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Krystie P. Lennox He is an expert in [inaudible 00:00:02] class that sold out very quickly. Those of you [inaudible 00:00:16] I'm sure you'll learn tons. Dr. Runels, to you.

Charles Runels: Thank you. So thank you guys for having me. Leonardo da Vinci said that he wanted to do miracles. And I think that if you are careful about selecting your patients, you can come close to doing miracles with PRP. And I think we might as well face it, if we wanted to make money, we could take half the energy and do real estate or something. But most of the people in this room, we're here because we want to do miracles.

I have a couple of things, disclaimers, I have a couple of non-profits, no companies making money, although we've been offered some interesting money to put our brand names on different devices. We do have a group though, and much of what I'm telling you today comes from that group. I've become more of a note taker. We've published 2 papers so far this year, and 2 more that were approved this month. We're in 50 countries now; this slide has gone up a lot just in the past couple of months. Many of the ideas that I'm giving you are from the people in our group. Many of whom are in this room, so my hat's off to them.

Facial aesthetics. You heard some interesting ideas yesterday about shape, and I think it's worth noting that some mathematicians have thought about shape. Leonardo da Vinci, Richard Feynman, actually 5 Jewish scientists won Nobel Prizes this year. Richard Feynman was a physicist who won 2 Nobel Prizes, and he was also interested in beauty. This is one of his notebooks where you see him sketching women on the same page where he's doing math, and he had ... If you go to the internet, these are all his sketches. Here's another mathematician, Dr. [Marcourt 00:02:24] who was a bridge engineer and became an oral surgeon, and he did that topographic map. Lots of measurements about shape.

Here's the guy for whom the movie The Elephant Man was made, and you can see that that shape would not be attractive no matter what color or texture. But the Blue Man Group, you can see even though they look like they're made of plastic, and they're blue, they would still be attractive because of the shape. So you heard a lot about shape yesterday, and when it comes to fillers, or HA fillers, I think there's nothing that beats an HA when it comes to shape.

A lot of people who are disheartened by platelet-rich plasma, it was because they were trying to make platelet-rich plasma change shape. On the other hand, if you know how to combine it, you can do some amazing things with shape if you combine the HA with the PRP. To me this is the perfect candidate for an HA filler. You can see that she has loss of volume in the cheeks, she's got some drooping. This is with an HA filler alone, this is no PRP, this is just an HA. Here's HA done the wrong way. Chasing nasolabial folds and that's me trying to correct it. So a lot of people tried to use, 8 years ago when I first started using PRP, a lot of people were trying to use it as a standalone, like an HA, and it will not work if you do it that way.

On the other hand, combined it can do ... Literally do some miracles. So what is the technology all about? I mean what exactly is it? I know a lot of you are doing this. This is just a picture of a test tube full of blood. If you just let it sit there, and do nothing to it, eventually it would settle as like a sediment, like if you put sand and dirt in water and just let it settle, with the heaviest settling to the bottom first. And the centrifuge just makes that go faster. So the red cells are the heaviest, they're at the bottom, and then that little pink thing in the center there is called the buffy coat, where most of the platelets live.

Now most of this technology evolved out of trying to heal hard to heal wounds. Dentists trying to heal a wound where someone had radiation for throat cancer. An orthopedic surgeon trying to heal tissue of the knee, where there's almost no blood flow and cartilage. That's where most of this technology came and a lot of the reason that the urologists, the gynecologists, and the facial plastic surgeons didn't really have to look at it, because it's a very vascular space, so there's not really a need to try to work on hard to heal tissue because it's not hard to heal. The devices that we are using were developed over the past 15 years by the dentists and orthopedic surgeons, and were just rebranded and repurposed for facial aesthetics and for the [inaudible 00:05:12] space, when we started figuring out that they worked in those areas.

So sort of an interesting opportunity in time if you think about it. Back in the 80s, as an example, the gynecologists were all using endoscopic surgery, but the general surgeons were not. The gynecologists were very proficient at doing hysterectomy endoscopically, and the general surgeons were still filleting people open to take out a gallbladder. And the first person to really teach how to take out a gallbladder endoscopically was a gynecologist. Something similar is happening now, in that you have a huge body of research that's been published over the past 15 years about how to use platelet-rich plasma, but it's mostly been looked at by orthopedic surgeons and dentists. And you are in opportunity, I think, to now take that research and apply it in these spaces. I'll get to some of the research we're doing, but first a couple of ideas about how it happens, and what about the FDA.

I hear this a lot, "Is this procedure FDA-approved?" And you may have patients who ask you that, about PRPs are FDA approved. The FDA does not govern your hair, your urine, your skin, or your blood. It's the Food and Drug Administration. You can also call it the Food, Drug, and Device Administration, and I'm glad we have the FDA, but they do not govern your blood. However, they should be governing, and they do, the devices that are used to prepare blood to go back into the body. So if you're doing these procedures, the correct answer is that the FDA does not govern your blood, but that's a procedure. Just like if you were suturing a wound, the suture material is a device that must be approved by the FDA. But the FDA has nothing to do with how you suture and tie a knot when you're sewing up a wound. In the same way, the FDA should and does govern the devices that process blood to go back into the body, but once that blood is in your hand, that's your business, and the FDA is never going to have anything to say about that.

On the other hand, it's called minimal manipulation. So if you take a piece of skin from one part of your body and you transplant it to the other, that's your skin, FDA has nothing to do with it. Same thing if you harvest an egg for implantation. But if you do a lot to the tissue, the FDA says, "No, this is no longer tissue, it's a drug," and they've been warning us for the past 5 years that, "We're going to start cracking down on the stem cell clinics, because stem cells are a drug." So just be careful, if you're doing or advertising stem cell work, you probably need to have that under the umbrella of the Institutional Review Board, because the FDA now counts that as a drug. But they specifically do not count platelet-rich plasma as a drug.

There's lots of PRP systems out there, and they all have to do with just the best way to get those platelets, because again this was developed with the idea of getting as many growth factors as you can into a tiny space. For example a surgical wound in the jaw, or in the knee, where you want a lot of growth factors in a small space. We don't really know what the absolute best therapeutic concentration is for easy to heal tissues. In the joint space, the research seems to indicate that somewhere around 5 times concentration of whole blood works the best. Honestly, I'm not so sure that whole blood has platelets in it. When you do surgery, when you do a biopsy, you don't have to go use the centrifuge. The same process, the [inaudible 00:08:52] cascade, the growth factors caused that wound to heal. So 1 to 1, the same concentration that is whole blood, that's all you need to heal a surgical wound.

I'm not so sure that wouldn't work with the face. We don't know. But there's 2 basic kinds of kits. There's a single centrifuge, like a gel kit, and there's a double centrifuge. The orthopedic surgeons would tell you, "You need a double centrifuge and 5 time concentration," but we don't know yet what we need for the face, and the [inaudible 00:09:27] space. Always laugh when people say, "Well there's no research to back this up." If you just go to PubMed and put in "platelet-rich plasma," there's 9,000 papers that have been published. Just 1 of the manufacturers, and there are over 20 of them that are FDA approved, just 1 of them sold over a million tubes last year alone. Do you really need to do, if you show wound healing, and fibroblast activity, and [inaudible 00:09:53] in the foot, do you need to go repeat that research for the arm and ear and the genitals? Maybe you do. But maybe, at least for some indications, you don't.

Section 1 of 5 [00:00:00 - 00:10:04]

Section 2 of 5 [00:10:00 - 00:20:04](NOTE: speaker names may be different in each section)

Charles Runels: But maybe, for the least some indications, you don't. And so we are publishing studies specifically for the genitalia and the face, but it's laughable to me when people say there's no research to back up what we're doing. Here's some of the growth factors. The other thing that people often get worried about is well, growth, is it indiscriminate? Like throwing fertilizer on your lawn and you're gonna grow bad horrible things like neoplasia? Or is it more intelligent? I think it's more intelligent because, if you think about what you're doing, these growth factors were ... They're made to heal a wound. So it makes sense that it would help fight infection, that it might help fight foreign bodies and nurture healthy tissues versus unhealthy tissue. And indeed, in all of those 9,000 plus papers, there's never been one neoplasia documented, there's never been one serious side effect documented, except in one case where it was injected into the eye, where they had a retinal detachment. So no one do a shot anywhere near the eyeball.

And if you had a serious side effect, you would literally have the first one known to mankind. So although it doesn't cure everything, this is something that can change lives and you never lose sleep over it. You're not going to cause blindness, necrosis. You're literally injecting what the body would use to heal itself if you did injury.

IG [inaudible 00:11:34], as a matter of fact, is what we use to document and measure acromegaly, that's one of the growth factors that are released. And people who have acromegaly, or high growth hormone levels, like Tony Robbins and these big guys. They have 25% less cancer than in the general population. So you could make the case that perhaps it's even protective for neoplasia.

So here's some of the things that PRP does. Collagen production, fiberglass neo angiogenesis, neurogenesis. Stefani did some nice work with some gel tubes back in 2010, 2011. Published quite a bit showing fiberglass activity and [inaudible 00:12:13] proliferation and not just numbers, but enlargement of fat cells, which makes it intense, right? What's the easiest thing to grow in you body? It's fatty tissue. And fat cells just go crazy with this. Which, if you think about it, that's helpful, because if you had fat in the cheek or the breast, you might be able to make those fat cells, enlarge and multiply and have a nice cosmetic effect. And indeed, I'll show you some pictures shortly, where that is true.

Now this is just an example of we do have double blind placebo randomized control studies in different parts of the body. Here's one with [dis 00:12:48] disease. Here's one where Stefani injected the back of the arm and biopsied and demonstrated all these tissue types generating healthy tissue. But here's two studies that are particularly interesting to what we're doing. In these studies, they had people who had exposed bone and tendon or the foot and ankle, from trauma. So the skin has been torn away. You're trying to regrow the skin.

