*Biggest Hurdle to Getting Started with PRP Procedures-"Belief"
*THE Fix for the Biggest Hurdle (I learned it from Sam Walton)
*P-Shot® for Size. Tips
*Does Adding PRP Make the Filler Last Longer?
*Anesthesia for the P-Shot® & for Penis-Enlargement Procedures
*Bags Under the Eyes After a Vampire Facelift® What to do?


Charles Runels: So you guys are in for a wonderful treat tonight. Dr. Bill Song is on the call with us. He's been teaching for us and various success with the procedures now for I think five or six years. Let's unmute him. As you know I like to cover in these calls, some with marketing, some with research and then some pearls from people in our group that are doing well and have some experience. Obviously when something's not in the textbook, the textbook is the patient and we have lots of bright doctors out there reading that textbook and reporting in these meetings so that hopefully we're getting ideas about how to do procedure better and for our next research. So Dr. Song I think has had time to think about this quite a bit. Let's unmute his mic. Let's see. Should be coming live here in a second. There you are. Dr. Song, how's it going?

Dr. Bill Song: Hey, Dr. Runels, very good. How are you? How's everybody?

Bill Song, MD

Charles Runels: Wonderful. Thank you for making time to be on the call tonight. When did we first meet? Has it been five, four or five? How long? How many years?

Dr. Bill Song: Yeah. It's probably been almost five years now.

Charles Runels: Yes. Well, I know you've been very successful and always willing to help with, I know you've taught some people how to do this stuff for various... And they loved your classes. And so I would like to start with just asking you if you are talking to a new person who just signed up or just did a workshop and they're trying to get started, just talk to them as if you were talking to yourself when you first got going about the science and your pearls, you want a hand out about the marketing or the procedures. You've got the floor.

Biggest Hurdle to Getting Started with PRP Procedures-"Belief"

Dr. Bill Song: Well, I think that the biggest hurdle, I mean not so much now, but at least when I was first starting was actually believing in it yourself that the PRP is actually working and what it's doing. Because I think even now, a lot of, there are people who still think that it's just kind of hocus pocus and they don't realize that the mountain of research and data that's out there and what's really going to finally convince you in your mind is if you do it, if you do it to for your patient and have it done and then only then when you really become a believer in it that you can be successful because then you can just really believe in what you're doing and get better results.

Charles Runels: Yes. Can I comment on that very quickly?

Dr. Bill Song: Yes.

Charles Runels: That is a huge point that I don't think anyone has made yet in these webinars and it's so big and obvious that it's not obvious. I call albright thoughts. They're obvious when somebody says it, who really is the beginning of being successful I think. And there was a couple of things that I think hold people back from, as you said, understanding in their bone marrow that this works. One is that they don't have it done themselves as so anything that you're able to have done, obviously you should have it done and most of it can be done to yourself, but you can come see me or see one of the other providers and we get that done. Second is treating of course like any other procedure there that's selective those on your staff or family who would want to have it done.

Charles Runels: But here's the big hold back when it comes to treating patients. And the same thing happened to me is that, because we're ethical, we don't want to take people's money and here's where the money back guarantee comes in. I think that if you're not sure if it works, you're going to be hesitant to recommend it to people if you have in your mind that you don't want to steal from people. But as soon as you make up your mind that if it doesn't give them the results they're looking for, you're not going to keep their money, then you actually become more free about offering it when you think it might help. And then with time you learn, oh, this really works. And just to make you feel better. I think about that idea about not thinking it works. I've taught it very sheepishly for the first, at least two years when my patients got better.

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Charles Runels: And when I got better, I still wasn't so sure wasn't placebo. And then when I taught a few other physicians and they're telling me it's working. And it wasn't until we had about 30 other doctors out there doing these procedures that I thought, okay, this must really work. We need to get this done and some research done. And so long way of saying I was difficult to convince as well. And I think that comes with time. I think with a lot of people it's two to six months in, unless they have a dramatic turnaround. Personally, it's usually two to six months in before the light bulb goes off and people say, "Wow, this is really changing lives." And they run with it. So, great point. Sorry to interrupt. Keep going.

Dr. Bill Song: Yeah, I think some of the things that, that you can do to really see the results right away. I mean the vampire face lift is one of my all-time favorite treatments because you can get that wow factor and if you've been doing fillers and the minute you start combining it with PRP and you see the difference that adding that PRP makes, you can see right before your eyes that something's happening in the glow in the skin as a patient is walking out the door and if they're very glowing. So that-

Charles Runels: And the shape becomes more polished. It's like it becomes more natural and attractive from the PRP.

