JCPM2019.7.10VampireFacialResearch.TearTroughs.BagsUnderEyes.OShotPearls.DyspareuniaPostRadiation

Topics Discussed Include the Following…

*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

Transcript

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. Edward Tangchitnob, MD, ACOG

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.

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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.

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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.

Gyn Surgery with PRP as Adjunct<--(click)

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: Yeah.

Dr. Runels: Okay. I’m going to put a link … I don’t want to stop your flow and I’m not changing the subject. I’m just going to put a link into the chat box, guys, with a few … to just a PubMed page that shows a few, four papers, about using PRP in surgical situations, one with mesh, one with rectal-vaginal fistula, along those similar lines. So, when you’re using this as part of a hysterectomy are you making a gel with your Regin kit, or how are you processing it to make it do the same thing that the previous Vetigel® was doing?

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.

Dr. Edward T: Thank you, everyone. Goodnight.

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Q&A.The “Capture & Heal” form, treating acne scars, treating dyspareunia, our current research…

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International Society for the Study of Women’s Sexual Health (ISSWSH)
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Transcript

I’m just back from an ISSWSH meeting, which I highly recommend that you guys do if you haven’t been yet. Here’s their website for the Fall course. Maybe once every year or two I recommend. You can see the content is pretty amazing. These are the handouts that they had. I thought I would just run through some of the highlights of the lecture that Andrew Goldstein gave on dyspareunia.

Dyspareunia

Dyspareunia, as you guys know, to a gynecologist, it’s like saying back pain to a orthopedic surgeon or an internist—the etiologies are so numerous that it’s almost the name of a symptom not a diagnosis. Although there was an article, an editorial, in the Green Journal Obstetrics and Gynecology about three years ago now where the editor said, “We’re not treating it as well as we can, and often times it really does go undiagnosed.” But even with that being the case, it’s worth looking at in more detail, the different diagnoses/etiologies

I’m going to unmute your mic, Kathleen, because I know you’ve been to this meeting (ISSWSH). You are going to have things to say about it. It would be very helpful to talk about it, I think. I don’t know if you’re able to talk. Can you hear me, Kathleen?

Kathleen Posey: Yeah, I can hear you. Can you hear me?

Charles Runels: Yep. We’re recording this because even though not so many compared to speaking, not a huge percentage of our people make it to the call, usually it’s in the neighborhood of 20 or 30 people out of over 1,000 people, I think it’s really worth thinking about pain/dyspareunia.

The good news is that often times when we have pain and it’s not easily diagnosed, our O-Shot® procedure seems to be working. Whether it’s healing damaged tissue or if it’s causing a decrease in inflammation like it does with lichen, I don’t know. But I thought we’d run through these known causes. I don’t pretend to be giving this presentation the way Andrew Goldstein gives it, but I’ll hit the headlights, the highlights. Hopefully, you guys can hear the lecture for yourself sometime in the next year or so.

This is the textbook that he helped edit about dyspareunia, which I highly recommend that you go through this. Eventually, I think there will be a chapter about an O-Shot. You can find this on Amazon.

This is the one, the version that he wrote for patients.

These are the known causes [see video]. Talk about this for a second, Kathleen. What on here do you see us helping with? Obviously, we wouldn’t try to treat fibroids with an O-Shot, but talk about this list for a second, and just the diagnosis of dyspareunia in general. Can you see it?

Kathleen Posey: Yeah, I can see it. I basically put PRP wherever the pain is. I map it out. I rule out the things like yeast infections, chlamydia, endometriosis, PID. I treat them just like we would treat those, but usually when there’s no reason, I just get out that Q-tip or just my index finger and say, “Where’s the pain? Does it hurt here?” Then I put the PRP.

Actually, a case I talked about a couple weeks ago was a anal cancer in a 40 year old that had radiation and complained of menopause and decreased lubrication. She went to a plastic surgeon who did Thermi-va on her, which only made her small vagina smaller. But mainly the pain was a posterior fourchette. I did put the PRP and did an O-Shot® because I do both. About two to three weeks later, her pain got better. That’s my method.

