Monique: [00:00:00] You're listening to The La Jolla Cosmetic Podcast with the LJC Chief Community Officer, Monique Ramsey. 


Monique: [00:00:15] Okay. Welcome, everyone, to another episode of The La Jolla Cosmetic Podcast. I'm your host, Monique Ramsey, and I'm here today to talk about a sensitive topic and we're, we're going to have fun with this one. 


And I'm joined today by Dr. Brahme, Johan Brahme, plastic surgeon. And he's been with La Jolla Cosmetics since 2004, and Kara Pennington, who is a PA and experienced injection and non-surgical treatment specialist in our medical spa. 


And we'll be talking about the lady bits. So we're going to talk about vaginal rejuvenation or feminine rejuvenation, Vaginoplasty, Labiaplasty, O-Shot, ThermiVa, Thermi-O, Mons liposuction, all kinds of fun things. 


So we're all going to get super comfortable with the topic. I'm going to make it as easy as I can for our two esteemed experts today and for the audience too, because I think this is something that so many women worry about or deal with, or have questions about and sort of how to bring up the topic. That's what we're here to talk about. 


So welcome to Dr. Brahme and Kara. Dr. Brahme, tell us a little bit about yourself and why you got into this area of expertise. 


Dr. Brahme: [00:01:37] Well, it's actually a funny little story. I've been doing this now for about 15 years and it's become a pretty big part of my practice. Now, I would say probably a quarter of all the surgeries I do are from feminine rejuvenation, which is a pretty big number. But, uh, the way it started for me was that I had a patient who was referred to me for something else, some breast work. And I asked her, like, I ask all patients, have you ever had any surgery before? And she said, yeah, I had a Vaginoplasty. And I said, what's that? Never heard of it. And she said, oh, you know, they tightened my vagina after I had children. She said was the best thing I ever did. 


So I went home and I talked to my wife about it and she said, why don't you learn how to do that? And so I said, you know, that's a great idea. So I found a very senior and experienced, uh, urogynecology surgeon. And I went up and I spent some time with a fellowship with him about a week and a half or so. And he showed me what he did and it was fabulous. The women were so happy and you know, I've been doing it now, like I said, for about 15 years. And it is an incredibly rewarding field to be in because a lot of women don't really have any the idea of what goes on down there or whatever it's supposed to look like, or what's quote unquote normal or how to change it. And very few people do. 


There are a lot of people who sort of dabble in this, but we made it a really big part of our practice. And so we're very comfortable with it and we're very comfortable making the women very comfortable because it is a sensitive subject. 


And it's interesting most, you know, a lot of our patients are referred by other patients, but when it comes to feminine rejuvenation, everybody's referred from the internet. They do their own research and very few people are referred by other people who have had vaginal surgery. So they do their own little quiet, private research, and then we take over for them. 


Monique: [00:03:50] Interesting. Well, I remember that very first seminar that we had and the room was packed. The very first seminar we did, talking about it and we said, no, men would be there, you know, so women can feel free. And of course, one man shows up with his wife and we're like, um, you know, and all the women in the room were like, he can stay it's fine. But you know, it was really, it was, you know, that's amazing that it's really grown to be such a big part of your practice. 


Dr. Brahme: [00:04:18] And not only that, but, uh, nationwide, this has grown dramatically. When I first started doing this. You know, the big plastic surgery meetings would devote maybe, you know, half an afternoon to feminine rejuvenation. Now it's the fastest growing part of plastic surgery procedures. And, you know, they devote entire entire meetings to feminine rejuvenation. So it's, it's really taken off and become part of the mainstream.


Monique: [00:04:45] That's wonderful. And Kara. Tell us a little bit about yourself and the sides of, you know, what, what made you learn about the non-surgical sides of feminine rejuvenation? 


Kara: [00:04:57] Of course going into PA school. I really had a strong will to kind of think that I wanted to do women's health. And luckily I got to do my preceptorship with you guys at La Jolla Cosmetic. And Lauren was a great preceptor for me and I had a really, like I said, strong passion for women and working with them and educating them on like women's health issues. 


And it was the first day that I was there at my elective rotation that I thought this is like women's health but on steroids. It's fun.It's a lot of art. It's a lot of, kind of like talking with patients about personal issues like Dr. Brahme mentioned, it's one of those things that a lot of women don't feel comfortable talking to you with their girlfriends, but as a provider, when they do open up and they talk to me about these issues, I feel very kind of rewarded that they actually feel comfortable enough to talk to me about those kinds of things. And it's very rewarding to be able to see that they have such great outcomes in the end. A lot of times patients seek out after, you know, they've had children to help with some vaginal issues as well as kind of women that are going through menopause. 