Dr. Bill Song: Yeah. So that's like a home run procedure. And then of course we have all the other treatments where it does take some time to see the results but as you do more and more, you're going to be more convinced and you'll be more confident in recommending the treatments for your patients. I have a question for you. With the money back guarantee. Do you tell the patients before you do the treatment that you have a money back guarantee or only if it doesn't work or they're complaining?

The Fix for the Biggest Hurdle

Charles Runels: Yes, and I found that, well let me start, let me back up a step. When I first started my cash practice, so I'm doing insurance, yoga, open practice, insurance based and then I'll start doing some cash things. And then in 2003, I just go all cash. That was the heyday of Walmart in part. Sam Walton was the richest man in America and driving around with his bird dogs in the back of his pickup truck and worth billions and everything in the store was money back. And actually if you read his book Made in America, he talks about that one thing made the difference in their business. Their first son said, satisfaction guarantee. And I just decided, okay, if Sam Walton can guarantee you a $20 watch, am I going to be less responsible or less reliable than that?

Charles Runels: And I thought, if most people aren't honest then Walmart would be out of business instead of worth billions. So I decided to make a big deal out of it. So with almost every patient, if they pay me anything in cash, but especially if they pay me something over $1000, I will say almost these exact words, every time I'll say, you have to love this. You can't just like it. You have to love what I did or I want to know about it and I'm going to make it right. So that's the way I put it. And so it's not, I'm going to give your money back usually, but if it's something that I'm not sure I can get better, this is kind of the way I taught me and the patient into. Let's say it's a severe parental disease. It's been there for a long time and it's pretty bad. It's nine degrees or something. I'll say, "We have some research to back this up. We have had successes. I honestly don't know if this is going to work for you, but if you're not happy with it, I'm not going to keep your money."

Charles Runels: And so then we embark, now to make that work, you have to be mostly taking care of not all the time, but mostly taking care of the people where you have an 80% or greater chance of making them well, and you need at least three, preferably five times cost of goods so you don't lose money. So you're profitable on the next procedure. And it needs to be procedures that don't take a day of your time. And so this is the perfect storm for all of those things where you have something where if you give someone their money back, you still have enough profit built into the next procedure to cover your time and cost of goods.

Charles Runels: So ethically what you're doing is you're having your successes, finance or failures. Now, if you're not good at patient selection or you're doing your procedure where cost of goods are high, not so good. Which is part of the reason I never carried Lattice. I know people who've made a lot of money with it, but with 20% markup or whatever it is, I can't make money on that. If one of them goes out the door because my employee decides that they want put it in their purse, well shoot, I'm breaking even on the next five unit. So-

Dr. Bill Song: That's true.

Charles Runels: ... That's maybe more than you wanted, but that's kind of the way I think about it and it saves you so much heartache as well. It actually flips your... My thinking is that if you don't keep your promise, but you make up for it in a tremendous way like Sam Walton did, then even your failures become your advertisement.

Dr. Bill Song: Yeah, that makes a lot of sense.

Charles Runels: So, you flipped to [inaudible] though. That's okay. But I wouldn't pick your brain. By the way, that's a great tip. So what are the things, could you tell us, give us a pearl about maybe something that you mentioned the face, any pearls about doing the Vampire Facelift® or the facial?

Dr. Bill Song: Yeah, so, when you're doing the Vampire facial I also like to inject the PRP as well as do it topically. I think that makes a big difference. And usually have enough stuff left over and I just injected, I love injecting it in the tear troughs, inject it wherever you would inject a filler because the microneedling is pre activating the skin, you're going to get much better results than if you were just injecting it without doing the microneedling. I've done enough to know that it does make a big difference. So whether you're using microneedling or using a radiofrequency or a laser, the act of causing that injury to the skin is going to create the activation of the platelets when you inject it. So don't throw that away when you're doing, if you do have the capability, I understand that if some estheticians are doing it that they can't really inject it, but if you have the ability to inject it, that makes a big difference and give us a wow factor.