You can look at all these diagnoses. We know how to treat most of these things, but it’s the unknown ideology of the pain that I think the PRP helps. It doesn’t always. I had a classic vulvodynia around Hart’s line that was real painful, and she really didn’t respond that well, but that’s just one out of the many that I’ve treated. I’ll still try it on another patient like that, too. I wouldn’t limit it to that.

Charles Runels: Beautiful. Let me add to what you just said.

First of all, I agree. Most of the people, by the time they get to us for an O-Shot®, the patient’s already, before they are willing to pay cash, they’ve already been to other physicians and had lots of tests done. The good is that most of these things, if they were there, have already been treated.

The other thing I would add, which I know you do this, Kathleen. I know you treat some people for free, as do I, and that we’re both careful not to keep money if people don’t get well. I highly, highly recommend that everyone do that. If you’re treating pain and someone doesn’t get well and you keep their money, they feel like we stole from them. Even though we’re not used to giving back copays or whatever, insurance doesn’t refund money if we don’t … Obviously, we know we can’t get everyone well, highly recommend that if you treat someone for pain, and they don’t get well, either repeat it or refund their money.

By the way, the reason I’m talking to Dr. Posey for those of you that don’t know, you’ve been involved with the group right now for quite a few years. She’s been teaching it to other gynecologists. She’s a gynecologist, board certified, out of the New Orleans area, who has recently presented some research where she treated lichen sclerosis with a combination of surgical procedures and PRP, and teaches that method. A lot of experience seeing many thousands of women over the years as gynecologist and very well-trained, busy surgeon in the day. Back in the day, I know you were a high … Anyway, lots of experience.

Back to this list. Back to the list. The endometriosis, obviously, you wouldn’t treat it. The psychological, that hopefully is going to be teased out with your conversation. I wouldn’t try to treat psychological, obviously, with PRP. But let’s get to some of these pictures, though, because I think a lot of our providers don’t really know what to look for. I know that you’ve seen quite a few people who are being followed by a gynecologist-

Charles Runels: Some of these women, saw gynecologists who never diagnosed the pathology the gyn just went for the pap smear and never stopped to look at what was going on.

You just mentioned … This, by the way, is his algorithm for pain. I don’t show this, obviously, expecting anybody to memorize this whole thing from my overview here, but I just want people to realize there’s some thought that goes into figuring out pain. They’re not just willy-nilly treating someone without making sure that someone, if they’re not a gynecologist or a dermatologist, that someone hasn’t thought through a differential diagnosis … If there’s a rash for example, it should be biopsied. Someone should be thinking about that.

This first one is a big one. There is a pain disorder that’s associated with low testosterone. This is stressed over and over when I talk to people who treat a lot of vaginal and vulvar pain. The vagina and the vulva needs testosterone to stay healthy, and there’s a actual syndrome associated with pain and birth control pills, which almost always drops testosterone levels. Some women are susceptible to that, and some are not, but that’s something to think about.

This vestibulodynia of different ideologies is a whole subject in itself, but interestingly, I did meet a woman at this last ISSWSH meeting who had a woman with long standing vestibulodynia that was of this [neuroproliperative 00:09:01] type that responded to our PRP. Somehow it decreased that inflammatory whatever makes things go on here. This is a whole area for research that we need to take up, talk about. But obviously this is not a healthy looking vestibule. When you have this erythema around Hart’s line, then it’s worth thinking about testosterone creams. I think it’s worth trying our PRP as a way to modulate that.

Again, I’m just skimming through this just so you can see this should be thought about. This is that Hart’s line that you just heard Dr. Posey talk about that one. That’s inflamed, and this responded to using testosterone and estrogen creams.

Our O-Shot® is not the cure all, end all, be all, but I think it’s an extra tool that can be used in the thoughtful treatment of these problems, so I just-

I just wanted people to get a look at what some of this neuroproliferative. Vestibulodynia is a horrible problem. Basically, someone stays inflamed to the point that then if the inflammatory agent is removed they still stay inflamed.