And in one group, they had a layer cake, where you had an HA, like a Juvederm, but orthopedic version of it. And then you had on top of that, PRP. And the other group just got the HA covering. And they looked to see who could grow the skin back. And the people who had the layer cake, which is what we do when we do it in the face if we're trying to change shape, and HA followed by PRP, you do your best work with an HA filler and then polish that odd with platelet rich plasma, that's what they did. And the people who got that layer cake more easily and quickly grew back healthy tissue to cover the exposed bone and tendon.

So here's an example of a scar that I treated. You can see this woman had, the year before I did this, she had a cortisone injection in the ankle. This was little college woman who was embarrassed to wear a dress to sorority functions because she had cortisone that caused atrophy of the skin. And if you look carefully, there's to hypopigmented scars. One of them is where she was cleated playing soccer. And then when it didn't heal properly, she went to the dermatologist who biopsied it. And the dermatologist said, "Yes, this is atrophy from cortisone. There's nothing I can do." And then six months after that, so a year after the cortisone, she was a friend of one of my sons and asked me if I would treat her ankle. So she came in and you can see it goes all the way up the leg. And so I put one CC of an HA filler there, and five CC's of PRP. So you can still see the needle marks. This is a few days later. This is a month later. This is a year later.

It's now been seven years since I've treated this woman's ankle. She's an insurance salesman now. I bought some insurance from her to pay her back for me showing her ankle around the world. And it still looks like this. So when people ask you, "How long does this last?" Well, the answer is, if the edeology is gone, it's permanent. You do not have to go spin blood and do a centrifuge to keep a surgical wound from dehiscing, so if you have an operation and you suture a wound together, when it grows back together, it's there permanently. On the other hand, if the edeology is still present, then it will need to be repeated. For example, with we use PRP for a woman who has dyspareunia, she has dryness and painful intercourse because she cannot be on estrogens and she's had breast cancer. This is the balm. That's an easy treatment for us. And she will get lubricate and she will love you for it and you will change her life. But she'll have to have a repeated treatment in about a year because the edeology is still there.

When you treat a woman, however, who's had an episiotomy scar and has severe pain after she tore after she delivered a child, you will also change her life and she will love you for it. And I have people that I've treated like that six, seven years ago and they are still comfortable because they haven't delivered another 10 pound baby. With the face, however, age still goes on, as you guys know. We can't freeze people in time. So when you do this with the face, they're probably going to want ... They'll still want their Botox, they'll still want their everything you do to maintain the face, the creams and everything else and they'll probably want this procedure done again in a year and a half to two years, just because of age. But the tissue that grows there is permanent.

This is what you can do with one syringe of a filler. The fillers last longer and it's like it polishes off your work. This is one syringe of filler and five CC's of PRP. So you have an effect that is I think more natural, in some ways more dramatic than you can do by using larger volumes of filler. The other thing if you think about that ankle, it's growing based on the genetic code. When you use your filler, it's what you're seeing. It's your eye. But you cannot make an abnormal shape with PRP because the shape that grows is dictated by the genetic code. So it's a really nice combination where you make some structure with your filler, but then let the genetic code polish off the structure you've made to create a really nice natural shape, which of course is what your patients want. They want younger and they want natural.

Micro needling has been more well known. As you guys know, we have a name that we use to help promote that. We're all over the news. This time of the year is a great time to start to join our group because people love talking about us around Halloween. I won't say the name, but you guys know it. So if you use micro needling ... Split face studies have been done for scarring and for just rejuvenation and anti aging type effects. Comparing micro needling with platelet rich plasma versus micro needling with vitamin C, micro needling with platelet rich plasma compared to micro needling with saline, and the PRP wins. Multiple studies. Those are two examples. And the same thing with the hair. That treating alopecia areata, treating hair loss. Most women will get all their hair back. Men will get about 30 to 40 percent of their hair back. And those studies have been done over and over now. So much has come out in the past couple of years.

So let's switch to the sex part. I hope that the women in this room become angry. You have reasons to be angry. If you're not angry when I finish this next part, I don't know. Maybe you're not listening. Because you should be very angry with what I'm about to tell you next. So before I get to that, the people ... I can see several people in our group in this room, and they will tell you that this becomes some of the most rewarding things that you will ever do in medicine. If you think about it, even when you're doing the face, you're really a love doctor, is what you are. Because why do you need your face. You relate to the people you love. You relate to the people you work with.

If someone throws a baseball at you, you cover your face and your genitals because those are sacred and the reason they're sacred, it's because that's how we relate to our lovers. And Emerson called sex and beauty the scaffolding of love. This is me before I shaved my head. And those are my three sons. That kind of hair, [inaudible 00:19:46] about sex just doesn't work. This was more conservative. But this was me as an internist with my three boys. And the reason I give you that picture is so that you can see, this is not sex for pleasure, although pleasure's wonderful. This is sex for relation-

Section 2 of 5 [00:10:00 - 00:20:04]

Section 3 of 5 [00:20:00 - 00:30:04](NOTE: speaker names may be different in each section)

Charles Runels: - for pleasure, although pleasure is wonderful. This is sex for relationships. When sex doesn't work, then babies live down the street and they go back and forth and people get divorced and the ripple effect goes throughout the community. People are married for 40 years and they're soulmates, but they can't connect like they did when they were younger and it puts a strain. This is not just about pleasure. I've been amazed and the people in our group have been amazed at how grateful people are when you do these procedures and you save the relationships.

It's not just about sex. Real key talked about the creative experience being related to the sexual function. I have many women that I've treated who say, "Why should men have all the fun?" I don't even want a lover. I don't want a woman lover. I don't want a man lover, but I have sex with myself. My sexual function gives me energy and creativity. It makes me a better salesperson. It helps me sleep better at night. It makes me less depressed, so it's okay to love yourself. This is not just about even the relationships with another person. It's about relationships with your creativity. Sex is so all encompassing.

Now, this is the part that I hope makes you angry. In 1980, who knows what was thought to be the most common cause of erectile dysfunction. This should shock you. I'm 58 so I remember this. In 1980, the most common cause of erectile dysfunction, this is from urology in 1980, and I'll blow that up where you can read it, most instances of acquired impotence are psychogenic. It was thought to be 85%.

Urologists in particular were confronted with genital problems and may be best suited as therapists. It wasn't until we accidentally discovered that Viagra got a lot of these guys well who we thought it was all in their head that we figured out it's not 85% psychogenic, it's 85% neurovascular. I think it's useful to remember how not smart we were. Imagine being one of these guys where your erection won't work and you're trying to keep your marriage together and somebody's sending you home telling you it's all in your head. Okay?

This is the part that should make you angry. Female sexual dysfunction, what are we telling people? Education, counseling, psychotherapy. We finally got the first drug approved to help women with sexual function and it's a psych drug. You have to become a teetotaler to use it. It's basically a spinoff of a serotonin dopamine Prozac sort of drug. We're taking it every day the average is one extra sexual encounter per month. It's just for libido. Nothing for painful intercourse or trouble with orgasm.

What I'm about to show you, I have no intention to tell you that this is some magic shot. I still think you have to think about endocrinology and relationships and surgical problems like ovarian cysts and cervical cancer and all that. I also want to propose to you that the penis is physically and embryologically like a small ... the clitoris is very much like a penis and that maybe it may also have things that can go wrong vascular and neurologically.

To tell a woman that it's all psychogenic who has pain because she delivered a 12 pound baby and ripped her vagina is criminal in my opinion, or at least should make you angry. That goes on every day, "Oh, here's a little lidocaine cream. Go home baby. It's all right." I've had so many gynecologists tell me they do not want to talk about sex. Research bares it out, even though 40% of women will have sexual problems. They'll only have the conversation 14% of the time, and if they bring up the subject, the doctor will change the subject after the first question. Now, if you're not angry you should just go have lunch because that should make you very angry.

I don't claim to have all the answers, but I claim to have a tool that I think is useful and I'm about to show you the research that shows that it's useful. I hope that some of you guys will jump in on this revolution. Now, the sex revolution of the 1960's was it's okay for a woman to have sex. I'm from Alabama, so I'm from the Bible Belt. The 1960's I can remember as a child all the ladies carrying their New Testament around. Now, they all carry their 50 Shades of Gray around. Okay? Which is a good thing because now the new sex revolution, and this was a cover of a Newsweek magazine article about the time 50 Shades came out, is that now it's okay for women to want to have good sex. You don't have to put up with bad sex. We are part of that revolution.

Now, we just went through this. The reason I show you those pictures again is the idea that maybe if there's a genetic code and you put platelet rich plasma there and the tissue grows back to recreate tissue the way it was genetically intended to happen, maybe that might happen around the urogenital space and create something nice.

First, let me show you what happens with the breast. I'm not trying to give you something that would take the place of implants, but look what we can do. This was a woman who had two separate surgeries. First, to get implants at a major university in a big city from an amazing surgeon, but this just happens. You see where she has a little double bubble there? The cleavage is a little bit apart, so she had it repeated. This is beautiful surgery, but it's a nuisance, so she had to wear that blue bathing suit right there to cover up that little double bubble. I took two syringes of Juvederm, filled in that little double bubble.

Now, remember the ankle? What happened there? This is six months later. By the way, she looked like that immediately, but I'm showing you the six month view and the bathing suit she wears now so you can see that just like with that ankle, it's not going away because she recreated tissue to fill in that double bubble. I treated both breasts, so it also brought the cleavage.

Anybody in here think you might have a patient that would like you to do that for them? They love it and they can go ... I've treated Playboy Bunnies that shot, one shot three weeks after doing this. She could have shot the same day with a little makeup. I've treated women that went straight from my office to the swimming pool. People love this procedure. Not as a replacement for implants, but for a touch up for women who've got a little nuisance defect or for a woman who's not really wanting implants, she's just wanting a touch up to make her breasts more like they were 5 or 10 years ago.

As far as the safety of that, here's some studies showing the platelet rich mixed with fat helps the fat survive. Most surgeons are now mixing fats with platelet rich plasma before they put it in the breast and we have multiple studies showing ... I'd just as soon buy that, but there's two different really long-term studies looking at what happens with re-biopsy rates and cancer rates when you put fat in the breast trying to reconstruct post-breast cancer.