Charles Runels: Yeah. So just to add to, when Selphyl was first to market with their PRP, they sold it as, of course, they've learned a lot since then and they've changed their marketing in their kits a little different. But and it's still a wonderful kit by the way. It's the only one that includes calcium chloride. But when they were first to market, they promoted it as used like 'Juvederm.' And so it was injected as a standalone subdermally. What I found was the younger patients liked it just like that. And doctor Scofani out of New York did some nice studies where they graded nasal labial folds. They had blinded people, blinded observers, grading that showing benefit, which makes sense because the dipocytes in the cheeks go so crazy to the PRP. And they did biopsy studies showing the... We've talked about that a lot about in the back of the arm, injecting PRP and showing tissue changes that would account for increased volume.

Charles Runels: But what they didn't contemplate at that time was you can't more specifically sculpted shape with the PRP as a standalone. But as you just said, if you injected subdermally, especially in a younger patient, you'll get some really noticeable results. So it's a nice combination if you do in the microneedling I agree it just a squirt in each cheek and little in the tear troughs and microneedle like crazy and it can enhance the results of it. So maybe give us a marketing tip or two, when you started out you've been successful and what would you say to the beginner about how to get started? Assuming that now they've done it enough that they at least have some understanding the way this might work. What would you say are the top two or three things that have helped you in market?

Dr. Bill Song: Well, I think marketing has been a moving target. It's been changing. So right now, the marketing strategy is using social media influencers. And I had no idea what these were until one of my younger staff members said, "Why don't we get an influencer in here and give her a free treatment?" And I said, "Well, what's an and so why would I want to give her a free treatment?" I said, "All right, whatever, let's try it." And we had somebody come in and we gave her a Vampire Facelift®. And she went and she had something like 50,000 followers, and she's a local person who lives nearby. And when to know it, we start getting all these inquiries and people calling because they saw this woman get her Vampire Facelift® on Instagram.

Charles Runels: Beautiful.

Dr. Bill Song: And the cost was the cost of one treatment and some of my time and if you compare that to the return I get in doing cable TV ads or magazine ads, it's night and day. It's nothing. So we've been really having fun with that and growing our social media. And that's what's really working now. I mean, we used to do a lot of email marketing, but nobody opens their emails anymore and print that seems to be kind of it's not pulling the way it used to. So and a procedure like these, like the Vampire procedures, O-Shot®, P-Shot®, these are kind of niche procedures. These are treatments that capture people's interest when they see it on social media but it may not be something that you want to put on in a newspaper. So that's, I would say the social media right now is where we want to put our money.

Charles Runels: Okay, interesting. So that's working well for you. So what other procedures would you want to talk about? I have a study I want to bring up and always have questions.

P-Shot® for Size. Tips

Dr. Bill Song: So because my practice is an aesthetic practice, with the P-Shots, my clientele aren't really coming to me for ED, although everybody wants better function but they're looking at looking up P-Shot® and they're finding that you do get some increase in size. And as you always said, don't emphasize that because it's modest and people will fixate on that, and sure enough that's they're fixating on. So what I started doing was using some fillers and you can use different filters, but I put in HA fillers the easiest and actually do it like you do the wing lift. I would kind of put it, mix it half and half with PRP and inject it kind of accordion style along the shaft multiple injections. And then when you put it in with the PRP, it really causes a nice volumization that can last over a year.

Dr. Bill Song: I'm doing now with Bellafill and fat, but that's more advanced stuff because there's some issues that if you don't know what you're doing, you can create some lumps and irregularities that are hard to fix but an HA filler's a nice way to start. And it's basically a Vampire Facelift® for the penis.

Charles Runels: When you do this procedure, are you mixing the Juvederm in the PRP is as emulsion in the syringe? And then are you injecting the corpus cavernosum or in subdermally or?

Dr. Bill Song: No, you do the regular, you do the P-Shot® with just the PRP because it is vascular tissue, so you don't want to inject filler. And that's actually a very important point because theoretically you can cause an embolism if you're putting filler or fat into the corpus. So you're injecting it right under the skin, superficial to the Buck's fascia because you don't want to inject it deep. So it's kind of like when some people know how to do hand injections, it's very superficial. So you want to stay superficial and people are injecting HA into the glands but it's mainly the shaft that we can successfully enlarge. And I mentioned doing it like the wing lift where you mix it because that's an easy injection and you can kind of spread it and it'll be less lumpy then if you're injecting the straight filler in there because until you really get the hang of it, you can kind of inject it on evenly and make it a little bumpy.

Charles Runels: What ratio are you using?