And during my gynecological preceptorship, I found an interesting book and it was The Great Wall of Vagina, and it was on my preceptors desk. And I thought, well, this is kind of interesting. So I skimmed through it and it was very beautiful. It actually had like all these different murals and kind of like these different pictures of vaginas and they’re like snowflakes. They're all different. There's not one that's the same. 


So, everybody, you know, has this taboo about talking about like their genitals and things like that.So I really feel passionate about working with women and helping them feel their best. And it is something that is treatable if they're having different types of issues. So it's definitely something that I feel it's a great rewarding part of our whole practice.


Monique: [00:06:47] Kara. That is so interesting. And we're going to put a link to The Great Wall of Vagina in the show notes. I'm so curious and I bet all of you listening are too. So thanks for that. That's fascinating. 


Okay. So let's get into the procedures. So some women have no problem opening up and talking about their vaginal health, but for most it can be a pretty tricky conversation. And a lot of us don't like the words that are required to have a simple conversation. And maybe that has to do with our upbringing or, you know, does anybody remember Oprah when she talked about her Vijayjay? That was when that term became, uh, something that is common in the media. So whether it's sensitive areas, lady bits, downstairs. Have you guys heard any interesting euphemisms or? 


Kara: [00:07:37] I grew up in Kentucky. I called it cooter. That's what our household called it. 


Dr. Brahme: [00:07:44] Yeah, I just, you know, I tried to demystify it to try to make it just another body part, you know, to take the stigma or whatever away. And so the consultation, I start the talking…So we're here to talk about your vagina and then I tell them we do the different things that we do and ask them what, you know, what they're most sensitive desires are, and you know, is it that the vagina is loose? Is it the appearance and so on and so forth? 


And, patients become comfortable very quickly if you're comforting and we've been doing it so long now that we've seen everything. And so we’re very comfortable with this and our patients leave sort of relieved that this was so easy. You know, they have all these things, all these worries that they're abnormal and so on and so forth. And we do a lot of teaching and a lot of reassuring, and it's usually a very comfortable conversation. 


Monique: [00:08:47] That's wonderful. And it's wonderful that you can help make that an easy conversation for them. So when you're seeing somebody for help in this area, is it specific to any one group of people, ages or moms or not moms, or, you know, do you have a core patient base, so to speak, or is it sort of everybody?


Dr. Brahme: [00:09:10] Well in my practice, I see women from 16 to 60 and beyond. I remember my very first patient, after I got back from my training. She was a woman in her late sixties, and she'd always hated her, her labia. And she had gone to her gynecologist who looked at her and said, well, you look very normal. But that wasn't enough for her. And my usual response to that is, yes, it is normal, but it may not be the way you like it. And we can change that. So it's important to point out that yes, it is normal. They're not on the spectrum of something strange, but you know, we can make it better. 


Monique: [00:09:53] So for people who might not know, Labiaplasty is typically a woman, maybe isn't happy with the appearance of her labia, maybe because they're too, too much skin? 


Dr. Brahme: [00:10:06] Yeah, too large, too fleshy or too redundant, too much skin. And you know, it presents a lot of problems, not just appearance, but you know, clothes don't fit right. And bathing suits, or maybe they, you know, maybe they like to ride horses and things are just uncomfortable. Or maybe sex is uncomfortable or maybe sex is embarrassing. And so, uh, you know, we try to demystify all of that and to say that, you know, we can help you, we can make that better. And it's always surprising to me that, you know, the gynecologists usually are sort of fairly helpless. They don't do this and they don't know about it, which is pretty shocking to me. 


Monique: [00:10:51] So for a Labiaplasty, then there's also the more functional side, which is the Vaginoplasty where you're actually the canal. Am I describing it right? Sort of the canal of the vagina, if it's gotten stretched maybe from childbirth where they're wanting it a little tighter. 


Dr. Brahme: Right, right.


Monique: Tell us about how you approach that surgery.
 
Dr. Brahme: [00:11:16] So when I talk to the patients, I say, you know, we do both external and internal surgery and the external is more for appearance, although it can certainly help with function, but the vaginoplasty, which is the tightening of the vaginal canal, and tightening of the muscles, and 99% of the time it's after childbirth. And, you know, I ask them, is sex comfortable for you? Is sex what it used to be? And usually, you know, it's all, no, I'm too loose. I don't feel the same way. 