The trend is towards less cancer. It wasn't statistically significant. There was no increase in biopsy rates. No increase in recurrence of breast cancer. The trend was towards less, which makes sense if you buy the idea that platelet rich plasma is somehow helps fight infection, fight abnormal tissue. I'm not claiming this is an inoculation against breast cancer, but I think 20, 30 years from now someone is going to do some long-term study that shows that perhaps it decreases the chances.

This is another woman that I treated. That's day one. I use a combination of HA with PRP. I wound up using three Juvederm syringes and about 15 ccs of PRP. These are saline implants that are about 15 years old and that's 8 weeks after that procedure. Remember how easy fat grows and remember my ankle? This was a combination of fertilizing fat and using an HA filler to help correct, and her husband calls me up belated because he doesn't have to suffer with her through another surgery.

As far as the genitalia itself, imagine this woman walks into your office. She's got that callus because she has to use a vibrator that's like a jackhammer and it takes her an hour to have an orgasm. The reason is her ex-husband abused her and the genitalia, the anus and the vagina, and left her with so much scar tissue it hurts to have intercourse with a man. She feels unlovable. All of her hormones are normal. Multiple gynecologists. What can she do?

She saw me on her lunch hour. I gave her platelet rich plasma into that callus and into the scarring that she had. I didn't think of the idea that PRP helps scarring. We've known it for 10 years. It's just a new idea to it treats scars in the vagina. People are afraid for some reason to go down there, but that has collagen and blood flow just like your arm or your face. Six months later she was engaged to a high school sweetheart for something that took me 30 minutes on the lunch hour after she had suffered for years.

These have been reorganized recently, but these are the description of female sexual dysfunction. As I mentioned, we only have one approved drug by the FDA to help these problems. It's only for arousal and desire. Nothing for orgasmic disorder. The treatment for pain is lidocaine cream and-

Section 3 of 5 [00:20:00 - 00:30:04]

Section 4 of 5 [00:30:00 - 00:40:04](NOTE: speaker names may be different in each section)

Charles Runels: ... [inaudible 00:30:00] cream and anti-depressants. It's really aggravating.

Now when it comes to incontinence, who in here would put Radiance in the mouth? Nobody, right? Because it links to granuloma. But there's an FDA approved version of calcium ascorbate crystals called Coaptite to inject around the urethra, approved by the FDA for urinary incontinence. And as you might expect, one in 40 women get the granuloma, that has to be surgically removed, because it causes obstruction. But it does work, and it's approved because it does work. There has never been a documented granuloma from PRP. So, I didn't think of the idea to inject something around the urethra that you can use a little 27-gauge needle, and I promise you, if you learn it the way I teach it to you, they will tell you it hurts less than Botox.

People think the vagina is sensitive. You can literally make a laceration on the vagina without numbing cream. All the sensation is on the other side, where the clitoris drapes down around the vagina and the urethra. That was Doctor Grafenberg's big idea. Doctor G. for the G-Spot, that all the stimulation is happening on the other side of the vagina. So, you can do these injections with almost no pain, usually zero pain and have dramatic effects on -

This is just some of the research showing the granulomas that happen when you use the calcium ascorbate crystals.

But, you can do this without fear of granulomas and sure, it does not work all the time, but it does work in a young woman who's leaking because she's exercising or because she had a baby, and she's dripping a bit enough to where it bothers her at work and keeps her from doing aerobics. We get over 80-percent efficacy and even if it doesn't work, these ladies are usually very grateful that you have offered them something non-surgical before they went for a mid-urethral sling or had to take anticholinergic or a diaper. So they'll love you when you do this.

These are all the other things. All those still stay there. Kegels. They all still there. There's still a need for slings. But, in between physical therapies and anticholinergic, that's a big jump. Something that makes you feel stupid and constipated, you might want to try a 10-minute shot before you jump to that step. We get lots of press.

This is a cartoon of an urethra up on top, and the reason I put this here, I want to see where we put this injection when we're treating incontinence. It's like a liquid sling. Where you see a green material there, that's a cartoon of the skins glands and the periurethral glands. It's literally like the prostate gland of a man, but a man ejaculates once the fluid comes from the prostate gland.

And women who ejaculate, we have ultrasound studies and physiological studies. The fluid that comes from that, if you gave it to a pathologist, she would not be able to tell the difference between that and prostate fluid. It tests positive for PSA. It's not like the goal is to have all women ejaculating, but when you put the injection right there, you will have women who will tell you their orgasms become...they use words that sound like some infomercial. They're exploding and thunder and all sorts of things.

I can read you a text I got yesterday about this. It's amazing and women in their 60s becoming ejaculatory. Wasn't their goal to do that, but their orgasms become amazing. And I think part of what's happening is that we are making that tissue there wake up. So, the space most distant from the bladder between the vagina and urethra, that's where we do the injection. Simple little technique. Don't even need a speculum. Takes five minutes.

Now this is the clitoris. Most people when they think of the clitoris, they think about the part that you can see. But, you can see it drapes down around the vagina, and we have ultrasound studies that showing that when we inject the platelet rich plasma, which travels like saline, it's aqueous, we can see it going down into corpus cavernosi, bilaterally. And even the weigh form changes to what you see in a flaccid penis to what you see in an erect penis. It wakes it up.

Now, we have studies. This is one that was posted in the Journal of Sexual Medicine, showing that when you do an MRI of women who can easily have an orgasm and when you do MRIs with women who have difficulty with orgasm, the women who easily have orgasm tend to have a clitoris that's larger and closer to the vagina.

It's kind of odd thing to think about but when men and women have sex, they're basically rubbing penises together. Or you can say they're both rubbing clitorises together, however you want to look at it. But, it's the same structure. It's just like a penis that you unzipped when you think about the clitoris. And so it makes sense that if it's closer to the vagina, then it's more easily to have the orgasm. But the conclusion of the study was, "Well we know this, but we don't know what to do about it." I'm telling you there may be something to do about it. Because when you inject the clitoris with PRP, it wakes up.

Because one of the studies we did when we looked at female sexual function index, the female sexual distress score, and all the ranks improved. Satisfaction, which is another thing that I hope makes you angry. Satisfaction did not always improve. But this is the interesting thing about drugs in men verses drugs in women. If you went to approve a drug for a man that gets...of course we have over 20 FDA devices and drugs for men. Now I just told you we have one for women. Does that make you angry? It should make you angry. If it doesn't, just go have lunch.

Men have over 20. Women have one. And the one women have is a psych drug, but to prove, we'll say you want to get a drug approved for a man. All you have to do is to prove that it makes his penis hard. Boom. You can say. If you want to approve a drug for women, you have to approve that not only that said libido goes up, orgasms improve. You have to prove that she's more satisfied. That's not the same thing. For example, one of the ladies I treated became less satisfied, even though her orgasms improved because she said her lover couldn't keep up with her anymore. So, if that were a drug, it would have been disproved because she became less satisfied. So, hopefully that's making you angry.

It sounds cool to say that we will have a couple thousand providers in 50 countries, but there's 35,000 gynecologists in the United States alone and there's another 30,000 urologists. There's 200,000 primary care providers, including nurse practitioners and MDs, and we have 2,000 worldwide. That's nothing.

The average time to adopt a new procedure is 20 years. The first heart cath done in the 1940s. So the fact you're even listening to me makes you know you're a doctor. It takes 10 years to do the research. 10 years for people to adopt it. We're eight years in, and now, the first year we publish one study. This year, by the end of the year, we'll have five studies published this year alone. And so, the research is taking off and now is the time to jump in.

Again, I don't claim that these procedures are magic shots. You still have to think, "these are the hormones I think about when I think about a woman's sexuality". I want to know about her prolactin, her DHA, her testosterone. All these things. So, you don't quit thinking about this. On the other hand, it sort of aggravates me when I have a sex therapist want to therapy and counsel someone out of their dyspareunia when they have a [inaudible 00:37:51] up there that I can treat.

So, this is a young woman and I've just treated one side so you can see. I get a lot of flack from people sometimes, saying, "well you should just let women let their vagina be whatever it is," and that's okay. But what if we said the same thing about the face? When people say "Well, you should just age gracefully." always go back up and would you say that about your house? Would you not paint it? Not wash it? Not mop the floors? Are you just gonna let it age gracefully? If you have the right to take care of your home and your face, it is okay to take care of your labia. And so, this is just taking some platelet rich plasma and half a syringe of an HA filler and just treating one of the labia majora and it just wakes up and looks happier. Who wouldn't want that?

And I'm not going to show you my more dramatic cases. This is a woman in her mid-30s. When you do it to a woman in her 60s or 70s, we know sometimes they look in the mirror and start sobbing, because "Oh! That's what I used to see when I was 30." So, that's just something else.

Now, there's a lot of devices out there. Lasers, radio frequency, and it's not a new idea. When you do the face, we've known for 10 years, when you do a laser, you follow it with platelet rich plasma, you get a more rapid healing and get a better result. So, the same thing happens with the vagina and all the luminaries who are doing research with the different lasers and radio frequency devices, they will tell you that if you follow it with platelet rich plasma, you get a better result. I don't use the words, "tighter vagina" or because [inaudible 00:39:28]. Maybe it needs to be tighter. Maybe it needs to be more - maybe she's married to King Kong. I don't know.

And there are quite a few people who, due to surgery or because of some sort of disease process, they use dilators. So, not everyone needs a device, but I would say to you before you buy a device, consider doing it like you do at your facial practice. You start with your injectables, and when that part of your practice is going, then you buy the device. You don't the device and let it sit there and eat up your bank account while you look for patients. So, in the same way, once you get to where you're doing these procedures...