Dr. Bill Song: When I'm mixing it with the PRP, like a 50/50. The other way you can do it is what I like to do is use a cannula and if I use a cannula, I inject a filler first and then and then inject the PRP over it like we do Vampire Facelift® and yeah. And that's a nice technique that we've had a lot of success with.

Charles Runels: Wonderful. Let's answer a couple of questions. That's a great tip and good advice too. I've actually injected PRP lots of crazy places on my own self, including in the corpus cavernosum but I would never do that with a patient because if something went wrong, you're right, it could be bad. And because you [crosstalk] what's that?

Dr. Bill Song: Did you say filler or PRP?

Charles Runels: I have done the mixture similar what you're talking about and used it in the corpus cavernosum but I would never do that with a patient because of what you just said, the risk of emboli. And so I want to reemphasize what you just said in that, I mean, I've done liposuction on myself, so I've used myself for a guinea pig more than I like to talk about. But-

Dr. Bill Song: There have been some deaths from people injecting fat into the vascular tissue of the penis so.

Charles Runels: Yes, exactly. So not to be done. And so I want to reemphasize, so no one missed it, what you just said, is it subdermally just lifting the skin as you would with the hand? And if you want to hear another explanation of that, I don't know if I had it posted yet behind all my transcriptions, but Dr. Zimmerman out of-

Dr. Bill Song: Nevada.

Charles Runels: Yeah. Las Vegas, talked about it a couple of months ago, three months ago. So a slightly different technique, but the same idea. So you're mixing about one to one ratio of the two?

Dr. Bill Song: Yeah, yeah. I think that's the simplest way to do it without having lumpiness.

Charles Runels: Okay. So you just got a bunch of questions here, so I'm just going to unmute some of these smart people and let them ask you, is that okay?

Dr. Bill Song: Sure.

Charles Runels: All right. Here we go. Let's unmute [inaudible] I think was first to hit us up with a question about that. Let's see if I can unmute him. Another one of our teachers. Oh, by the way, when's your next class?

Dr. Bill Song: My next class is in... I have two classes actually, one for the Vampire course and that is in June. Let me just-

Charles Runels: Is it listed on our events page?

Dr. Bill Song: You know what, I am not sure but I have a-

Charles Runels: You've got an email?

Dr. Bill Song: Yeah, actually gubum G-U-B-U-M .com and I have my classes listed on there.

Charles Runels: Okay, let me see.

Dr. Bill Song: The next training is on June 8th and ninth. That's our full Vampire training. And then-

Charles Runels:

Dr. Bill Song: And then in July we actually have... I'm doing this with a doctor Steven White who does the Myrtle Beach butt lift. And we're doing a penal enhancement training and the butt lift training and we're certifying people for the P-Shot® during that training too and that's in July.

Charles Runels: Beautiful. There you go. G-U-B-U-M. So you guys check it out. So let me unmute and I know that DR. Song is a really clear speaking, get it done teacher. So I think you'd enjoy that class. Okay, Mark, let's see. Your microphone is almost live and there you are. Hey, thank for jumping on the call.

Mark: Hi, how're you doing?

Charles Runels: Great.

Mark: So very interesting. It seems like this is the new trend. I was at a meeting in January where at the International Society of Cosmetogynecology, actually you were there too with me. There was a fellow from south Florida who was talking about HA injections into the penis and he works for Dr. Paul Peredo. And it seems to be like the hottest thing, the hottest trend right now for girth enhancement. So my question to Dr. Song is, how many patients have you injected with HA? Are you using needle technique or cannula technique to get under the Buck's fascia and how much HA do you inject at any given time?

Dr. Bill Song: Okay. So now I'm actually not using HA any more, I'm using PMMA the Bellafill. And but I kind of worked my way up. I started with the HA, I'm typically putting five syringes in at a time. And the reason is because I think if you just do one or two, the patients really aren't going to be wowed. It's better to just charge them the pricing and inject enough filler to give them that wow effect and if you combine it with the PRP, I think that's going to give them the volume that makes them feel like they had a substantial and they can see it. And one of the things that's, this is kind of fun. I had a patient recently came back in and had a complaint and his complaint was that is pump didn't fit him anymore. So I said, "I will gladly give you a bigger pump." So.

Charles Runels: Why, PMMA over HA?