And then, you know, I'll draw on our audio visual, helping tool and show them what we actually do in the surgery, where we actually remove some of the vaginal lining and tighten the muscles. And then we have some before and after pictures too. And then we do an examination and make sure that they're a good candidate for the surgery. 


And, you know, sometimes they're pretty tight to begin with and I tell them, Hey, you're about as tight as I, I would make you if we were to do surgery. And so sometimes they're just happy to find out that I'm normal.


Monique: [00:12:32] Well, and at that point, does Kara step in with ThermiVa? So ThermiVa is an ultrasound technology. Am I correct with that? Or is it radio frequency?


Kara: [00:12:44] It’s radio-frequency to kind of bulk heat the tissue. Yeah. And yeah, that would make them a great candidate. I recently had a patient that was trying to conceive with her husband and, it was interesting because with the O-Shot, we centrifuge it and then inject it into different areas of the clitoris as well as kind of like the vaginal canal that can help with what we call sexual dysfunction. 


So there's a few types of sexual dysfunction. There could be a woman that is decreased in actual desire. Um, meaning she doesn't really feel like she's interested in wanting to have sexual intercourse with her spouse. And then there could also be where you're having trouble reaching a climax, or it could be that the vaginal canal in general is a little bit dry. So there's different things that can cause that, what we call sexual dysfunction. 


And this patient was trying to conceive with her husband and she had reached out to me. And she had Googled just like Dr. Brahme said, they kind of do their own little research there and she was interested in the O-Shot so that it would give her more of a desire for her husband so that they could, kind of, get down to business to have that baby. So that was a unique situation that I was really happy with. So it wasn't that she was actually after childbirth. She was kind of wanting to do it to have childbirth. That was a unique situation. 


But I do have patients that are great candidates that are all the way, kind of like what he was saying, like very young patients, all the way up to people that are like post-menopausal that are having different difficulty with urinary incontinence, as well as kind of just overall wanting the appearance to look a little bit more tighter. 


Monique: [00:14:21] Refreshed, sort of youth-anize, not euthanized, youth. Sorry. 


Kara: [00:14:29] It's the vagina.


Monique: [00:14:31] We can revaginate, re, no, never mind. I give up. I give up,


Kara: Re-vagination.


Monique: There you go. That's what I was starting to say, like, no, that's not the right word. Well, there you go. So really to make it more youthful, you know, the tissue's more plump
 
Kara: [00:14:51] Plump. Hydrates it. The radio frequency uses the bulk heating to kind of build collagen. So a lot of times what happens as we age, we decrease in that collagen production, and it's not just happening in our face. It happens all over our body. 


So that's kind of the thing is, is that with the O-Shot, we're also kind of encouraging more blood flow as well as more cellular growth to the tissue. And then it also will help to improve the vaginal sensation by kind of increasing the small nerve fibers. And so those are things that can kind of be decreased as well, whenever we're kind of having that decrease in the collagen production. 


A lot of times, women too, aren’t great candidates for hormone replacement because they have maybe a history of breast cancer in their family. So that's where ThermiVa can kind of help with plumping that vaginal tissue, so that overall they don't have that dryness as well. And it's something that we can do in conjunction with that O-Shot as well to help give them the best benefit. 


Monique: [00:15:46] So the ThermiVa is nonsurgical. 


Kara: Correct. 


Monique: And as I understand, you can have sex the same night. There's no downtime, right? So it makes an ideal treatment and it builds upon itself. So you've got, you know, a series maybe of three months apart. And then after that first series, then you can maybe wait a year or two to have a touch-up or do people need that? I guess they'll know if they need it because they would. 


Kara: [00:16:17] Yeah. And usually, with the, um, ThermiVa we'll do like a series of three, but we'll do it about a month apart. And then I'll tell patients, you know, it's up to you maybe like annual or biannual. I mean, you might want to come in and kind of just have the treatment done. A lot of times, the patients are so happy with the results that they are looking forward to coming in at least annually to have that treatment done. 


Monique: [00:16:36] At that point, they only need one time. 


Kara: [00:16:38] Exactly. Kind of just like a maintenance. Yeah. 


Monique: [00:16:41] And then you mentioned the O-Shot and that could be done at the same time. Is that a one time procedure? 


Kara: [00:16:47] So the O-shot, kind of similarly, like we would want to be doing that one in like a series as well. I would say, depending on the reason why you want to have the O-Shot done, if it's just particularly like the sexual desire and your sexual dysfunction, if it's just that area, then you could do the clitoris the same day. 