Section 4 of 5 [00:30:00 - 00:40:04]

Section 5 of 5 [00:40:00 - 00:58:28](NOTE: speaker names may be different in each section)

Charles Runels: ... patients. So in the same way once you get to where you're doing these procedures, then you go buy the device and some of them will benefit by using that along with your platelet rich plasma. So we published a paper this year in the Journal of the American Academy of Dermatology. I'm very proud of that article because until we published this, there was really nothing out there for women with blackened sclerosis other than [inaudible 00:40:26] which leaves them with a 10 percent chance of squamous cell carcinoma. Now that may sound rare to you, blackened sclerosis, but it's about one in 80 women and also goes undiagnosed and I'm showing you this eczema because imagine that's your labia because that's what it looks like, and these ladies because of our research have let me into their closed Facebook groups and the stories are just heart wrenching.

One woman posted I was rocking because it attacks prepubescent girls and it eats their labia away and by the time they reach puberty their labia is gone. So one woman's post how she was rocking her 12 year old and her 12 year old's crying and she doesn't know what to tell her. Another one posted she's sitting there on the couch with her husband whom she loves and has been married to for 20 years. They're watching television, get the picture? They're sitting on the couch. She loves the man, and she wants to hold his hand, but she doesn't because she's afraid he'll become aroused because that's what her vagina looks like, and she's hurting and bleeding and does not want to have to tell him no. Can you imagine the loneliness? And that's out there, and they're not going to talk about it with you if you're their best friend because they're embarrassed by it.

But anyway, so this is eczema, the same autoimmune process, both processes are autoimmune, and this woman was treated with PRP by one of our gynecologists and that's six weeks later, and she was disabled from that eczema, okay? So anyway, we published first in the Journal of Lower Genital Tract Disease. Andrew Goldstein spearheaded this research for us, and then we published again in the Journal of American Academy of Dermatology. This had already been done with stem cells, but most of the stem cell studies, the stem cells have to be in something, and they're usually in PRP. So it's really two variables. So we just skipped the stem cells and did it with platelet rich plasma by itself, and we showed benefit. These are biopsies from our patients and this is the same magnification, so you can see the hyperkeratosis, the paleness, the sclerosis, and this is after platelet rich plasma.

So that's what the pathology looks like, but this is what it looks like when you go to the bathroom, those ulcerative type sclerotic bleeding, cracking, painful lesions and that's what you see six weeks later. So that's a little article that we published, and this is, we had two [inaudible 00:42:54] pathologists who looked at it and told us it was better. This is what it looks like long term. This lady, you could put about half of your thumb in that space that used to be her vagina and she had not had sex with her adoring husband for seven years. You can't pull her clitoral hood back but it's under all that scarring. Normally if you release that, it would be back like that within a couple of months because of the active lichen sclerosus, but if you, in this study, and Kathleen Posey's one of our gynecologists who just presented this down at a big meeting in Argentina and this series will be published, actually it's already out online but it'll be in one of the journals this upcoming month. She dissected this out in the office, injected with PRP and that's eight weeks later.

This woman is now two years out and still having comfortable sex with her husband. She had not had sex with her husband for seven years and was being treated with high dose clobetasol, high dose cortico-steroids and still had that scarring like that. Now, if you're not a gynecologist you couldn't do the surgery, but you could treat the lesions in people who did not have that hood phimosis and they will love you for it and they will come from everywhere. So, I have 17 minutes. Let me get to the men side. So, John Grisham has a rule. He says he will never write a book that would embarrass his mother. So, Priapus to this being the Greek god of fertility is from, and spelled with a lower case letter is the synonym for penis, so that's why I call this the priapus shot so that I don't embarrass mothers and grandmothers out there. Sort of code for penis shot. This was the research that first kind of alerted me to it. This is from Urology 2003.

If you're using Viagra and Cialis or a penile implant or every one of the 20 something devices and drugs that are approved to treat erectile dysfunction, if you're using one of those, you might be making the penis hard but you're not correcting the underlining etiology, and so this article was just bringing up the idea 2003 that neovascularization was shown in animal models and maybe it might help in people. So, 2010, this article came out where they took diabetic rats and they used stem cells, adipocyte derived stem cells, injected the penis of that rats and then they harvested the penis. You can see why they wouldn't have men volunteering for this, but they harvested the penis and they demonstrated that increased nitrate oxide activity in the dorsal nerve and new endothelial growth which means a harder, bigger penis. Now, women, I think God sort of plays a bad joke on us because let's think about the normal progression. You get married at 20 or 30 or whatever and you have your soul mate and sex works. Now, the woman delivers a few children and her vagina's growing and the average man by the time he reaches 65, half of his endothelium goes away, so his penis is shrinking and her vagina is growing.

It's just a bad joke, isn't it? But when they come in as a couple and we inject the penis on the man, it's almost like, it is a romantic thing. They've been married 40 years, they're going on vacation. You inject his penis. Then he sits at the head of the bed while you inject her vagina and they're like little teenagers and you get a text a week later how they're rediscovering their bodies because they work different and they feel different. So they get to keep the soul mate and get new genitals. It's really very touching.

But anyway, in this study, they documented that but the stem cells were tagged and they died, and so they postulated it was the growth factors as in the PRP that caused the growth. So that's what encouraged me to sort of try this thing out first on my own penis and then other patients and now we've published. A study came out of India, one of our providers in India treating men who had smaller almost micropenis, three inches, showing that he could demonstrate growth, and for Peyronie's disease which is the equivalent of dyspareunia in women, we have a crooked penis that hurts. So Dr. Varag who is the Parisian urologist who came up with TriMix, now his focus is on looking at what platelet rich plasma will do for a crooked penis which looks like that. So this is the equivalent of a woman who hurts. The man loves his wife, but he knows if he gets an erection it's not going to fit into her vagina and it hurts and basically he feels like he's out of commission, and the treatment for that is surgery which can leave you impotent and with a shorter penis and it can recur because it's autoimmune.

You can cut out that scar tissue and next year you can have it back. Well, there's a new FDA drug out called Zyflex that costs 50,000 dollars for a series and Dr. Varag has a study, he's already published one but he has another one that should be out soon, I saw him present in Venice that shows that PRP works better with fewer side effects than Zyflex. So you will see that research published soon, and this is a procedure that takes you ten minutes in your office. This is the study that he, the first study he demonstrated that PRP works for Peyronie's disease. We combine it with a penis pump which also helps Peyronie's disease, and we get some of the hard cases for the urologists are our easy cases. Here's two rat studies that came out showing that PRP helps regrow the nerve in a penis. Where would you need that? In men who have prostate surgery. So there's a whole protocol about penile rehabilitation post-prostate surgery.

You think there are a few of those men out there, trying to get their penis to come back after they've had, there's just so many of these men, and many of them have gone through this protocol but when we go back through it, which is a, basically you keep, it's just a glorified water balloon so you keep the penis stretched out until it recovers blood flow, and then you add a daily low dose Cialis, but when we add the PRP to that protocol, I'm having men that are a year or two years out when it didn't work and now six months later they're back able to have sexual relations with their wife of 50 years. So really, really moving stories, and it's just using, injecting into the penis platelet rich plasma just like, it's easier than the face. It's just right there to look at. You go into the corpus cavernosum with your needle and into the glans penis and get amazing results.

Just like with a face, you can combine it with devices like the shockwave therapies. So you do shockwave to the penis and PRP afterwards, and get a synergy that's like crazy, so once you get to where you're doing two or three of these a week, you add in the shockwave therapy and you get even better results and a really nice cash flow and a lot of healthy patients. So, I have ten minutes left. I think I'm going to stop there. Can we take questions or should ...

Speaker 2: [inaudible 00:50:21]

Charles Runels: So that'll give us time for questions. Before I take questions just let me say we have a booth here and your money's no good, but we're giving away stuff. We give away research. We give away free training on [inaudible 00:50:35] because I know if I just showed you one of the videos to how to do the O-shot or the vagina shot that'd be 20 minutes of a video but we're giving away a chance to see those things and of course if you stay in our group then we might ask you for money but we let you look at everything and so go pick up, if nothing else, a free t-shirt. Okay. So, and that's where you can go online and get access to a lot of things for free. So, it's okay to take questions?

Speaker 2: [inaudible 00:51:03].

Speaker 3: I think I have a loud voice. I don't know. Can everybody hear me?

Speaker 2: [inaudible 00:51:23].

Speaker 3: Okay. So, when you said [inaudible 00:51:26] when you do [inaudible 00:51:28] then do you do micro-needling or are you going to PRP with injecting ...

Charles Runels: So that's a good question. So, if you want to, a lot of people tried PRP back eight years ago when I first started playing with it, and then sort of threw it aside because people said use it like Juvena. It doesn't work like a filler if you inject it subdermally. You get new collagen, but it's like your putting new upholstery but you're not changing the shape of the mattress. So if you want color, texture, the picture you see of Kardashian, she was pregnant when she had that done. PRP is very safe, but so micro-needling with PRP topically would help color, texture, but if you want shape then that would be going in subdermally with your HA of choice, doing your best work and then going subdermally with PRP behind it to polish off that work similar to what you saw with the breast and the ankle. Does that make sense? So the facelift would be subdermally, the facial, so frankly speaking what happens when a patient comes in if they have acne scars, I may use a filler as you saw those beautiful photographs yesterday in the lectures to expand it and make it better and then you put PRP subdermally and then micro-needling and PRP topically on top of that.

So use a combination of tools based on what you're seeing.

Speaker 3: So you're saying both, micro-needling and ...

Charles Runels: Depending on what I'm seeing. If someone came in like yourself who has a nice color, texture already but wanted a little touch up with the shape, then I may not do micro-needling. I may just do subdermally with the HA and the PRP, where if you were complaining of crepe papering under the eyes and some acne scars, I may just do micro-needling with PRP topically, so it's kind of based on what you're seeing.

Speaker 2: [inaudible 00:53:19] question. Okay, so [inaudible 00:53:22]. So I have a question.

Charles Runels: Okay.

Speaker 2: If you [inaudible 00:53:31] tear troughs, how much [inaudible 00:53:35]?