Dr. Bill Song: Well because it's, it's a costly treatment. So we want something that's going to last. The PMMA is going to last them for years, five years more. I mean probably permanently but the bell of fill in the face is FDA approved for five years. So then that's what they're looking for because a lot of people are actually going down to Mexico to get PMMA and because it's cheaper but the Bellafill is what's FDA approved, so we're not putting as much volume of the PMMA in, as they do in Mexico. But again, using the PRP we can get that volume and without the risk of or that, because the biggest risk of the PMMA is the lumpiness.

Charles Runels: Right. So my question is, if you're injecting five MLs of PMMA, is that actually 2.5 a PMMA and 2.5 of a PRP or is it five of a PMMA in five of PRP?

Dr. Bill Song: Well, each syringe of Bellafill has 0.8 CC's and most of it is collagen, bovine collagen and say 20% PMMA.

Charles Runels: Do we have to skin test?

Dr. Bill Song: Yes. You should skin test but the collagen in this product is really clean. So I've never had a positive skin test, but they do provide skin test kits to skin tests and that actually makes it more of the process. They come in first for the skin testing and all that. So they kind of see it as a more significant procedure.

Charles Runels: So the ultimate question is this, if you're injecting 0.8 of PMMA with approximately one MLs of PRP, so you're injecting approximately two MLs of the actual product that's going to hang around for five years and the PRP. Do you counsel the patient that, "Yes, I'm going to inject five MLs or 10 MLs total, but you're going to lose half of it because the PRP isn't going to stick around. The PRP is, it says that's nice for skin rejuvenation and for other things, but if you're putting it right underneath the skin, that's going to be gone and within a couple of weeks and the only thing that's going to be remaining is the Bellafill. Correct?

Dr. Bill Song: Well, the collagen in the Bellafill is going to go away, but those little PMMA particles are going to act as a scaffold or for living collagen to replace it. So the PMMA is actually implant material and it's permanent. So it's going to stimulate collagen or-

Charles Runels: It's very similar to Sculptra then.

Dr. Bill Song: It is, it is. It's the same principle except the sculptural kind of dissolves away, but the PMMA is more like an implant.

Charles Runels: So when you inject the PMMA like with Sculptra, do the patients have to be very sort of religious with doing massage to smooth everything out and to get it to like very similar to sculpture, you have to do the massages three or four times a day for a couple of days?

Dr. Bill Song: Well, because it's embedded in the collagen, it's going to stay better where you inject it. What I do is I inject it with a cannula and then I inject the Bellafill first and then I go in the same entry PRP and put a good volume of PRP over it so that you can get the collagen stimulation and yeah. And then when they're-

Charles Runels: Have you ever just tried just putting PMMA on one side of the shaft versus PMMA and PRP on the other side to see if the PRP actually does make a difference?

Dr. Bill Song: I haven't done that, I don't think [crosstalk 00:32:22].

Charles Runels: I'm going to interrupt just a second. So I see where you're going and I-

Mark: I'm just wondering [crosstalk]

Charles Runels: [crosstalk] experiment more.

Does Adding PRP Make the Filler Last Longer?

Mark: I'm just curious as to see by adding PRP. I understand just like what the Vampire Facelift®, it's theoretically going to help things along and keep the filler there a little bit longer, but is it actually doing anything or is it just adding more volume?

Charles Runels: Well, let me see if I can answer that question? It's actually, it's a very good question. And I don't have the research to back it up, but I have something to think about as we think about what might be happening with the penis. That's easier to see and you've seen these pictures before so you know, I mean obviously just for you guys who don't know, Dr. Lana has been doing the procedure also for probably five or six, I don't know, seven years. I'm not sure when we met a long time, lots of procedures, but just to remind you guys this as an example of what you're talking about with the penis, that you guys have seen this pretty large defect from a cortisone injection that left... Actually I saw this woman running down the street a moment ago. She won Miss Alabama last year. She just gave up her crown, but this was maybe six years ago, seven, I don't know, eight years ago actually.

Charles Runels: This was early on and the way I treated this hypo trophic defect in her ankle was with Juvederm, with PRP on top. Now this is a year later. The question is, would this have worked that well with Juvederm alone? And I'm thinking what might be happening is that true as in the wound care literature, there really is PRP by itself. As you just said, Mark, is more like a upholstery, not much volume to it, but maybe there's a synergistic effect so that when we put either an HA or the PMMA such that stem cells are recruited and build on top of it as a scaffold and you truly do get something more than just [inaudible] with an enhancement of the cross link, whatever it was you put there.

Charles Runels: Now that's just me, that's purely anecdotal, but I've seen other scars respond similarly and somebody just needs to do the research. But I think you make a good point. Someone needs to prove to us that the both is better than just the one. But I think it'll show that it is most likely.

