female sexual distress improved significantly with that treatment. I propose that it would have improved much, much more had they used our protocol. But still, it was statistically significant. So we’re back to my protocol, but let’s … Let me break this down to what we initially did in our study, so that you can understand what they did.
In the study that we did, we took the Platelet Rich Plasma and then … which you get by doing a centrifuge, and then the centrifuge separates out Platelet Rich Plasma from the red cells, and I can show you a picture of what that looks like right here. So you start off with a tube that looks like just a tube full of blood, has an anticoagulant in it, and then when you get through with the centrifuge, you’ll have red cells at the bottom, but instead of a buffy coat and platelets on top of it, and plasma on top of it, there’s a gel that separates them so that now they’ll remove the plasma and inject it into the area. So, it mimics what happens every time you have surgery or injury. This is not a new idea, it happens every time you have to heal a wound that the platelets release growth factors, and then those growth factors cause recruitment and activational plural potent stem cells that migrate from the bone marrow and heal the tissue.
This is very well known in the orthopedic and dental space, so much so that it’s quit being about whether it works or not, it’s the best way to use it. You can see here’s one from the National Journal of Implant Dentistry, where looking at using calcium chloride to activate the Platelet Rich Plasma. Now, what does activation means of this FDA approved, and what does this all mean?
Your blood does not require approval by the FDA. It’s your blood. Just like your saliva, your hair and your skin. But if you’re going to isolate a part of the blood for re-injection to a human body, you should use a device that’s FDA approved for that purpose. Those devices vary based upon method that isolates the platelets and how the platelets are activated. For example, this one uses a gel that I just showed you, and to separate it. But others use filters, and double centrifuges and pipe fitting techniques and all sorts of things, so, that’s not the only way to do it. This one has a gel that separates. There’s the gel … the red cells from the plasma, and then the plasma’s re-injected.
Activation is widely accepted within the orthopedic and dental literature as being helpful, because it tells the platelets to release all those growth factors. That activation can be done with vacuum, calcium chloride, calcium gluconate, and with a hyaluronic acid filler, like Juvederm or the orthopedic versions, like Hyalgan, because the platelets interpret that to being a form of collagen, which causes the platelets to release those growth factors and cytokines.
This particular kit has a small amount of hyaluronic acid, which is again like a Juvederm, or Restylane, or Hyalgan, or Synvisc, or all hyaluronic acids, that comes with the kit, there are other kits that come with calcium chloride. Some kits don’t come with anything, and you have to add the calcium chloride or the calcium gluconate, or the HA yourself. So, this kit was sponsored by a company that makes a kit … Region makes a kit, that comes with an HA. The point I’m making is that there’s really two variables here, right? They’re injecting two things. Platelet concentrate, which they’re calling … That’s the word they’re using for Platelet Rich Plasma, and hyaluronic acid. That’s two different variables. So, don’t let that confuse you though, because the HA is just a way of activating, and you never cause rejuvenation of tissue of any significant degree with an HA, although there is a mild effect. The major effect is from Platelet Rich Plasma.
Now, how do I know this, and what’s my background? In addition to inventing the O-Shot®, also invented the Vampire Facelift®. This was something that most people don’t know, but when I was experimenting this, which Kim Kardashian did, and many celebrities have now done, when I was inventing this, I was actually doing this as a way to figure out how to use it in the genital-urinary space. Now, of course out of it came a useful cosmetic procedure, but as a wound care physician, I had already been looking at this in other arenas. For example, this one. Where PRP is used in combination with a HA for healing a wound, and others like it, where … But others like it, for example this one. Using PRP combined with an HA, and it helps heal wounds. But it’s the PRP that’s active and you have many, many studies showing PRP as a stand-alone for healing wounds.
So, if you go to PubMed and you put in Platelet Rich Plasma, and then you put wounds behind it, or wound healing, you get lots of stuff and most of these don’t use an HA as part of the process. And you can see it’s all about it heals muscle, there’s collagen, there’s new blood flow, and so it’s really a very well-documented way of regenerating tissue, all tissue types, nerve, blood flow, collagen, even fat cells.
There are 1,700 studies. Back to what we’re doing here with the dyspareunia secondary to dryness from lack of hormones, particularly estrogen, in the case of someone who’s had breast cancer, what we’re doing is using the PRP to recruit plural potent stem cells that grow the new tissue, and the HA as an activator. Go into more detail about what the studies show. They measured vaginal health index, which you can see I said that ought to do with fluid, the PH, the moisture, and they did a Xylocaine cream, but we use a Bupivacaine/Lidocaine/Tetracaine cream that works I think better than this. So, our pain ratio would be different. They injected four CCs in the vestibule in the first three centimeters of the vagina using a point-by-point technique. This is not needed. This would hurt more, because you … PRP spreads so easily through the tissue. You don’t have to do so many injection points. In the posterior vaginal wall, and the posterior wall of the introitus.
You can see here where they’re putting the injections. The thing about this is that it’s missing out on the anterior wall. Now, why would they skip the anterior wall? The reason is that there are multiple studies showing that HAs in the anterior vaginal wall, hyaluronic acid in the anterior vaginal wall can cause granulomas, it can lead to obstruction. That’s not a good thing. But by leaving out the anterior vaginal wall, you miss rejuvenating the Skene’s glands of the periurethral glands. Let me show you where those live.