Charles Runels: Oh, yeah. Yeah. Thanks for asking that. So I'm doing a experiment with my face. I'm not sure if it shows up here, but I have a little trick that I do where I take a small [inaudible 00:53:46] of an HA and mix it with a larger [inaudible 00:53:49] of PRP and make a little emulsion and using that, you can use it, it'll flow in the tear trough like water but you don't have to worry about a Tyndall effect and you don't have to worry about causing too much unsightly lumpiness that you get if you're not careful with an HA. So, that's what I'm using in the tear troughs.

Speaker 2: [inaudible 00:54:15].

Charles Runels: Yeah. So it's okay to use brand names. Yeah. So, with that ankle picture that I showed you, that was Juvena multiplus, one cc with five ccs of PRP on top of it. What I found is that when you put the PRP, well you saw it. That ankle's now eight years out and still looks like that, so that combination is very dramatic. If you go to the wound care and it lasts longer. So if you go to the wound care literature, you see that using an HA with a PRP overlay sort of layer cake with amazing results. It just hasn't been published as far as I know in the facial aesthetics literature. I've been all about the sex. That's where our group spends about 200,000 a year on research and like I said we'll have five papers published this year because there are so many things out for the face already, but nothing. Are you angry yet? Hopefully you're angry. You should be angry when you leave here. That part makes me angry that women have one drug for sex and it's a site drug. So that's where my resources have gone.

Speaker 2: So we're going to take [inaudible 00:55:30].

Speaker 4: [inaudible 00:55:32].

Charles Runels: Have I treated children with lichen sclerosus? Was that the question? I'm sorry. I couldn't hear.

Speaker 4: Have you treated children with lichen sclerosus [inaudible 00:55:50]?

Charles Runels: So I personally have not, but we have gynecologists in the group who have treated children and they're usually in the nine to 11 year age group. Because it's PRP, there's really, there's nothing dangerous about your own platelets, and so there's no contraindication to treating a child with platelet rich plasma.

Speaker 4: [inaudible 00:56:21]? [inaudible 00:56:33] versus platelet rich plasma?

Charles Runels: Oh, yeah. Yeah. So, I like when sales people play with words and I have, did your dad ever tell you jokes you wish you could forget? So my dad told me about this woman who just, in high school, that just had sex twice, once with the football team and once with the basketball team, so you kind of have to know what people mean and I know people throw around the platelet rich fibrin matrix and say oh, that's, this one's not good because it has red cells or this one has a different kind of white cells, and all the sales people are confusing everybody, and this one makes fibrin matrix and this one just makes PRP. When you do surgery if you just stop and use your common sense, when someone does surgery or you scraped your knee as a child nobody had to sort out the different types of white cells, you just grew new skin. And it's the same process. It's the thrombin cascade is growth factors from the platelets and then it's recruitment of [inaudible 00:57:30] stem cells that migrate from the bone marrow and regrow healthy tissue, and it happens with platelets.

Now, as far as the matrix goes there is a kit that's out there that comes with a little calcium chloride. We activate the platelet rich plasma and it turns to a matrix in your syringe, and I sometimes do that. I just buy calcium chloride as a vial and add a few drops and I do that as part of the process, but when you inject platelet rich plasma into the tissue as soon as it contacts the collagen it turns to platelet rich fibrin matrix. So you can't use it without making that matrix and if somebody kind of plays the semantics game with you, although it's technically true that only one kit comes with the calcium, to make the matrix in the syringe. We're all making it every time you inject platelet rich plasma into the tissue.

Okay. Thank you guys for having me.

Orgasm, Mechanics, Surgery, & O-Shot® (Discussed with Dr. Michael Goodman)

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Charles Runels: Hello, this is Charles Runels, and I'm extremely honored, very privileged and excited to be able to introduce Dr. Michael Goodman, who really needs no introduction. I've seen him lecture now on many occasions to other world-renowned gynecologists, and he always commands respect. He recently released a textbook that he edited about female genital plastic and cosmetic surgery.

One of the true pioneers who blazed the trail for the people who are doing it now, and I consider him to be actually one of the premiere physicians living today, and paved the way with some of his research for what's now widely practiced worldwide when it comes to cosmetic surgery in the female genitalia, and not just because it looks better, but how it actually contributes to a woman's functioning.

When I asked him to talk about the procedures he does, surgery versus the various devices, versus, of course, the O-Shot, how he uses those various modalities, combines them, and how he thinks about those modalities affecting a woman's sexual function. Of course, that has extremely far-reaching affects on her whole personality and her life, her family, and her career, and all that research has been done, but specifically how he combines these different modalities.

Hang on until the end, because when he's finished with demonstrating his ideas, I would like to ask him some more in depth questions about particularly how some of this relates to orgasms. Hang on until the end, and we'll some question and answer time.

Michael Goodman: What fun, Charles. I get to speak with you, one of my favorite people, about two of my favorite things, orgasms and vaginas. Without further ado, let's talk about that. Those of you that are looking at this podcast are well aware of orgasms. That's one of the reasons, probably, why you're looking at it and why you're either considering administering the O-Shot or are already.

Let's talk a little bit about how things really work, or the biomechanics of the whole process, and the physiology of orgasms, and the different types of orgasms. They certainly relate to the O-Shot, and they certainly relate to the whole idea of vaginal tightening. I really like to use that word, vaginal tightening, rather than the ubiquitous word vaginal rejuvenation.

That's an unfortunate choice of terms, because that term, vaginal rejuvenation, has been stolen out from under us by pretty unscrupulous marketers, who will have you think that all you need to do is put a wand in the vagina, either radio frequency and laser, and you will tighten the vagina, and you will improve orgasms, and no, that will not work.

Let's talk a little bit about terminology first. The term vaginal rejuvenation, by the way, refers to surgery alone, period. Vaginal rejuvenation was first popularized by one of the fathers of dental plastic and cosmetic surgery, David Matlock from Los Angeles, and was called Laser Vaginal Rejuvenation. By that, Dave meant the use of a Touch carbon dioxide laser as a cutting tool for surgery. Understand, vaginal rejuvenation refers to surgery. If someone's saying they're going to rejuvenate your vagina not using surgery, they are wrong, they will take your money.

Let's talk about why these operations work. If you look at the first slide, you see this lady had labioplasty also, we're not talking about labioplasty, which can happen [inaudible 00:04:01]. Why do vaginal tightening operations appear to improve sexual function and improve orgasms?

First, what are they? We talked a little bit about that. I got on my soapbox, which I tend to do when we're talking about that term vaginal rejuvenation. Really, a wonderful term is colpoperineoplasty, which is Jack Pardo's term from Chile. We don't use that that much, but really the best terms I feel, in my opinion, are perineoplasty and vaginoplasty.

Basically, these are surgical procedures designed to reapproximate the levator muscles, do basically a levatorplasty, bringing them together over the thinned out vaginal floor, decompress the rectocele, bulk and elevate the perineal body, to push up the penis or any inserted object to the anterior vaginal wall, excise all the scar tissue, to utilize a space closing, plicating 3-layer closure designed basically to tighten the outer half or two-thirds of the vaginal barrel, to result in greater stretch of the clitoral bulb and the anterior vaginal wall, and to result in greater penetration of the penis against the anterior vaginal wall and the cervix.

Additionally, and here's where these non-invasive technologies really may be helpful, is non-invasive technology such as radio frequency and fractional CO2 laser can be used in the far upper vagina, or what we call the [inaudible 00:05:50] of the vagina. That area of the vagina that has no musculature, that really has little fascia, that's only just mucosa, way up at the top.

That [inaudible 00:06:00] the skin. All these technologies do is resurface skin, and can increase collagen and elastin fibers way up at the top of the vagina, and also increase the stretchability and increase the elasticity underneath the base of the bladder, and certainly has been shown to help with minimal and modest urinary incontinence. Combining these two ends up with a really good procedure.

Again, we talked a little bit about the names of these procedures. I like, again, perineoplasty and vaginoplasty. The next slide I'm going to show you comes from my friends, Rob Moore and John Miklos from Atlanta. They are premiere vaginal reconstructive surgeons. I put down this quote in its entirety, because it really says a lot.

We can read it together. Vaginal rejuvenation surgery, again, surgery, is one of the latest trends in elective vaginal surgery for women. It is a repair of the vaginal caliber in women who suffer from decreased vaginal sensation, or of feelings of laxity, basically, that affects their sexual life. In many instances, women who present with these symptoms also have other pathology, such as prolapse. That must be addressed in any repair that's contemplated.

Sexual dysfunction, or decreased sexual sensation, may be one of the first symptoms that women suffer from in this progression from laxity to prolapse. There's ample evidence in the literature that prolapse and vaginal relaxation can create sexual dysfunction, and that repair may reverse these changes in many women. We're dealing with these early changes. When dealing with sexual dysfunction and the caliber of what's in the vagina, the surgical, underlining surgical, repair must be meticulous and exact to enhance sensation and function, and not impair it. This truly is the art of surgery.

With that introduction, what are the mechanics that we're talking about? This is a cross-section of a normal female nulliparous, in other words, no kids yet, anatomy. If you take a look here, and I'm not sure if you can see my arrow on the screen, hopefully you can. I'll put it all up.

Charles Runels: Yes, they can see your arrow.

Michael Goodman: Cool, good arrow. If this woman were supine you'd see that her vaginal barrel goes downwards. The angle of the vaginal barrel is downward. When a man is mounting her or she's on top of him, there is pressure, especially because of the angle, especially because of the pelvic floor, and very especially because of this robust perineal body here. There is pressure against the anterior vaginal wall, the G-spot, the internal clitoris, and then the dorsum of his penis, as you can see right here, the dorsum of his penis, the top of his penis, has pressure against there, has pressure against the clitoral glans, the clitoral body, and his pubic bone has pressure in that area, and all is fine.

But, but, but, with childbirth, or multiple childbirths, things change. The angle of that vaginal barrel no longer goes down, but is horizontal. It's lax. The floor is lax. You don't get that pressure against the anterior vaginal wall, you don't get the pressure against the G-spot, you don't get the pressure against the clitoris. It results in less stretch on these anterior vaginal wall receptors that we'll talk about in just a little bit. This is basically what I see, and what occurs frequently after childbirth. The procedure that we're talking about, perineoplasty and vaginoplasty can be performed ...