But if it's more in the vaginal canal to kind of help with that tissue there, then that would be something that, after doing the ThermiVa, the woman is pretty tight, which is a good thing. And I would want to put a speculum in there to inject into that tissue because we want to make sure that they're having that max benefit from that. So two weeks later, it would be a good timeframe to kind of follow up and do the O-Shot.
 
Monique: [00:17:26] So, Dr. Brahme, getting back to, you were mentioning the drawing tool that you use and we call it touch MD. Can you talk a little bit about how you use that tool and how it helps the patients? 


Dr. Brahme: [00:17:41] Yeah, it sort of has a pre-programmed template for different types of surgeries. So there's a, there's a tool for facelifts. There's a tool for breast surgery and there's also a tool for, for vaginal surgery on it. It has some, some stored template pictures, and it also stores our before and after photos. So we can show a whole host of before and after photos. 
We've elected not to have that on our website, you know, just to discourage looky, loos, but in the office we have tons of pictures and that's also, you know, it's very comforting for patients because they realize that, like Kara said, every woman is different. I mean, there are not two vaginas that look the same. They're like a fingerprint. 


And so it's very comforting for them to see that, you know, yeah. People look different, nobody looks the same and they can, you know, sort of show on that tool, what they feel that they look like and what they would like to change. 


And, and the way that I do the consultation, is that, you know, first we talk and then they change and then we take a picture of them and then we discuss the picture. So we're discussing what they look like and what they would like to change. And so it's, uh, not very stressful at all. And it's important for us to know exactly what it is that the patients want so that we can say if that's a reasonable thing to, that we can achieve for them. And in the vast majority of cases, it works.


Monique: [00:19:17] And who else is in the room during one of these consultations? 


Dr. Brahme: [00:19:21] So I have my nurses, Christina, and Nancy, and they're with us. This obviously does not lend itself very well to zoom consults. So the vaginal patients we see in the office, so it's just me, my nurse and the patient. And, you know, the nurses have been through this so many times that, you know, they usually see the patient first before I come in and get a little idea of what the main concerns are. And then I come in and sort of hone in on that.


Monique: [00:19:56] Talking about taking the picture. I bet that's maybe the first time some women have seen their own vagina.


Dr. Brahme: [00:20:01] Uh, I think it is, but it's so much easier than mirrors and pointers and this and that. This way, they get to look at it objectively and say, oh, I don't like this. I don't like that. And this is what I'd like to change. And it just works very well. 


Monique: [00:20:18] In addition to the Labiaplasty, then there's also a clitoral hood reduction. And that's when somebody has maybe too much skin in that area.
 
Dr. Brahme: [00:20:30] Yeah. I mean, you know, the size and shape of the clitoris, and the clitoral hood is different for every woman. And sometimes there's a, you know, excess skin there and we can reduce the size, not a whole lot, but we can certainly make a nice change. And even just the healing process after will shrink everything up. So I would say that in at least 50% of patients, I do a clitoral hood reduction when I'm doing a labia reduction just to, to make it all look harmonious, to make it look non-surgical so that people don't look like they've had surgery. 


And in this area, I should say that it heals so well because the blood flow is so so plentiful in that area that, A, it heals very well, and you can't see any scars. And there are very, very few complications because again, so much blood flow and so few scars and so on. And so for example, I've never seen an infection and I've done hundreds, if not thousands of these surgeries, and I've never seen an infection. We have very, very few complications with this again, because the area heals so well. 


Monique: [00:21:43] Interesting and something we mentioned at the beginning of the show is the Mons area. So that sort of the area above the pubic bone, am I right? Can be fluffy, maybe a little bit fatty. And what can you do for that? 


Dr. Brahme: [00:22:02] Oh, there we go to just a traditional old, uh, liposuction. And, you know, we can shrink that a lot. Sometimes it's fallen down, especially after C-sections, sometimes it's sort of flops over our patients who've had a large weight loss, for example. So we can do a lift where we remove some skin and lift the Mons up combined with liposuction. And, you know, some of these patients, very sad, they've they haven't seen their vaginas for years because of all the extra tissues. And that is a huge relief for them. 


Monique: [00:22:39] Yeah. And I would think it completely changes what you can wear and what you're comfortable in. 


Kara: [00:22:47] The pants, wear yoga pants again.