A lot of times, they’re treated with creams that have some sort of propylene glycol or paraben in it that causes the inflammation. You’ve got inflammation, you treat it with a cream that actually causes a chronic inflammation to the point that when it stops, sometimes they’re left with a continued process that turns into this.

I think that was the main thing. The other thing to think about is here’s the pelvic floor muscles. Normally, these have been treated historically by palpating, as you heard Dr. Posey talk about, palpating and finding the place where a person’s tender, just like you would look for trigger points in a tender back and in the same way that physiatrists are now injecting PRP to treat this.

When you find that tenderness, you can now inject PRP. That will usually hurt worse for about a week and then it goes away. You have anything to add to these pelvic floor injections?

Kathleen: Not really. I’ve never really done them. I refer to pelvic floor PT, but I will say that even of the lichen sclerosus patients I’ve seen, a lot of them have pelvic floor dysfunction. You just touch them and their levator ani muscle just almost goes into spasm. It’s interesting, a lot of women when they’re touched, they wanna squeeze that butt together and I’m telling them, “Look, put your butt down into the table.” There’s a lot of comorbidity there with vulvar pain and then these muscles getting involved is what I see.

Charles Runels: Just to add to that, we do have people in our group who work with the pelvic floor therapists. I know you have them in New Orleans. Our little town doesn’t have one. But that’s a good referral source. One of our people actually had a pelvic floor therapist put a satellite office in their office actually they had a good working relationship [inaudible 00:12:30]. His O-Shot helps her therapy work better. That’s worth looking into.

The way that he established that relationship is he just had her bring one of her patients over and he treated the patient with the therapist in the room so she could see what was involved. Then she went back and did this therapy as she normally would and had a nice result. It’s a way both to help their therapies work better and to help everybody’s business. Let’s see.

Kathleen: At the conference in Boston, they talked about putting Valium in the vagina.

Charles Runels: They did.

Kathleen: Did they talk about that at all?

Charles Runels: They did. It didn’t seem to be as helpful, at least the feeling I got from the lectures, as using Botox. That was something that was talked about.

We don’t have the research showing that our PRP works with pelvic floor trigger points, but it should apply, since that research has been done in the physiatry literature with back pain.

They did talk at ISSWAH about trigger point injections of Botox and they mention diazepam and suppositories, but Botox seemed to be the first choice on the menu (before diazepam).

100 units is what they talked about using, which would be one bottle of cosmetic Botox. Some are doing it under anesthesia. I know Andrew Goldstein was saying he likes to use it without general anesthesia so he can tell better about where to put it.

Let’s see. I think that was the main thing I wanted people to see was just that. Oh, yeah. He does a vulvar vestibulectomy but he says he does a whole lot less of these than he did in the beginning of his career when people were not using testosterone creams.

It was really talked about a lot, especially in someone who’s on birth control and how common it is that that gets dropped in people who develop these pain syndromes, not just this vestibulitis pain syndrome. But this is a last resort, obviously, but it’s something that’s done just to know what’s out there. It can be done if somebody develops this pain that just won’t go away.

I think that we’ll find that there’ll at least be a subset of these people that get better with our O-Shot. We’ll see. I think that was the main thing I wanted to show. I don’t feel like it’s my place to just put all this stuff out since it’s their intellectual property, but I just wanted people to see that there’s a lot of stuff out there and it’s worth, I think, attending one of their meetings. It’s called ISSWSH, International Society for the Study of Women’s Sexual Health. Maybe go there once every couple of years and get a good update.

Amnion with the Priapus Shot® Procedure

Okay. We didn’t have as many questions this week as we normally do. We had one question that showed up on the Priapus shot website about has anyone used PRP combined with amnion with the Priapus shot. Some of us have, but I don’t think I have enough experience yet to tell you that it’s working better. I think it would be worth trying if someone didn’t respond and you were treated Peyronie’s disease especially if you’re trying to heal scar tissue, or someone just wanted to get the best that you knew to do.

Again, amnion is not stem cells, it’s where you’re harvesting the proteins from the amniotic membrane and then they gamma-radiate it. There’s nothing living in there. You just have the cellular proteins, the amino acid peptide chains that code for wound healing. That research has been done. I think just as a general help, I always like to add in a couple things that have to do with marketing and something to do with business.