Section 1 of 5 [00:00:00 - 00:10:04]

Section 2 of 5 [00:10:00 - 00:20:04](NOTE: speaker names may be different in each section)

Speaker: We're talking about perineoplasty and vaginoplasty can be performed in the hospital under a general anesthetic. I perform virtually all of these, as does Red Allensade perform these. Red and I, I believe are the only two that perform these in the office under local anesthesia and kudos to my friend Red Allensade, who's also, by the way, written and helped to edit an excellent textbook on genital plastics. Red took a already existing tractor system, The Lonestar, changed it a little bit and made it a wonderful system for exposure that does allow performance of these procedures in the office, under local. As has another friend, Marco Pelosi, who's designed an amazing retractor that can be used.

So just very briefly walking you through what we're talking about when we talk about a perineoplasty and vaginoplasty, this is not meant to teach you how to do this operation. It just shows you a little bit about what we mean as a basis, as a foundation when we talk about the physiology and the biomechanics in just a little bit.

So here's a woman with a paris vagina, a little bit of laxity, a little bit of gaping. In making the incision, what we can't quite see is the perineal incision. This starts just inside of the hymenal ring, just inside the introitus at about 4:00, 4:30, goes down on the outside encompasses lax perineum to the nadir, just above the anal verge. Comes down also from around 7:30 or 8:00, that comes down on the outside, then we'll make a line. A horizontal line between these two. Size that line with different instruments. I like a radio frequency needle electrode. Make that incision. Go ahead and undermine. You can see the retractor system in place. We'll undermine. We'll go to above the rectocele. I get in six, seven, eight centimeters inside. We'll go ahead, we've already removed part of the vaginal mucosa. We will remove this other part, you can see the rectocele a little bit over here. You can see it better in the next slide. What I've done is I have just a stay suture on the recto-vaginal fascial layer. So you can sort of see the rectocele. The levator muscles, bulbocavernosus, ischiocavernosus, and so forth. The levators are against the pelvic side wall and they come this way.

They're not transverse, they're vertical and they stretch apart. So basically what you're doing in this repair is you are putting in vertical sutures way over here. We can retract and expose that. Suture goes in here, it comes across to the other side, it's tied, and that basically will bring the levators as a levatorplasty and cover over, build up the pelvic floor, cover over the rectocele either with that same layer or a separate layer. We will bring the rectovaginal fascia that we dissected down off of the vaginal mucosa. We'll bring that over to cover up the floor. The other thing we'll do, after we've developed the perineum, is to get rid of all of this scar tissue from lacerations and episiotomies. We'll take out a plug of tissue that literally is about two centimeters by two centimeters from this whole area. So when everything's brought together it's going to snug up the vaginal barrel. So here you see just finishing the procedure, again this is not teaching you how to do the procedure, just giving you an idea of what we accomplished.

So what we've done, again we're only looking at the outside, what we've done is we've built up this tissue. We've re-approximated the transverse perinealis muscle. We've re-approximated the perianal musculature. Inside we've brought the levators together and we've rebuilt the pelvic floor. So to understand why these procedures work, it's nice to understand a little bit about the physiology of orgasms. And understand that, again arguably there's a lot of argue about this. My opinion is that, and many opinions, many people's opinion is that basically there are two types of orgasm, clitoral and vaginal, or perhaps better said vaginally activated orgasms. And certainly the two can work in concert.

So many of you have maybe seen this, certainly if you've attended my lectures you've seen this slide before. There are a lot of things that go on in women's orgasm. And what we're going to do today is talk a little bit about the clitoris, both the external clitoris and also the internal components of the clitoris. Here's a slide that is seen in many different places. It's a wonderful slide. But the clitoris is not just the little pink button that you see. The clitoral glands, you know if you look at a woman's clitoris real closely, it's like in looking at a mini penis. It looks exactly like a tiny little penis. And like a penis, it's not just the head. There's the body, the clitoral body, and that comes down underneath, and really it wraps these internal organs of the clitoris, wrapped around the urethra and really make up part of the, I like to call "G" area rather than G spot.

There are the true ... There's a crus on one side, a crus on the other side. Together they're called cruri, or corpus cavernosum. There's the bulbs of the clitoris, these are in loose, a realer tissue. But both of these consist of erectile tissue. And you can get an idea of the formation of this. This is innervated by the clitoral nerve, a branch of the pudendal nerve, which comes out from the spinal column around a little bit from L4, mostly L5, S1, S2. But a very important thing to understand, and this is probably one of the most important slides of the whole presentation. Is this concept of unity, in just a moment I'm going to show you a slide of a reference, it's a wonderful reference to look up with this concept of unity. The distal or the outer vagina and the vulva. The clitoris, the urethra are not separate, really they have a shared blood supply, a shared innervation, and they really respond as a unit to stimulation.

The urethra orifice is a very sensitive area in a woman, as is obviously the clitoris, the vulva, many different areas. But really it's a shared, this is a shared concept. So it's really a complex, and I really like to talk about the clitoro, this is a mouthful, the clitoro-urethro-vaginal concept. Clitoro-urethro-vaginal complex, which is really a unit, an anatomic and a functional unit. And that unit is activated by stretch. The greater stretch, you see what we're getting to soon, the greater stretch, the greater activation. So the vulva outerlies the wrapping, there's the urethral orifice surrounded by erectile tissue of the clitoral bulbs. The clitoris is not just the glands, it's an important distinction. All of these have erectile tissue components. And please understand they don't have a single innervation. There are really two sets of nerves. In the whole body there's two sets of nerves. There's somatic or skeletal nerves, and there's the autonomic nervous system. Two separate nervous systems.

The nervous system that tells you when your bladder is full or when you have to have a bowel movement is very different than the nervous system that tells you that you've been punched in the face and you get ready to punch back. So the somatic nervous system as I said comes from the dorsal clitoral nerve, which is a branch of the pudendal nerve. Supplies the skin and some of the underlying stretchers. The more visceral, autonomic fibers come by a cavernous nerves, by the inferior hypogastric plexus, branches of our old friend the vagus nerve. For you doctors that are looking at this, you remember the vagus nerve. It starts at the top it goes to the bottom and innervates everything. So vascular engorgement involves both somatic and visceral nerves. And there's a reflex arc here with cutaneous and somatic afferants and visceral efferents. And this is the reference I was talking about, Helen O'Connel and [inaudible 00:19:18] Patriots, this is an article 2008, Journal of Sexual Medicine, called The Anatomy of the Distal Vagina Towards Unity. It's a wonderful article that talks about the clitoro-urethro-vaginal complex.

So let's talk a little bit about our friend the anterior vaginal wall, and it's sensitivity, and Charles knows a lot about this because he puts, he and several of us put platelet-rich plasma okay, which has growth factors and angiogenic factors, and where do we put it? Into the anterior vaginal wall. Why do we do it? Because of proximity to peri-urethral tissue.

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Michael Goodman: -do it because of proximity to peri-urethral tissue, proximity to the clitoral bulbs and the crurae, and again, in this area there is both a skeletal and an autonomic nerve supply. While this slide is up I want to talk just for a minute about the peri-urethral glands, AKA Skene's glands. Skene's glands have their opening, their ducts, just around the urethral meatus. If you look real carefully, not in all women, you can see these little gland openings. Every once in awhile, they'll get plugged, and you can have a Skene's gland cyst, but female ejaculation, and not all women have well-developed Skene's glands, but there's a difference between squirting and ejaculation, and that's not the purpose of this to talk about. Squirting is losing urine. Female ejaculation is discharge of prostatic light fluid from the Skene's gland, little detour there.

So remember in medical school, at least I remember back in ancient times when I was a OBGYN resident, we were told that the vagina is poorly innervated, and indeed, one can go into a woman's vagina, one can visualize a woman's vagina, and can take a scalpel and cut that vagina, and the woman will not know that that happened. Okay. But that doesn't talk about stretch receptors, which certainly that organ, the vagina, has. So this organ, especially in its outer portion, and I love this quote. This is one of the best quotes I've seen from Glorida D'Amati and Emmanuel Jannini, two beautiful Italian women, and only an Italian, I guess could say it this way.

"This organ, especially in its outer portion, contains enough nerves to participate in sexual response as well as the whole biochemical machinery known to mediate excitation and arousal in the male copulatory organ."

What a wonderful quote. Do you have anything to say about that, Charles?

Charles Runels: Yeah. So I'm a big fan, as you know, of Dr. Gräfenberg, for whom the G-spot is named, but if you read Dr. Gräfenberg, he doesn't talk so much about a spot. He thought what was going on is exactly what you're saying. It really had to do with the whole complex, and especially the entire urethra, and not so much some magical spot. As a matter of fact, I think personally that the spot changes sometimes day to day in the same woman, but he was all about the whole urethra, and if you think about it, not only do you have this excitatory response from the stretch receptors itself, but by bringing those structures next to the vagina closer to what is making the stretch, if it's a man having sex with a woman, then you're going to have more pressure in the corpus cavernosi of the clitoris as well as on the urethra.

So lots of things are happening. That's why I like your phrase the ureal, clitoral, vaginal complex, because you get not only excitation from the stretch receptors on the vagina, but that stretch brings pressure simultaneously on the part of the clitoris that wraps down next to the vagina, as well as on the urethra. So absolutely. I'm over here cheering for you.

Michael Goodman: And I didn't need you to say that, but that just sort of segues into what we're going to talk about in just a little bit, which is vaginally-activated orgasm. I like the term "vaginally-activated orgasm" better than vaginal orgasm, but we're talking about the same thing. Again, these are relationships between clitoris and vagina. There is a reflex called a vaginal-cavernosus reflex, so what this is, is when there's vaginal distension, I mean inserting an object, that induces contractions of the bulbocavernosus, the ischiocavernosus, and the magnitude of that contraction, and this is research data, increases with the volume of vaginal inflation, therefore if there's increased inflation, or increased pressure from a tightened vagina, a large penis, or growth factors and androgenic factors in the anterior vaginal wall, this increase contact between the vagina and the congested clitoris leading to vaginally-activated orgasm caused by contact of the internal portions of the clitoris, again, somatic, skeletal innervation, and in the anterior vaginal wall stretch receptors, which are autonomic innervations.