Dr. Bill Song: So Mike, I haven't done one side versus the other, but I've done enough with them without both on the penis and lots and lots and lots on the face to know that it makes an absolute difference in PRP by itself or a filler by itself versus the combination. I mean there's definitely a synergistic effect and the only way you're really going to be convinced is to start doing it. And then you'll see.

Charles Runels: Can I expand on something else that was just mentioned about Dr. Lani? I just want to make sure because I think I heard it two different ways. I want to make sure, you guys are looking at my screen. So here's skin. There's Buck's fascia, now we're a layer deeper. So which leg are you putting it?

Dr. Bill Song: So you're putting it just under the skin.

Charles Runels: Here?

Dr. Bill Song: Yeah.

Charles Runels: So superficial Buck's fascia?

Dr. Bill Song: Yeah. So then you're putting it superficial Buck's fascia. There's a little space, like if you go in with a cannula, you can actually and move around in that space with a cannula.

Charles Runels: Beautiful. You good, Mark?

Mark: Yeah, I'm good. Yeah. That's awesome.

Dr. Bill Song: Stay on the line.

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Charles Runels: You guys, cool stuff. Good questions. Let me unmute someone because there are other questions. So Ann asked, what filler do you use? I think that was answered. Let's see-

Dr. Bill Song: As far as the HA fillers and I think I've said this before, it doesn't really matter, you don't need to use the Voluma. You can use Versa, which is a great filler, which is really cheap because the fillers, you're just using it to activate the PRP.

Charles Runels: It's a scaffold just like... I left that out of my story. But that woman has now just won Miss Alabama and she got one treatment and then another one about after a year just to help the sensation, which wasn't quite back to normal. So yeah, something permanent goes on when you combine the two. Let's see what else we got. Oh, so Dr. Kumar lists on YouTube, one second. Okay. Romish how are you?

Romish: Hi. How are you doing? Can you hear me?

Charles Runels: Beautiful. [inaudible] perfectly clearly. So you probably have more than one question, go for it.

Anesthesia for the P-Shot® & for Penis-Enlargement Procedures

Romish: So basically my concern is, Dr. Song, do you use just the BLT cream or do you inject a local anesthetic when you do these kinds of invasive procedures?

Dr. Bill Song: So I have a compounded cream, like Pronox that it's like 24/7 and that works pretty well, but you can also do a block.

Romish: Okay. All right. So any idea about using Pronox? Have you tried that at all for your procedures?

Dr. Bill Song: [inaudible] is great for any procedure. Just calming the patient down and making them not care so much about, but it's not as painful as you would think.

Romish: It's looks painful though.

Dr. Bill Song: Actually the P-Shot® probably hurts more because it's poignant. Yeah.

Mark: Am I still unmuted or am I muted?

Charles Runels: You're unmuted go for it.

Mark: So, yeah, one of the techniques that I learned, which I do and I modified it a little bit, is what I do is I inject on the side of the shaft. I don't go at the 12 o'clock position. I go more to three o'clock and the nine o'clock position. So right on the side of the shaft, about midway down the shaft, I put about 0.1 or 0.2 CC's of [inaudible] with Epi. And I know people are probably going to look at me and say, "You never use that in the penis." That's true. You don't want to inject around the base of the penis and put a lot of it in it. But if you go halfway down the shaft, you put 0.1 0.2 CC's of Lidocaine with EP and make a little wheel. And then the way I was taught is then I'll go in with a 27 inch needle and I use 1% lidocaine and I use that to hydro dissect up and down the penis.

Mark: And it's 100% painless. So I form a column up in on the side of the penis with a 1% lidocaine. I wait about a minute and then I put my HA filler in, right down that column and it works like a charm. Patients, they fill that initial little pinch of... I use a 32 gauge needle. They put the one to the 1% with Epi to make the wheel and that's about all they feel. And I was going to try putting a little BLT cream or ice or something, but it's such a quick little like mosquito bite. They don't even feel it. I have Pro-knox, I have all that stuff. You really don't need it for this. It's much less painless than the P-Shot®.

Charles Runels: Well, let me make sure I understood what you just said. So you go subdermal with lidocaine with Epi or and then you [inaudible] about mid shaft at nine o'clock and three o'clock, and then you go subdermal with lidocaine without Epi and hydro to say proximal inducively to create a column at three o'clock and nine o'clock, correct?