Press. Men’s Health

We got a really big hit that’s worth talking about when it comes to the Priapus Shot® procedure. If any of you guys are doing this, it’s worth talking about. Dr. Gaines is in our group and he popularized the Gains Wave™, which is combining the Priapus Shot® with shockwave therapy.

You can see the guy in the Men’s Health article talks about the Priapus Shot® itself, or the P-Shot®, and it’s a very complimentary article, somewhat sensational, but he’s an entertainer. This is “Men’s Health,” this is not “The New England Journal.”

Obviously, we don’t make claims we can’t fulfill and you want to have a consent form and make sure that your explanation is not the same as “Men’s Health” magazine, but Lord knows we get huge amounts of negative press that’s absolutely uninformed and factually wrong. Someone wants to make this a little bit entertaining by talking about his penis he claims was 10 inches when he put it in the pump, I don’t know, maybe it was 10 inches. Who knows? But I’m not one to dispute him.

It’s a nice article that at least can start the conversation and maybe lead to you helping some people who need your help for their erectile dysfunction. That article’s there if you just Google “Priapus shot in Men’s Health.” Some of us are combining the shockwave therapy when people want it. Just so you know, if you look on our director, PriapusShot.com/members/directory, I added a logo so that if you’re using shockwave therapy people can find you.

Also, I know Dr. Posey uses the- That right there, that’s our shockwave logo.

Our Directory and Helping People Find You

If you are doing shockwave therapy and want the logo by your name, let me know and I’ll add it.

If you go to the O-Shot® directory, we have a logo now if you’re doing radio frequency. I think what’s gonna happen is as the research becomes more available, as we do more research, then people are going to want different flavors of our procedure based on their problem. I know there are some things that one of these machines, like Dr. Posey just mentioned, someone who had dyspareunia had a small, constricted introitus, that’s not the place to use your radio frequency device.

But you can see I added this. This is what I added, Kathleen, to indicate you’re doing radio frequency. If you want one of those by your name, just send it to support. I’m gonna put it in here…

support@vampiremarketing.zendesk.com.

I just put it in the chat box. You just send that and let us know and we’ll put the little thing. This means you’re treating lichen, this means you’ve put five people in our research project or a survey, this means that you’re using radio frequency device, and we have one for laser’s too. I need to update.

This is the legend so that whomever’s using this directory knows what these little symbols mean. I just added this last week, so I need to add that to the legend so that people know that means you have Thermi-O or radio frequency device.

So, let’s see Dr. Desmond Ebanks just put something in the chat box. So, the automatic pump he uses, I don’t, the guy talks about this pump like it’s the bomb. Who knows if that’s part of his journalistic license, but he talks about this pump as being a pretty intelligent thing, so I’ll ask Dr. Gains what brand of pump they’re using.

Let’s see whats the other question…
which shockwave device do you recommend? As far as the shockwave device, what I have right now is the E-Vive. There are others out there, I think they’re all made by, or most of the main brands are made by the same company. They’re kinda re-branded, depending on who’s selling it. So I think a lot of it comes down to who you want to work with. And who’s having a good deal, and good support. But right now, I have the E-Vive, which is the one Eclipse sells, in my office.

Treating Acne

Let’s see, Dana Kirk just said here, okay, so here’s the question from Dana. She says, “Often the Vampire Facial®’s being administered for acne scarring often have some leftovers. Anyone injecting into the larger pock marks? If so, is it worth activating?”

Ok, so this is a good question about acne. When I treat acne, I use micro-needling. But two tips on that….

First of all, if it’s in their budget to do Juvederm. If you think about what happens to the divet, or say the divets in say a basketball, if you put more air in it? The divets become more shallow, just from expanding the ball. So even before you treat the pocks marks, or treat the acne scars, if you’ll use some Juvederm, if they can tolerate it, as in, do they have any room for some improvement in the cheeks, and if it’s a female, almost always they do, unless they’re obese, they’ll have some. You can add to their cheeks and things look better. And the acne scars are already smaller (before you actually treat them). At least the ones in the cheek area.