This is research-based, and these slides have that research on them. Odile Buisson and Pierre Foldes, Emmanuel Jannini have done a lot of work on that, as have others.

So again, not to beat a dead horse, but there is a clear reciprocal relationship between the clitoris and the vagina, and remember, functional [inaudible 00:25:40]. Let's talk about these different types of orgasms.

Clitoral orgasm, caused by both digital stimulation, external stimulation, again clitoral nerves from the pudendal are warm, electrical kind of feeling. Vaginally-activated orgasm, arguably more intense, more internal, more deep, more throbbing, and this is triggered by stimulation and expansion of the vagina, the G-area. Anterior vaginal wall, autonomic innervation. Very interesting. Very interesting. It's research that's been done by Barry Komisaruk and Bev Whipple out of New York City. I think, Charles, you know probably Barry. I don't know if you've met Bev. They did seminal research where they studied women that had spinal cord transection. They had spinal cord transection above L4, L5, and found that ... So what you're doing there is cutting off any input from the pudendal nerves. Well, they don't have any innervation from the pudendal, and these women were still orgasmic, really proving that it's not all the pudendal nerve, proving that the activation and innervation from the autonomic nervous system plays a big role here. That was really seminal research that Whipple and Komisaruk did.

So we talked a lot about the anterior vaginal wall. I won't beat that again. This is research, again, from Pierre Foldes and Odile Buisson. So in contrast to clitoral orgasm, vaginally-activated orgasm is orgasm triggered purely by penile, vaginal intercourse or a surrogate. Very interesting and very controversial research is this study down here by [Stuart 00:27:54] Brody and I don't know Weiss. I haven't met Weiss. Stuart I know. This is from University of West Scotland in Paisley. Brody has written a lot. It's very controversial, and basically Brody feels that women enjoy men who have larger penises, that women have greater orgasm response, especially vaginal orgasm, in men who have larger penises. Why? Because there's more stimulation of the anterior vaginal wall.

What are we doing when we do vaginal tightening operations? I don't think we're increasing the size of men's penises, but Charles, you've commented a lot about that, and you certainly have research in that, and you are working in an area that actually does increase the size of men's penises, certainly by tightening the vaginal barrel, lifting up the perineal body, you're doing about the same thing. You're not making the penis larger, you're making the vagina tighter.

So basically, relaxed vagina, relaxed perineum, less penile pressure against the pubis, the clitoris, less stretch on the receptors of the anterior vaginal wall. So the goal then, of a vaginal tightening operation, is to reestablish the angle and to increase the anterior vaginal wall and cervical pressure, but one other thing that I haven't mentioned is that just tightening the vagina, just doing that surgical operation I think is leaving half the job undone. We're bringing these muscles in together, but just bringing the muscles in together is doing nothing but strengthening the muscles, so just doing an operation without working with that women, her pelvic floor, strengthening exercises, working with her or working with a pelvic floor physical therapist who works with her, I think it's imperative for really doing the job right.

So I'm going to show you a few of my photos [inaudible 00:29:57] labioplasties in addition to their pelvic floor operations. You obviously cannot see inside the-

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Michael Goodman: -their pelvic floor operations. You obviously cannot see inside the vaginal barrel, but looking at this you can get a little idea of what we were talking about, what's accomplished with vaginal tightening operations.

With perineoplasty, working on the outside, that's perineoplasty, building up, reestablishing the angle, building up the clitoral body, bulking the clitoral body, doing an aesthetic repair of the opening, and then vaginoplasty, tightening the vaginal barrel.

These are just a few before and afters. Again, some of these have had minor labioplasties, or major labioplasties at the same time.

Different cameras, obviously here. We didn't do any work at all on the top. The labia are just so splayed outward here, where they're inward here, but you can get an idea of what's been done from here to here, as opposed to what obtains over here.

Same thing here. She's healing from her labioplasty. Again, this kite-shaped incision, we did no work to diminish these folds. This is just the incision that reconstructs the opening, builds up the perineal body.

You can see especially here, we've done no work on the anterior vagina, and this is a urethra seal, and there's nothing you can do really about a urethra seal, but we certainly have supported the perineal.

So concluding this part of the presentation, these so-called vaginal tightening operations, AKA perineoplasty, vaginoplasty, vaginal rejuvenation, surgical vaginal rejuvenation, appear to have good outcome via both mechanically tightening the barrel, forcing the penis more tightly against the anterior vaginal wall in Gräfenberg's area. Thanks, Charles. Which contain erectile tissue of the bulb and [inaudible 00:32:02] of the clitoris, as well as that rich autonomic supply, reestablishing the downward angle of the barrel with greater stimulation of the external clitoral structures by the top of the penis and by the partner's pubic bone.

So with that, I'm done with what I had to say. Any questions are welcome.

Charles Runels: Yes, okay. So-

Michael Goodman: And just one last thing before [inaudible 00:32:32]. There's no way on Earth that I could do the work I do without Nicole Sanders and Rachel Davis. Nicole's worked with me for 14 years, Rachel for five. They scrub on surgery. They work with women in every possible way, and we are truly a team, so I'll shut up.

Charles Runels: Beautiful. Well, it's a very elegant presentation, and the mechanics, when I talk with physicians, it's amazing how many physicians would have trouble drawing a clitoris, and the entire thing, and how many gynecologists have told me that they prefer to not talk about sex. I'm not so sure that's a bad thing. Perhaps they're more interested in treating ovarian cancer and sex is off-topic, but as you know, it's not always a comfortable thing for people to speak about, and I salute you for blazing the trail for making it more acceptable.

Now, what I would like to address is some of the objections that people have about what you and I do. Now, for example, there are those that would say we shouldn't pay attention to the labia's appearance at all, and what I think you did was lay out a very good explanation about why it's not just about appearance. It's truly about function, and I know you've published in this arena, but if you wanted to talk about the appearance itself, talk about what you've seen, what the research has shown about how appearance affects function.

Michael Goodman: Oh, [inaudible 00:34:18]. I'm going to go talk about something that I very recently had contact with and then back up a little bit. I review for some medical journals, and I just reviewed for the Journal of Bioethical Investigation. I just reviewed an article for the Journal of Bioethical Investigation, one of the top bioethics journals. This is done by a bioethicist, who is not a surgeon, has no interest in female plastic and cosmetic vaginal surgery, and looked into the area of adolescents and whether they should have labioplasties or not.

I've had the opportunity to operate on a modest number of adolescents. We're talking about young women between the ages of 14 and 18, and adolescents really come in with the largest labia of all the women that I've operated on. They come in with their moms who couldn't believe what they were talking about at first, and then understand. Basically, what this article talks about is the feeling that other people have that, "Well, if it's a big functional problem and it really causes infections and so forth, then maybe you should operate on it, but if it's a psychological problem, then you shouldn't."

And this group of bioethicists begged very strongly to differ, saying that we do a lot of procedures for people because of significant psychological situations, psychodynamic situations, self-esteem situations, and felt that there's really no difference between functional and self-esteem/psychological reasons. Certainly, that is borne out in the literature. We did a study several years ago, now seven or eight years ago. It still is the largest study in the literature on about over 250 women and 345 procedures, of which about 150 were labioplasties.

We took a look at sexual satisfaction in women that had labioplasties and the reasons for labioplasties are usually either psychological, meaning, "I don't like how it looks. It makes me very self-conscious. I don't want to have sex in the light. I don't want him to go down on me. I just don't feel good about it." And none of these men are complaining. We guys, we're just happy to be there, and we love our partners for who they are and whatever's attached to them is fine, but women feel very different about this, so we looked at sexual ... enhancement of sexual function, enhancement of sexual satisfaction with validated questionnaires in women that had vaginal tightening operations, separate issue, and women that had labioplasties.

And women that had vaginal tightening operations, these operations enhanced their sexual function in our study by 87.5%, in [Pardeau's 00:37:35] study by 90%, and interestingly, we asked the men, who were happy to begin with, but 82% of the men felt that these tightening operations enhanced sexual function.

Well, then we also looked at labioplasties. Now, you'd figure that a vaginal tightening operation, one would hope, would enhance sexual function, but a labioplasty, we're just doing appearance. It shouldn't do anything with sexual function, but in women, two thirds of the women, 67% felt that the labioplasty had either a moderate or a significant enhancement on their sexual function and sexual satisfaction, and we banged our palm on our forehead and said, "Of course." If a woman feels more self-confidence, if a woman feels that, even if the guy hasn't said anything, if a woman feels that she's prettier down there, and she's not worried about her labia escaping from her thong, her lacy thong underwear, she is going to be much more participatory and much happier in her sexual function.

The other thing we did is published a couple studies, and others have published studies looking at body image and sexual satisfaction in women that undergo genital plastic and cosmetic surgery, and it's well-known that if someone has a sexual dysfunction, true sexual dysfunction, or if someone has body dysmorphia, true body image issues, you're not going to cure that with surgery. Period. We know that. Plastic surgeons know that. Well, very interestingly in our last study, which was well [inaudible 00:39:13] and well brought out in time, this was on 120 women. We followed these women for two years. We got feedback prior to surgery. They filled out four questionnaires that looked at sexual function, looked at body image, looked at body image, body dysmorphia, sexual function, and I'm sorry. I'm blocking out one other thing.

We looked at them before surgery, six months, 12 months, and 24 months, and these women as a group, qualified as body dysmorphic. If you looked at the validated questionnaire we utilized for body dysmorphia, these women-

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Michael Goodman: Questionnaire we utilize for body dysmorphia. These women were body dimorphic and their sexual function was generally poor. One would think that surgery would not change that, but at all points in time, moderately at six months, but very significantly in 12 and 24. This was a level two study. It was controlled. It was a controlled study that by 12 and 24 months the body image dissatisfaction, the so called body dysmorphia, had totally disappeared. This was not true body dysmorphia. This was body dissatisfaction, very different than body dysmorphia. Now, it disappeared and the sexual satisfaction went up to and actually went beyond that of the control group. I can go on, but hopefully that answered your question.