Mark: Yes. And then after I use about two and a half MLs on each side and then I'll massage that everywhere, I'll massage that over the anterior part of the peanuts, the dorsal part of the penis to get all that lidocaine plane right underneath the skin. Right above [inaudible] and completely anesthetize the area and then I'll use the... I don't even use a cannula. I'll use a 27 gauge needle and I'll slowly, I'll in a retro grade manner just like you do with any HA filler in the face or anywhere else. I'll just retro grade inject the anterior part of the penis, the side, the posterior dorsal part till I get the volume that I want and I've put up to 10 MLs at a time and then massage it all in and spread it out. And then I have the patient doing massage daily for like a week just to make sure that it's nice and smooth.

Charles Runels: Interesting. That's what a good, amazing tip. I think. It sounds like it would just make it pain free. That's something you modify to create that technique?

Mark: Yeah, and I don't use any PRP, but I was thinking about adding a little PRP. I just don't think, my concern is I wouldn't be able to get the volume of HA that I want it because four MLs is nice, Five MLs is better, eight to 10 MLs, that wows people.

Charles Runels: To 10 MLs of HA? Which one are you using? Juvederm?

Mark: Yeah, just Juvederm [inaudible 00:42:10].

Charles Runels: Beautiful. While we're on the... I don't want to leave that topic. I want to come back to it. But while we're on the topic of lidocaine within and without Epi, now we're not talking about the penis, but I want to swap over to the O-Shot® and show you guys a picture that was texted to me. So hold on a second. This I think is something everybody should see. I didn't get it. Hold on. Oh, here it, here it is. Oh, I missed it again. So this is, I'll tell you the story. So this lady had an O-Shot® and... Not having good luck showing you the picture. Let me try again. She had a O-Shot® and they use lidocaine we with Epi because she got some necrosis of the hood of the clitoris. And I want you to see it and see if anybody else has ideas about it. Hold on a minute. I hate when people make me wait. I need to make it where you can see it. Because this is a huge, huge teaching point, I think.

Dr. Bill Song: Yeah. So I do what Mark, what you said, make that little wheel with the Epi. But I usually don't teach that because I'm just afraid that people are going forget when, where and get confused and it's just the...

Mark: I've done a million circumcisions in my life and I never used Epi because they tell you the nose, the toes, the lobes [crosstalk 00:44:11]. The reason being is because as you know, the penis is very vascular and you can bruise the hell out of the penis and it can be black and blue for weeks. If you went on your initial injection, if you hit a vein or an artery. So it shouldn't hit an artery, but it's a lot of vascular plexus and right underneath the skin. That's why I use little Epi to get some basal constriction just in that spot. So then when I put my... I use a 32 gauge needle for that. So then when I stick my 27 gauge needle in to put the HA and to put the column of lidocaine, I should not get a lot of vascular... Get a lot of bleeding and bruising after that.

Charles Runels: Yes. So carefully, carefully. So this is the picture I was trying to show you guys and to decipher it, there's an area of necrosis and since this picture was made, she's going to be fine and sloughed off. There was no involvement of the clitoris. So if you look, the injection was done right where it should be on the frenulum where the Labia minora attaches to the hood right there. And then this whitish area became the necrotic and we think that it was from just picking up the wrong vial. So just was enough of horror pictures. So what you said Dr. Song, just be careful with it and make sure that people are looking at labels when they do it this way. Let's see what other questions we have about the... Let's see. Let's talk about [crosstalk] no, go ahead.

Mark: I was just curious, how much is 0.8 MLs of the PMMA are you using?

Dr. Bill Song: How much does it cost us?

Mark: Yes.

Dr. Bill Song: Yeah. So I mean depending on the volume, it's going to cost you anywhere from three to $500 a syringe.

Mark: So it's very similar Juvéderm and a little bit less than Voluma. Yeah, depending on how much, right now, most HAs cost me close to $400 for one ML. It's like 3.75 in ML. I'm trying to get that reduced to a lot less than that. But these are expensive. I mean if you inject 10 AMLs it's my cost is $4,000. It's going to cost [crosstalk 00:47:04].

Charles Runels: What's the [crosstalk] range to charge the patient for these procedures?

Mark: I double it.