Then, micro-needle with PRP (Vampire Facial®), but also go intra-dermal and sub-dermal with your PRP, subsize/undermine the scar, just like you would if you were treating acne scars before we had the Vampire Facial®, so taking the bevel of your needle and sub-sizing the scar releases it some. I

Inject a little PRP sub-dermally, inject some intra-dermally, and then micro-needle on top of it. Intra-dermally as in blanching the skin.

And all those combined will get a really nice result. Usually I treat them every six weeks for three treatments, and they love it.

As far as activating it for the face, I usually don’t (I used to do so). Because I don’t think it adds to it enough to warrant the extra pain. In the face. But I do activate the PRP in the O-Shot®, the P-Shot®, and for loss of sensation in the breast.

The Order to Do Shock Wave, Radiofrequency, & O-Shot® or P-Shot®

So Sherry, I don’t see your question, it just says … maybe you can type it again. Okay, wait, here it is… “Does it matter which order you do the p shot, the shockwave therapy, and did the p shot … okay….”

So, the way I think about the energy, whether it’s shockwave, laser, or radio frequency, the way I’m thinking about it is, if you’ve ever used, say, insulin or growth hormone, if you just take, if you buy Omnitrope or a growth hormone, or Genitropin, whatever brand. These are small amino acid or peptide chains. It will tell you not to shake, to gently stir when you put the water in. Just shaking the vial, it mechanically shears the amino acid protein chains, so it’s like taking the words of the sentence and just chopping them up and turning them into letters. And now that amino acid chain no longer acts as a small peptide signal. Right? So these amino acid chains act as signals that plug in to receptors on the cell, and that’s how growth hormone, that’s how insulin, it’s how all those amino acid chains work.

Over 200 made by the pituitary gland that we know about. Peptide chain signals. So, imagine if you did that, I have no research to back this up, but imagine if you injected a peptide chain, and then now you hit it with shockwaves. In the same way, imagine what happens to an egg when you put it in a skillet and fry it. Obviously those peptides or those proteins are being changed.

So the bottom line is, I like to use the energy, whether it’s shockwaves, lasers, radio frequency, whatever it is. Use that on the tissue first. And then immediately afterwards, same visit, then apply your PRP. Now if you want to, if you did the shockwave yesterday, or last week, or three weeks ago, or a month ago, and you wanted to do PRP after that, that’s fine, you’re not hurting anything. And if you want to, if you did the PRP three weeks ago and now you want to add the energy, you can. But in my opinion, as soon as you add the energy, you are probably shutting down whatever growth was taking place, from the PRP that you put. So it’s like you’re stopping, it’d be like you just watered a seed, the stem cells are [inaudible 00:25:26] stem cells that you just put there. And now if you’re trying to generate more growth by damaging tissue, now you’re crushing the little sprout or whatever tissue is growing. You’re crushing it or injuring it, in my opinion, if you didn’t do the shockwave therapy before it has a chance to mature.

So I would try to do them back-to-back on the same visit. And not do anything else mechanical to disturb the growth of the pluripotent stem cells until at least six weeks out, maybe even eight. To give what you did a chance to work.

So if you did the P-Shot® three weeks ago, yeah, you could do the shockwave now, but you’d probably be stopping whatever further benefit might have occurred from that original P-Shot®. It might be better to give it at least another three weeks before you did the shockwave therapy.

How Your Losing the Chance to Take Care of at Least 30% of the People who Visit Your Website…

Okay. Let me give you guys, I don’t see any other questions that are up. I want to give you guys one quick marketing tip, and then unless somebody has another question, we’ll shut it down.

This one has to do with when people get to your website. It is something you can ask your web designer for. This is my old internal medicine website. And this is just a form and here’s the scenario that will happen. And this is why this form is so important. You don’t have to make it, I just want you to know it exists, and this is a ten minute job for your marketing person. And if you don’t have one of these, you’re losing about at least 30 to 40% of the traffic that you could be getting to call your office.