Monique: [00:22:50]  That's true. And it's, you know, and I think this is where you referred earlier to, you know, you might see somebody who's 16 or 17 or 18 years old, and people in the audience might think why in the world is somebody that young coming in. But if they have a whole lot of extra skin in the vaginal area and they can't wear yoga pants or they can't, if they're on a swim team and they can't comfortably feel like they can wear a bathing suit without looking funny. I mean, that’s serious, you know.
 
Dr. Brahme: [00:23:23] It’s a huge thing about self-esteem and feeling comfortable and anxiety and all that. You know, I would say that that is the common thread among all our patients is that they have anxiety, whether it's about the appearance, whether it's about the function, whether it's, uh, you know, just the knowledge of the area. So as educators and practitioners, We have a great opportunity to make them feel better, both psychologically and physically, which is wonderful.


Monique: [00:23:57] And now the things that you've talked about surgically, can they all be done at the same time? 


Dr. Brahme: [00:24:03] Sure. I mean, I do patients who have a vaginoplasty and they have their, uh, the labia and clitoral hood reduction at the same time. It's not, not a problem at all. 


Monique: [00:24:15] And is that something done under, I would think general, right? Or do we want to be awake for that? No.


Dr. Brahme: [00:24:25] You do not want to be awake for this. No, no , I mean there are people who do it under local anesthesia. I think that, A, it's so psychologically tense that, you know, they're better asleep. And the other thing is that once I inject the local anesthetic, then you know, I distort the anatomy. 


So I would rather have them asleep. And then we inject the local anesthetic at the end so that they don't have pain afterwards, but I can, I can do a much better job if I see the unaltered anatomy that I have to work on. 


Monique: [00:24:59] Interesting. Okay. So I want to go into some of the most common complaints that we have and what treatments are available for each. And then I would like each of you to answer, because there's going to be different ways that each of you might address those complaints. So I’ll, we'll kind of go rapid fire and have you each talk. 


So incontinence or overactive bladder. So if they say I can't hold it anymore, or I can't laugh, or cough, or jump without leaking. Tell us about what treatments you have for that problem.


Dr. Brahme: [00:25:33] Okay. So that is a very common complaint, especially after childbirth. And it used to be that, you know, a bladder sling was the treatment or, and the only treatment. Right now, I think that the ThermiVa is a great treatment for stress incontinence. I've had no patient who did not get better after at least two treatments. So everybody gets better. And it's non-invasive. And the guy I trained with who was part of the development team for the ThermiVa, he's a gynecologist and a urologist. And he used to do about 50 bladder suspensions a year. And he told me recently he does maybe three. Now he does all ThermiVa, and has great results.


Kara: [00:26:22] It depends on how bad the vaginal prolapse could be. Sometimes there's the anatomy. That's like where the bladder is kind of fell down if you will, into that vaginal canal. And at that point, that might be something more surgical that they might want to talk to with their gynecologist about. But for patients that have like that stress urinary incontinence, where you said, you know, they cough, they sneeze anything with like increased abdominal pressure. Those are ones that respond great to the ThermiVa. 


And I agree with Dr. Brahme. I think it's such a great treatment for patients where there is no downtime with it. They see such great results like internal and external. And I think it's just something that a lot of patients deal with. I know my mom has been asking me for so many years about like different options and I think there's a lot more women out there that probably deal with this that don't feel comfortable talking to people about it. Where they wear mini pads throughout the day, because they're scared that they might have a leakage. 


So that would be something that if a patient, you know, is out there listening right now and is wearing a few, mini pads throughout the week to kind of get by through the day, then ThermiVa would definitely be a great treatment option for them.


Monique: [00:27:28] Yeah. And it's something that, you know, I think. Can be so life-changing that probably most patients would be like, wait, why have I lived with this for 10 years? You know, I could have done this and three easy treatments. 


Dr. Brahme: [00:27:43] There’s absolutely no downside. I've never seen a complication from ThermiVa. And this is something that, it’s very embarrassing and people are aware of it all the time. You know, they wear the pads and so on. So why not just try the ThermiVa? You have nothing to lose.


Monique: [00:27:59] Right? Exactly. And could kegels fix incontinence?


Dr. Brahme: [00:28:05] Well, they say that, but no. That’s the short answer.


Monique: [00:28:08] Well, and do any of us want to do them all day long every day? You know, I mean, it's not a bad thing, but you know, if it's not going to really end up working at the end of the day, then I think most women including me want to know what's going to work.


Dr. Brahme: [00:28:24] Well. Also, the other thing about kegels is that the kegels will strengthen the vaginal floor, but that's not where the problem is for incontinence. The problem is on the other side. And so kegels don't really do much for that. Though, they’ll help you with maybe a little bit of tightening, but it's not going to do much for, for incontinence.