Charles Runels: Well, very elegantly and much of that research, I know that you spearheaded. I hear other physicians who are in hardcore science forums where they're talking about like Lichen sclerosus and other diseases. That will sing your praises because until that research was done, a lot of people did assume that anybody who wanted to change the appearance of their labia must have a psychological problem and they're better off with a psychiatrist than doing something about the labia. This research demonstrated that not to be the case. 67% is a strong number and still a year out and farther still working.

There are others that, as you know, strong movements among some of our colleagues, I think becoming more and more the minority, that we shouldn't even have before and after pictures of the labia or even say anything about it on the internet, which goes back, I think, more to do with relationships with sex than with medicine because, as you know, there was a time in the not so far past, 20, 30 years ago, where before and after pictures of the face with facial cosmetic surgery was considered to be unethical. Things changed because we realized you can't really demonstrate to a patient what's possible and what's not possible without photographs. I think this idea that it's okay to change a person's face to make them feel better about themselves, and obviously even facial plastic surgeons, as you said, they're not going to do surgery on someone who's psychologically, and we can find this out with an interview, they're not going to get better no matter what you do with them. They're going to have surgery after, surgery, after surgery and there's a way to discover that about a person with an interview.

There are those who get a legitimate facelift of something done cosmetically, they get their Botox or whatever, and it makes them feel better about themselves. If you think about it, the concept that it's okay to do that with the face, but yet if you apply those same ideas to genitalia, somehow that's wrong. It smacks or some Victorian era. It always surprises me that that idea still exists even though you've done the research to show the same thinking applies. The idea that a woman can go buy a dress and feel sexy and want to have intercourse tonight, but yet you couldn't make her feel better about her vagina to me just seems a little bit hypocritical. I'm just saying amen. I know that you did that research, which is why I wanted to bring that out and get it out there for people to think about.

When I post this video, I'll put some of those links to some of that research under the video so people can educate themselves. Just one other comment I'd like for you to elaborate upon. Let's just scenario here. People get married. They're 20, 30, whatever age, but let's say it's a typical young love. You get married, and you have children, and then you stay together. Now you have this soul mate of 10, 20, 30 years, 40 years. We see people 50 years in our office married, but the universe plays a bad joke, in my opinion, because by the time a man reaches 65, he loses half of the endothelium of penis. A woman delivers a child or two and estrogen levels change. His penis is literally shrinking and her vagina is growing. By the time they've been together for a while, these lovers who may have matched when they were younger now don't.

Again, the idea that you shouldn't do something about that because it's genitalia, where it's perfectly okay to do things to change your waistline or your neckline, to me, just seems a little bit hypocritical. Could you elaborate a little bit on this matching idea? That's why one guys penis may be too big for one woman and too small for another. If you're just thinking in terms of those stretch receptors, but when you think about these other modalities, like laser versus surgery versus the O-Shot, and talking to the woman about this matching of her lover, could you tell me maybe a few stories about people you've taken care of and integrate with it the way you think about the science?

Michael Goodman: Yeah. An interesting paper that I just reviewed for The Journal of Sexual Medicine and unfortunately was rejected by the editors, I think it should have a place in that journal, hopefully it'll be rewritten and resubmitted out of China, where they attract the anatomic changes of the relationships of different parts of a woman's vulva to her age as far as distance, distance between the pubic bone and the clitoris, distance between the clitoris and the vaginal opening, distance between the urethra and the perineum, distance between the perineum and the anus. What you mentioned anecdotally is true anatomically, that yes, with age, women's vaginas do fall down a little bit. The opening gapes a little bit. It becomes a little bit more relaxed and more open. That is saying that she's hormonally complete. Obviously if a woman after menopause is not on any hormone therapy at all, then sometimes the vagina can shrink if she's not sexually active.

As you mentioned, the size of a man's non-erect penis becomes somewhat smaller, so I understand, though I've not seen studies on that. Certainly a man's erection becomes less robust. I love that word, although you can use it both ways. A man's erections, for many reasons, become less robust. Certainly I work with men and a lot of times it's the partners of the women that I'm working with during their menopausal transition, where they weren't terribly interested in sex with all that was going on with menopause. Now they're feeling a whole lot better and a whole lot sexier, and the fact that now their partner can't either get or maintain an erection is an issue. Certainly working with testosterone, working with PDE5 inhibitors. I have not personally had experience with the Priapus Shot. You certainly have. Adding the Priapus Shot into that can all serve to increase the size of a man's penis.

There's a lot of things that couples can do. Obviously the use of fantasy, the use of toys. Love making is love making. Physical intimacy is physical intimacy and it doesn't all mean intercourse. It can mean using a toy in addition to the penis in the vagina to increase the stretch receptors. It can mean getting a Priapus Shot. It can mean taking testosterone and PDE5 inhibitor. It also can mean, for a woman, doing a surgical procedure to tighten the vagina. Obviously there's different age demographics. Certainly the age demographic for women who have having labiaplasties in my experience, and I've done about 750 labiaplasties and close to 200 vaginal tightening operations, the age demographic in women that are having labiaplasties is younger than women that are having vaginal tightening.

I've done vaginal tightening operations in women in their early 60s. I have not yet done it in women that are a more advanced age. I'm in my early 70s. My partner is in her early, mid 60s. Men and women in their 80s and 90s have sexual intercourse. A long winded way of saying, Charles, that there's a lot of different things you could do. That's the joy of sexual medicine is working with couples to improve their intimacy, which can be all of these different things.

Charles Runels: Yeah, it's so rewarding. We've both been involved in what others would consider to be more hardcore, life threatening type situations, but nothing has been more rewarding to me than having a couple to me than having a couple that's been married for any number of years, 10, 20, 50 years, come back to me and say, "We're rediscovering our bodies because they're responding more like they did when we were younger." Well, we could go on and on, but I just wanted to add that Dr. Goodman has several ways you can learn more from him. I highly recommend his book if you don't have it yet, of course. That's the place to start. Then he has hands on classes in his office where he mentors surgeons who want to learn more of the nuances of these procedures. He's been teaching for a long time. Many of the people who teach are his students. He's not also offering some didactic classes for those who qualify who can learn some of how we do the O-Shot, how to integrate that with some of the other methods that he's discussing with surgery.

I think your next class is coming up in Atlanta. There'll be others who will be posting and so I highly, highly recommend that, even if you've done these classes before, if you have the opportunity, spend some time with Dr. Goodman. He's recognized as the godfather of a lot of these procedures. Yes, sir?

Michael Goodman: I'm teaching classes in Atlanta in October and April and in Sacramento in January and July. The classes are excellent accommodations at airport hotels. They're two different classes. They're both didactic and experiential. I have full length surgical videos. The whole idea is to work with surgeons, whether they're cosmetic surgeon, gynecological surgeons, to basically teach the technique and to discuss how to work with women. We also talk about noninvasive techniques. We talk about platelet rich plasma for different indications including the O-Shot. We talk about the use and misuse of noninvasive laser and radio frequency. There's wonderful uses of both of them, and there's some misuses.

Charles Runels: Yeah. This is going to be some amazing stuff and I know there'll be other classes after that. I'll post links to them all. With that, I'll just tell you thank you. Unless there's something else, we'll end this call and I'm sure you'll be hearing from some of the people watching this video. Thank you very much, Dr. Goodwin.

Michael Goodman: Awesome. Thanks very much. It has truly been a pleasure.



Urinary Symptoms After an O-Shot® (Orgasm Shot®) Procedure

Question From One of Our Providers...

I completed an O-Shot yesterday. The patient had no pain during the injection or issues. I used 4 ml of the PRP in the anterior vaginal wall. Today, she is complaining of fullness in the bladder. She is urinating, but states that she feels that she has to urinate all the time. I have not had a response like this so far. Is this the PRP still needing to absorb and causing some irritation or is there something else going on?

So the way she describes this, it sounds like she did everything perfectly well, and actually, these sorts of symptoms, in my opinion, mean that you got it right. And the way I'm visualizing this, of course I could be proven wrong, but the way I'm visualizing this is whenever you have, let's say an abrasion and/or a scab, and you have this healing wound. Now, if you think about it, even as a child, you remember that scab itched, and you wanted to scratch it, and you felt burny and all sorts of feelings, sometimes throbbing.

So we're basically creating this artificial signal to the body because the body hasn't really been injured, but we're taking these platelets, releasing all these chemotactic factors and growth factors and vasodilators, and the tissue says, "Whoa. We've been injured." And there becomes lots of sensations surrounding this artificial hematoma that we've created.

Then if you imagine translating all those sensations around the urethra or into the clitoris, you might have all sorts of interpretations of that, and the things I've heard are everything from almost everything you can think of, hypersexuality. One woman said she felt like she became very aroused and even almost orgasmic every time she urinated. Interestingly, this was a woman who was competing in a fitness contest and was drinking lots of water as part of that getting ready for that contest, so she was having lots of arousal.

Others have urinary urgency, frequency, dysuria, all sorts of sensations. The bottom line is almost anything you can imagine they might feel it for the first three to seven days. Once you get to the two-week mark, really by the time you get to the one-week mark, all that stuff is usually gone, and by the time you get to the two to three-week mark, that stuff is gone, and now you're starting to see the beneficial effects of the procedure itself.

So hopefully that helps, and again, the first time it happened to me, I thought, "What's going on here?" But I hear this a lot from all of our providers.
I would highly recommend that you also check out the webinars. A lot of these tips are there. I just cannot over emphasize how many pearls and tips about patient selection and doing better with the people that you do treat you'll find if you go to the webinars and watch some of those, maybe one a week, just check them out.

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Vampire Wing Lift (TM)

Vampire Wing Lift™-Using blood derived growth factors (vampire) and an hyaluronic filler (like Juvederm®) to rejuvenate the labia (wings).

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