So let’s say that you’re in, let’s say that you’re, you do an o shot, or you do a vampire, or you just do a pap smear on someone. And they go back home, and they go to Thanksgiving dinner. And they tell their mother, sister, friend, cousin, whatever, how wonderful you are. And they say, oh, what’s their name. And they say, oh, it’s Dr. Posey.

So now they take out their cell phone, or they remember the name and tomorrow, day after Thanksgiving, they google you. And they wind up on your website. If all you have is stuff for them to read, they read it and they go away. And there’s very good chance that a week from now, they’re not thinking about you. It’s all done. They will never become your patient.

If you put something on here that they can have for free, that costs you nothing, not a free consult, it’s gotta be something that costs you nothing. If you put something on here that they can have for free, and we’ve all done this before, that’s worth something to them, but costs you nothing, somewhere between ten and 30 percent of the people who land there will do that.

And then, now you have their email address. They start getting your newsletter, and a certain percentage of those will eventually become your patients. So it gives you a chance- this is not the main way you get your patients. Most of your patients are gonna be word of mouth, or someone googling you. But this plugs the hole, and it will increase the number of people you have by about 20 to 30 percent, that come in through your website, by capturing those people who would have never called you, had you not created this form.

And the way you ask for it, is you decide something you’re going to give away, first of all. It could be, and I, it should be a podcast or an email, or downloadable book. It doesn’t even have to be your podcast. What I’m giving away here is a podcast where I’ve just recorded for an hour the benefits of walking. So it says, number one weight loss melt secret, free immediate download. So that takes them, you ask them for the first name and email address, and when they give you that, now they’re on your email list, every time you send out an email, they get it. And as soon as they do that, and you can sign up for this so you can see how it works, as soon as they enter that data, they’re taken to the place to download that.

So, it could be an email, excuse me, it could be a podcast or a video that you made. I know Dr. Posey made one on incontinence. So it could be free video on the treatment of incontinence. In exchange for first name and email. And so you tell your, here’s what you say to your web person, if you want to do this, you should write this down. And this works for Constant Contact, A-webber, Ontraport (what I use most), Mail Chimp, all those different places.

All those different places, it all works the same. And you can go online and figure how to do this yourself, but it’s a 30-minute job at most for whoever does your websites for you. You say you want a form and you want it to be in the right upper-hand corner of your website. On the homepage at least, maybe on all your pages, but at least on your homepage. And it should offer the thing that you’re giving away. And it should only ask for their first name and their email address, that’s it. If you ask for last name, you’ll lose about half of them. So first name and email address.

And then you let them know that you’re putting out a new health lessons every two weeks. Don’t call your newsletter a newsletter. Nobody really cares about your news. Give them a name that implies some sort of benefit. So I call this Health Lessons. You can call yours whatever. And then tell your person to put that on the form.

If you supply them the link to the thing you want to give away … You realize also on Amazon, there’s a lot of books for free. You could literally find a book that you can read on Kindle for free and give that away. But I recommend you find something either audible of a podcast or a video. Preferably something that you did. And that’s it. That one thing is gonna increase the production of new patients by your website by 20 to 30 percent. Now we talk more about this sort of thing in my workshop where I teach marketing, but there’s your freebie right there that is just some of the best stuff.

Okay. Let’s see if there’s any other questions and then we’ll shut this down. We didn’t have a lot of questions on the websites. Okay. I think that’s it. You want to add anything? And thank you for helping us, Dr. Posey. I know you’ve had a lot of … I think more experience with treating lichen with PRP than anybody.

Do you still treat the clitoris even if the woman is there for urinary incontinence?

By the way, the way I think about this, it’s all the freaking O-Shot, it’s just we’re varying the way we do it. Just like you do a hysterectomy and you vary the method based on who you’re taking care of. It’s all the same thing. But Dr. Posey made a good point and this is worth remembering, because some people asked me if they’re there for incontinence, do you still treat the clitoris? Or if they’re there for sex, do you still treat the anterior vaginal wall? Or if they’re there for lichen, do you still do the rest of the O-Shot? Or for pain, do you still do the rest of the O-Shot?