Monique: [00:28:47] So, and you were talking about the sling. So a sling is something that would hold the bladder in place. 


Dr. Brahme: [00:28:56] Correct. That's a pretty big operation and that's not something that is in our purview at all.


Monique: [00:29:03] Right. But you're saying it's almost not needed. 


Dr. Brahme: [00:29:07] In my friend's practice, he has moved away from that a lot and is now relying much more on ThermiVa.


Monique: [00:29:14] Interesting. Okay. So let's talk about external appearance, color, size and shape. So you talked about a sort of deflated labia or extra skin. So you actually just take some away, right? 




Dr. Brahme: [00:29:28] Yes. Yes. And you know, everybody's different. The color of the lips are different. Sometimes they're brown. Sometimes they're pink. Sometimes they are a little bluish and it. Obviously we can't change the color, but, usually it's the external parts that have the darker coloration and, you know, that's the part that people don't like. And that's the part that we trim off. 


Monique: [00:29:53] And what's the healing involved like, about how long before they can quote unquote, get back to regular life?


Dr. Brahme: [00:30:00] Yeah. I mean, this is the kind of surgery that is the external surgery, the Labiaplasty and clitoral hood reduction, you know, it's the kind of thing that you can do on Friday, and you can go back to work on Monday. Now when it comes to having, you know, sexual intercourse and things like that, we recommend about six weeks. And there is some swelling that lasts for about three months. So, the way you look at about three to four months after surgery, that's pretty much the final result. 


Monique: [00:30:28] Okay. And you talked about the darkening, or skin discoloration. So it's not something that you can treat. Right? Right. But if you're removing extra skin, that happens to be darker, the new result, does that get dark too? Is it, is it the person's skin or is it that there was extra skin there? 


Dr. Brahme: [00:30:47] No, I mean, there are some skin cells that respond to estrogen, for example. So skin will darken in response to estrogen and the skin that we removed is gone permanently, and doesn’t grow back ,and the skin that's left over, doesn't tend to get dark. So pretty much what you see when, uh, three to four months after surgery is that is the permanent result. 


Monique: [00:31:12] Okay. And so some women talk about like designer vaginas. And what does that mean? And I mean, do you have sort of, I guess like with breast implants, people can do different sizes? Is there a different looks that women might request ? Or,


Dr. Brahme: [00:31:29] Yeah. I mean, I think that there's always a question of how much should you remove? I mean, some women want it removed completely. I don't really recommend that. I recommend, you know, leaving a smallish, but natural contour. What you're raising is a very good point and that is that you have to have a realistic expectation . And, you know, there are women who come in with pictures of vaginas that don't look at all like there's and I, and I have to sort of guide them and say, you know, that's not a possibility for you. So we have to manage expectations too. But yeah, it's a very small number, you know, designer, vagina, very sort of vanity fair term.


Monique: [00:32:18] Right, right.


Kara: [00:32:18] You ruined it for all of us. You know, you grow up seeing her. And you're like, that's what it's supposed to look like, Barbie, to be just flat.


Monique: [00:32:26]  That's funny. So, you know, women, if they have dryness, or they can't have an orgasm, or pain during sex ,or lack of sensation. Are those things that, Kara, that is mostly what you see people coming to you for, or.


Kara: [00:32:44] Yeah, actually I do. I see a lot of them for, usually it's like the urinary incontinence. But if you start talking deeper with the patient and kind of asking them, like, you know, have you also noticed that since menopause or if they're around the menopausal age that their tissue is starting to feel a little bit dry. A lot of times patients say, you know, that's a concern of theirs as well. 


Sometimes they might have pain with intercourse because of that tissue being so dry. And a lot of them haven't even seeked out to their gynecologist to be put on hormone replacement, or they might not be a good candidate for hormone replacement. So yeah. That's really where that ThermiVa treatment will help to kind of give that collagen build back to the tissues so that it's more hydrated and plump, and also incorporating that O-shot in there as well. That will help to bring more of like that cellular growth to that area too. And it helps to kind of give that area a little bit more lubrication, as well as kind of to help with some of that tightness that they feel in that vaginal wall. 


It won't make it as tight as Dr. Brahme’s procedure where it's more surgical, but it'll definitely help to give them a little bit more of kind of that tightness that they'll feel in that vaginal canal.


Monique: [00:33:50] And for somebody who's noticing the dryness and it maybe it's around menopause, is it just the loss of hormones that makes that happen? 