If you look at the cross-section through the vagina and urethra, the Skene’s glands or the periurethral glands are very near the opening here on the front side of the vagina. So, if you’re doing all the injections back here, it’s not going to do anything with that. So, why is that important? Why is the Skene’s glands or the periurethral glands important?
Actually, let me get this where you can see it better. Here’s the urethra, here’s the vagina, here’s the periurethral glands or the Skene’s glands. Here’s another picture of it showing you where it may open up just near the opening of the urethra. Here’s another view of it, showing the Skene’s glands are right there, all of it on the front side, but these guys if you go back and look are injecting on the back side. That’s not a bad thing, they help the woman, but it’s a less than it could be thing. Now, had they injected the anterior vaginal wall, actually my feeling is that there’s not enough HA in that particular kit to cause a problem. I’ve used it, it’s a good kit, I don’t think it’s enough to cause a problem.
But, I don’t know that I’d want to risk it in someone without a study showing that I’m not going to see granulomas, like [Swissman 00:16:15] demonstrated before. So, when we do our O-Shot®, we inject PRP here, but we do not use an HA, so we use a PRP that’s activated with calcium chloride, like we talked about over here, using calcium chloride instead of an HA to activate. Back to our study, when they did this they activated with an HA and now these platelets have released their growth factors, we don’t even care about the platelets anymore, the growth factors are in the plasma, and that’s what gets injected here, after it’s been activated.
If you look what happens, it’s pretty spectacular that the effect of it … Now, this is PH and vaginal health, and you can see it levels off at about three months, which is what you see in most soft tissue studies. When they ask the women would you like to repeat it, 19 out of 20 of them said that they would. But then if you go back and you think well wow, what if they would have actually injected here, just like the men’s prostrate excretes a lot of fluid, it’s the main thing that makes the fluid when a man ejaculates, a woman’s Skene’s glands do as well. We actually have women who ejaculate for the first time after using PRP in the anterior vaginal wall. I think they miss some of the benefits. When we did our study, we had a larger improvement of female sexual distress than they did … they saw with their study.
But, I’m still very grateful. It’s a good study that shows that PRP with an HA can help, but I’m telling you, we’ve been doing it for eight years, and PRP injected the way we do with our O-Shot® does more than an improvement … The improvement in the female sexual distress that was shown here. So what the heck is the female sexual distress scale? This is what it looks like. You can see the most you could get … The more of the … All these questions, 13 questions are answered, and each question has a maximum of four, with a higher score means you’re having more problems. So, if you’re worried about your sex not at all, it gets a zero, all the time gets a four. So, the most you could get was four times 13 and we were able to see a large percentage of our people go from distressed to not distressed when we used PRP the way we do with the O-Shot®, which is anterior vaginal wall and the clitoris.
It’s a really important study. I think it backs up what we’re doing. But, I think that we have a better technique that we can use. I think if you want to know more about it as a patient, you would go to our O-Shot® website, which you just type in O-Shot®.com, or dot info either way, it gets you there. O-Shot®.com. Then, when you’re there, if you click on … You could read all about it. Read the research. You could see if you go to research thing here, you can see me covering other research projects that have to do with what we’ve done like in necrosis, urinary incontinence, all sorts of things. There’s a chapter about it in this textbook, and you can see some lectures where I’ve lectured various places.
That’s the place to read the research. If you want to see one of our providers, almost every page has a place on it somewhere that says that. Click here to find provider, and then once you’re there just click on your country, or your state and it will show you people in that area, or if you give it permission to know where you are, it will just show them nearest to farthest away. So, we have multiple countries, and multiple states here. So almost every state, and 50-something countries. Now, if you’re looking for someone who does other things, like treats lichen, use radio frequency, a laser, or has Emsella machine, then you’ll see those icons by their name as an indication that they treat that. So, this doctor for example uses laser and treats Lichen Sclerosus. This means that they’re a teacher for us, and I think that’s all you need to know. That’s where you go obviously, nothing works all the time ever, ever. Results do vary, so you should speak with your physician and speak with one of our physicians about being treated this way.
Now, if you’re a physician, you go here, under physicians and there’s a place to get free information. You just fill this out, and we’ll send it to you. Tell me where your office is, and you can get any kind of free information you want. If you actually want to go ahead and apply for either online or hands-on training, you go to O-Shot®.info/members, and that’s where we list a place for you to apply to become a member of our provider group. We have a very specific way of doing this. As you can see, [inaudible 00:21:22] every way that you inject PRP matters, and we have a very specific method that we teach. As a matter of fact, if you don’t see someone listed on our directory, then they’re not licensed to use our name, and they may be doing something better, but more likely they’re doing something not as effective. I highly recommend you use someone off of this list, and if someone’s using our name O-Shot® and not on this list, they’re pretending to be part of our group when they’re not. So, you can make your own conclusions about what that means morally.
Anyway, here’s where you would apply, O-Shot®.info/members, if you’re interested in being part of us. This is under the umbrella of the Cellular Medicine Association, where we do research. We spend hundreds of thousands of dollars every year researching the areas of female and male sexual dysfunction. We have teachers around the world. We also have online training that you can apply for. I hope that’s helpful to you. I think this is really important research, and I’m very grateful to these guys for doing this. But, there’s a lot more to know and we would love to help you learn more about it, whether you’re a teacher or a provider. Thank you very much for your attention.