There’s two reasons why you treat all of it. One is people lie about sex. Everybody does. And so if someone says they’re there for incontinence, maybe they’re not. Maybe they’re just too embarrassed to tell you. Or maybe they’re living alone, single and they don’t want to tell you they have a lover. Whatever reason. Maybe they just decided it’s not your business. And of course, you would want to treat the clitoris if you’re treating for sex, but you would also want to treat it for incontinence because if you look at the anatomy, the clitoral tissue actually comes around and forms some of the structure for urinary incontinence.

Also, it could be that those nerves of micturition that come down through that area are helped and our clitoris is acting like the wick to help rejuvenate those nerves of micturition. We do know that we have people with urgent incontinence that are getting better as well. And we’re not sure exactly why.

So I always treat the clitoris even if it’s for incontinence. And of course, if you read Grafenberg, the urethra is very erotic in women and you would definitely want to treat (even if there for sex). Also, you have the female prostate gland or the Skene’s glands, so you would definitely want to treat the anterior vaginal wall, not just the clitoris if you were treating for sex because the urethra is such a sexual organ as well.

And if you’re treating lichen and you’re hopeful that it’s going to get better, and you’re down there anyway, why wouldn’t you go ahead and treat the structures that have to do with sex so that that can be recovering at the same time you’re treating the lichen itself?

One big plug though, if they have sclerosis or phimosis, where you cannot pull that clitoral hood back, which many of them do, then you can go ahead and treat them, but make sure that you don’t stop there and you refer them to Dr. Posey or someone else in our group who knows how … If you don’t know how, someone else who knows how to free up that clitoral phimosis. So if you can’t retract the clitoral hood all the way back to see the shaft, if all you can see is the tip of the glans or if you can’t even see the glans, then they need a surgical consult from one of the people in our group so that that can be exposed and be more responsive. It’s hard to have good sex if you can’t get to the clitoris.

Okay. I think that’s enough rambling. Anybody else have any questions? If not, I’m gonna shut it down. Thank you for your help, Dr. Posey. Thank you guys for being here. I’ll put a recording up by the end of the day.

What can you measure with a ruler that gives a clue about a woman’s ability to have an orgasm?

Kathleen: I just wanna say something that I hear … I mean it’s going off on a little bit of a tangent. But to me, a lot of times, they want the O-Shot because they want that penis and vagina orgasm. And yes, it does help that somewhat, but I’m really … I look at a lot of vaginas, and I’m really paying attention to that distance between the clit and the vagina and/or urethra. And it really … You oughta start looking at it, Charles, because it varies with women. Some of them, it is like five to seven inches.

Charles: Yeah, it’s huge.

Kathleen: When I talk to those people, they have never had a penis and vagina orgasm. It might be something to really examine the person before. And if you really talk to them about why they really want the O-Shot, I’m seeing 70 percent of them really want that penis and vagina. And it’s being advertised or said it’s gonna make them have that. Just be careful because if that distance is a long way, yeah, the orgasm will get better. But to bring you to surgery, in my opinion.

Charles: Let me add to that. First of all, what you said is backed up by research. And that research I think is actually on our O-Shot website. But there was MRI studies showing that the further the clitoris is from the vagina, the harder … It was a correlation between … It was done about two years ago. You know this research, so you’re seeing it actually in your patients.

But there was a study where radiologists looked at women who can easily have orgasm and those who have trouble. And the distance from the clitoris to the vagina correlated with ability to have orgasm. And the size of the clitoris correlated.

Now, her conclusion was that she showed it, but there was nothing to do about it. Actually, we do know some things to do about it, putting someone on testosterone is going to make the clitoris larger. And it could be that doing our O-Shot® procedure actually helps, even though it’s not going to make that distance shorter or smaller, it could perhaps make it more responsive. But there’s also always a place for surgery, and there are ways to do that that you specialize in and others in our group to bring things closer together.