Kara: [00:33:59] Typically, I would say a loss of estrogen, and then it's just kind of, you know, the collagen is decreasing as well at that time. So it's just that unfortunate time of our life that we have everything kind of starting to have changes. So it's something that we can kind of start to look ahead and say, okay, you know, I want to take care of this before it's too late. Or having that also talk with your gynecologist about if you do you think you could be a good candidate for being on hormone replacement in conjunction with ThermiVa treatment, I think is always a good thing too. 


Monique: [00:34:30] And talking about the O-Shot you, you mentioned. So what, what really is it? Can you explain the process of what happens and what you use?


Kara: [00:34:39] Of course. Yeah. So the day that the patient would come in, we would do a little bit of topical numbing to kind of like the clitoris area, as well as kind of the vaginal canal. I've personally had one done myself and I was a guinea pig of kind of how much pain it would be. And I was terrified at the process and thinking how sensitive that area could be. And I didn't feel a thing. So if there's women that are concerned with the discomfort and thinking of the word needle and the clitoral area, it was a breeze. 


It's something that we would do a blood draw, and then we would put it in our centrifuge. And what that does is it kind of separates the blood. And then we add a little bit of some product to kind of help it vibrate so that it turns into kind of more congealed material. And at that point, we add that back into the vaginal canal in different areas. 


So, particularly if it's for urinary incontinence, we would kind of put it in like the anterior vaginal canal. If it's more for kind of overall helping with like the dryness, then we would help with the exterior areas of the vaginal canal a little. And then if it's more kind of like the sexual dysfunction, we can do the clitoris area. We do get quite a bit from the blood draw so we can do all three areas very good with all patients as well. We just kind of want to focus mainly on what the patient's overall goal is too.


Monique: [00:35:56] So where you're injecting it is dependent upon what their problems are or what they'd like to treat. 


Kara: Exactly. Yeah. 


Monique: Now what about the famous G-spot? Do you know where to go? 


Kara: [00:36:14] Yes. So I use the speculum for that particular spot because it is a little bit deeper than where we could get with actual kind of like a glove. So for that injection, it's numb as well, and patients feel absolutely nothing when we do that injection as well. And I usually will throw that in for everyone because I think we could all use a little. A little bit there. 


Monique: [00:36:37] That's nice. It's just a value add.


Kara: [00:36:42] They'll thank me later. 


Monique: [00:36:43] That's true. That's right. Um, so in terms of what procedures can be combined at the same time. We talked with Dr. Brahme about that. Kara, so you can do all these procedures that you've talked about at the same time as well. Correct? 


Kara: [00:36:58] Well, I would prefer if patients, you know, the more that I see them, the more we can kind of have like that discussion of like, okay, what are your results? How are you feeling? I like to kind of really see my patients more frequently so that I can gauge them on overall, like how the results are coming along. As well as with that ThermiVa treatment, if the tissue does contract, which it will, um, we don't want to be putting a speculum to get to the G-spot that day. And there can be a little bit of spotting or some bleeding when we do the procedure itself. So that's why I would prefer to do that one, two weeks out after the ThermiVa. 


So in the perfect world, we would do like a series of three of the ThermiVa, four weeks apart, and every two weeks I'd see them come in for the O-Shot. So we'd be getting to know each other very well. 


Monique: [00:37:45] Yeah. So, well, that's good. That's good that it makes them have to come in a little bit more, but we're gonna have your best results in more satisfied patient at the end of it, which I think is what all of us want. Exactly. 


So I thought it was really interesting, Dr. Brahme I had, I was looking online and I saw one of your consultation. If people are worried about like, how do I start the conversation, and what's that consultation going to be like? There was a Labiaplasty review. And she said, “This is a sensitive procedure, and I appreciate the level of professionalism and how both doctor and nurse communicated directly, and with intent. There was no beating around the bush or anything left up for interpretation. I left feeling educated and prepared to make a decision about the procedure”. 


So, one thing I want to say about that, first of all, I think that that was a wonderful little. Well put, well put.  And something that, you know, you can feel safe and knowing that you're in the hands of professionals who are going to teach you about the different options, help you make a decision what's best for you, whether it's surgical, non-surgical some combination at some point. 


But one of the things that you know, you, in the audience,  can do is read reviews, from either consultations or people who've had the procedures done on our website. There's a lot, I mean, thousands of reviews and most of the procedures, if you go, let's say to the Labiaplasty page or to the ThermiVa page, if we have enough reviews, they're specifically, the ones you see on that page are about that procedure. So that really helps. And we're one of the only practices anywhere that publishes reviews of consultations, not just the procedures, because we want to know that patients have had a good experience. And we want other patients who are thinking about the procedures to know about that consultation experience. 