Charles Runels: Yeah. At least you can't make a living without that. Let's look at this very quickly. I'll put a copy of this in the chat box. Even though this article came out about sports medicine, it's interesting to me that while POP was banned in sports medicine. Then it thought to be oils. It's not that much to it. And now they're reconsidering banning it back to your idea that things have changed in the past 10 years. The research side and the marketing side, because it's gone from being some hokey little thing to wait a second. This does a lot. So I'll just put this, obviously this applies to... I know Anne does some drawings and Heather and others on the call. So far it's more directly to the sports' medicine doctors, but I think it applies to us just in the fact that what they're seeing in sports medicine is so powerful with the neovascularization, the healing that is being reconsidered as being a banned substance.

Charles Runels: They also cover the idea that other people's platelets could be used, not necessarily all autologous. But you can see its pretty short articles. It's more useful just for the overview in the references I think, anybody have any comments on that?

Dr. Bill Song: So they're considering setting, banning it for what you said they're banning it for like not [inaudible] any injury.

Charles Runels: Yeah. At one time, for example, you can document a boost and IGF one systemically after you inject PRP. So.

Dr. Bill Song: Are they getting and the transfusions or just PRP injections into both?

Charles Runels: Well, they're considering the idea of both. And so nothing's really changed, but I just want, I think that part of what we do here and part of what we do in our group and as the physicians in our group is we're watching the research, but we're also watching the politics and this integrates both. It's just, it's worth reading through how the science has become strong enough that the politics of it is starting to change again. And I don't know if you guys remember, but back maybe six years ago, five or six years ago, one of the pathology journals did an editorial recommending that all PRP be prepared in the hospital. And unless something has changed, that's still how it is in France. She just recently heard that that might have changed, but I know as a four or five years ago you couldn't prepare PRP at the bedside in your office.

Charles Runels: So it's just worth keeping track of what the... It's just a little touch base with the science has definitely grown stronger than the fact that the sports committees are considering to ban it and they answered it sort of answer your question is all the above. And the politics is changing so the chances are possible that it could bleed over and become more restricted for us. So we just have to watch that. I think that's all, that's the only point of this article. Let's see what other questions we have. Anything else you want to talk about? Dr. Song while I'm looking to see what questions were asked? Because there were a couple more questions and then we'll shut it down. We just have about five minutes left I think.

Dr. Bill Song: So some of the other stuff that I've been doing is using, combining the PRP with some of the stem cell treatments, sometimes amniotic and I've used your amnion with it and I've used that as the activator for the P-Shot® instead of [inaudible] chloride.

Charles Runels: Yes. That and in the face and hands I've seen dramatic results.

Dr. Bill Song: Yeah. Yeah. So I think you see a real boost in effect if you do that.

"Bags Under the Eyes After a Vampire Facelift®" What to do?

Charles Runels: So let's answer this question and then let's call it a night. So this is a good one for you Dr. songs is, "Recently did a Vampire Facelift®." You guys can read it, "Came back at four weeks concerned about bags under the eyes of right tear trough that there was some bruising in that area. Two days later I thought resolved, still prominent. The same amount of filler is injected and left side looks good. Wondering if the filler can be misplaced or bunched up." Once someone... Go for it, I jumped in. I want to hear how you'd answer that question.

Dr. Bill Song: I put a tear troughs, I put I mean like literally a drop of HA into the tear trough. And then I put the PRP in because I just want to put that tiny bit to activate. I don't, if you put too much filler, you will definitely get bagginess and puffiness and that could last for a long time. So the PRP by itself will give you some puffiness, but that usually goes away after a couple of days. But I would be very careful of how much filler you put in to the tear troughs because when you put it in with the PRP, you will get a much greater volumizing effect.

Charles Runels: Yes. And so of course, the fix for this is just literally a drop of hyaluronidase and you're done. And I've seen people come through my class who are experienced injectors and saying, "No, that's not from being overfilled." And they'll have a tear trough that's puffing out, tear troughs don't puff out naturally. Obviously you can need a blepharoplasty from the whole area to [inaudible 00:53:20]. But just for the tear trough, if there's puffiness, I've never seen it. It might be an HA. And literally a point, just a drop of higher [inaudible] does the trick. Okay. So we're at the end of the hour. I want to encourage you guys to check out Dr. Song's class. He really is, as you can tell, experienced, he's been successful from a business standpoint. Thank you, the other guys for being on the call for the amazing... And thanks a lot for the detailed answers and questions. Have a great week.

Dr. Bill Song: Thank you. Have a good night.

Charles Runels: Good night.

Cellular Medicine Association<--