Now, and I’ll also say that of the things that we treat, trying to help a woman achieve penis and vagina orgasm, who is able to have it with a vibrator, is one of our more difficult problems. I think our success is probably in the 30 to 40 percent range in that group. Where if you’re treating incontinence in a younger woman, stress incontinence is probably closer to 80 to 90 percent.

So I agree that something ... And it brings up another point in that I recommend, especially in the beginning, that people stick to the problems that we have the high success rate, so the provider doesn't become discouraged. I know you were very motivated and trusting it. But way back, years ago, when we didn't have so many people doing this and we had less research to back it up. But anybody, even with our current researcher who is just starting out, they should probably avoid treating, I think, until they have some success under their belt, the people who never had an orgasm because those are the people who are more difficult and probably they're always gonna need testosterone on top of what we're doing, I think.

And the people who we just mentioned trying to have an orgasm with penis and vagina sex, they're more difficult. Stick to the stress incontinence, the dyspareunia, the lichen sclerosis, the women who can have an orgasm and wants to be stronger, those are our more easier cases. And in all cases, always, always, always, in my opinion, if they don't get well by the end of 12 weeks, then either offer them another treatment or give them their money back because we can make a profit and take good care of people without having to have people feel like we ripped them off.

Anything else, Kathleen?

Kathleen: I didn’t mean to say it wouldn’t help because I do think it helps and I do think you can even … I think the O-Shot, by putting it in the vagina, does shorten the distance a little bit. And maybe millimeters like what the P-Shot is doing. And it can get better, it just can’t … When you really see a big long distance, I would ask them and then I would just say, “Your orgasm is probably gonna get stronger, easier to obtain, but it may not help that.” I don’t know, it’s hard to give them a negative … I wouldn’t give them a negative embedded command. Just watch it if they’re there for penis and vagina orgasm.

Charles: I’ll tell you what I tell everybody. It’s good advice. And what I tell everyone when I’m leaving the room is I’ll say, “You just spent whatever amount of money it is. And for that much money, you have to love it. And if you don’t love it, I want to know about it.” Because of course, I’m gonna be following up with them. But what I found when I follow up with some of the people … So when people contact me and they tell me they’re not happy, I refer them to the doctor who took care of them because I’m not their doctor. So I don’t need to be involved. But it’s helpful for me to know who took care of them. Then I call the doctor and talk to them and see if I can offer help.

But back to this thing about satisfaction and setting expectations. I think that what I’ve seen happen sometimes when people are not happy is they never let their doctor know. Because maybe they’re afraid they’re gonna hurt their feelings or there’s gonna be some sort of conflict or something. I think it’s helpful to actually tell your patient, “I want to know. I want to know if you don’t love it because I want to take care of you, and I don’t want you to feel like that our energy and time and your money has been wasted.” And that really helps a lot, both with you getting them well and helps prevent them sliding away disgruntled without you ever knowing about it.

And in the process, you can say what you just mentioned, Kathleen, that if it’s a more difficult case, it’s worth telling them, “This is something that a percentage of,” if you’re dealing with someone who’s trying to have an orgasm with penis and vagina sex, “This is something that doesn’t work as well. We have a much higher percentage with treating stress incontinence, but we do have successes that by our surveys, are in the 30 to 40 percent range. If you want to try it, we’ll do it. But I want you to love it. And if you don’t, let me know. And we’ll either repeat it or we’ll figure out something else, including, I won’t keep your money.”

And in the end, although you give back money occasionally, you wind up making many more people happy and making more money and you sleep better at night.

Okay, I think that’s it. Thank you guys for your attention ’cause this thing … What we’re doing here, I think, is really changing medicine and I’m the facilitator between all you guys thinking about it and all the feedback and all the good research. So keep it coming and I’ll try to keep pouring our money back into it.

We have two double-blind placebo studies going on now. We’re having a little trouble filling the orgasm study (click to help), so I’m gonna put out a link to that again. So if you guys know people who live in the Washington D.C. area … Bottom line though is we’re investing into the research. We’re investing into supporting our group. And I think you’re gonna see medicine change a lot in the next five years from what we’re doing. Okay, you guys have a good day. Thank you, Dr. Posey.

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