So, Dr. Brahme you mentioned, you know, you can't really do a virtual consultation about such a sensitive topic, or have you had to do them?


Dr. Brahme: [00:39:55] Oh, yeah. I've had to do them because you know, people actually come from all over the world for this because there aren't that many people who do these procedures. I mean, there are a fair number of people who do ThermiVa, but when it comes to Vaginoplasty  and so on. You know, I've had people fly here from all parts of the country and sometimes from outside the country and. Usually what we do is we have them send us a picture, email us a picture and tell us their story. And then we can give them a better idea of what we can do for them. The more information they give us, the more information we can give them. But you know, people fly in here and have this done all the time.


Monique: [00:40:34]  Now, if they're thinking about a Vaginoplasty in the, at that there, that canal is too loose. How do you know what's the right size? 


Dr. Brahme: [00:40:44] Well, that is a very good question. And I have to ask them, you know, do you have a partner? How is your partner? Is your partner very large? Is your partner very small? And sometimes I've felt I've had patients who have, I felt that they were, you know, they were about the right size and. If they don't tell us, or if they don't have a partner, we try to do about two finger breadths of tightness. But some patients will say that my husband is well endowed and we'll leave it a little bit, you know, a little bit larger. And sometimes they'll say, well, you know, Make it real tight. and, uh, you know, and then we do. 


Monique: [00:41:25] To be a fly on the wall during these conversations, but, you know, I mean, it's, everybody's different and I think that's, 


Dr. Brahme: These are the things we need to know. 


Monique: Right, right, to make it right. 


Dr. Brahme: [00:41:35] Absolutely. And that's why it's a very straightforward and open conversation. And I really appreciate, I hadn’t read that review of the consultation, but that's, that's really is true, you know? I mean, we are very sensitive, but focused at the same time. 


Monique: [00:41:53] Hmm. Another review said, “I felt all my questions were answered and I loved my anatomy lesson while waiting for the doctor.” So what anatomy lesson was she referring to?


Dr. Brahme: [00:42:02]  Well, Christina usually goes through some of the pictures and, and I don't know what she does really, but she, she does some magic. She's great with the patients, so the patients love her. 


Monique: [00:42:15] Yeah, she's actually, we just yesterday celebrated her 22nd year with you, which is an amazing thing. And she's wonderful. She really is such a wealth of information and you know, she's your patient advocate too. So some of us have that white coat syndrome, you know, when the doctor, you think you have all the questions in your head, and once you get in front of the doctor, you're like, I'm good. Yeah, everything's fine. And you forget, your mind goes blank. And I think so Christina can help later. If you, you know, you get home and you're like, oh my gosh, I forgot these three questions. And she's sort of that intermediary and helps. 


Dr. Brahme: [00:42:53] Yeah. And you know, she's been with me for so long. She knows me better than almost anybody else. And, and she knows how I do things, how I approach things. And, you know, she does a lot of patient comforting both before and after surgery. 


Monique: [00:43:08] Yeah. So one of the things that I think people want to know is sort of about how much does this cost, whether we're talking about ThermiVa, or the O-Shot or, the Vaginoplasty, how much does it cost? And so one of the things that we feel is really important is being very transparent about pricing. And so we publish all our prices. We have ranges on our website, so you can go to that procedure page, it has a range, depending on what combinations of things that you have done at the same time. But that's something that's really important because we don’t want it to be a mystery and you to feel like, oh, we're not going to tell you the price until after you see the doctor. No, we want you, you know, we're going to be very upfront about that. 


And our patient care coordinators help with everything from financing, coordinating your surgery or your procedure date. But we want everybody to know that you're welcome to call any time with these kinds of questions and yeah. We'll be as open as we can. And, and if we can't give you, uh, an exact price, obviously if you haven't had a consultation to know down to the dollar, but we can give you a very good idea of what you're looking at. And then once you have that consultation, you'll have an exact fee quote. And that’s, I think, good for up to three months. So it kind of like lets you know exactly what you're looking at. 


So anything that we forgot to cover either one of you?


Dr. Brahme: [00:44:40] I think it's very, very good that you said that, you know, we're all about transparency and this is a very patient centered practice in every way. And the patient is the important one.


Monique: [00:44:51] Yeah. That's so true. You will see reviews, but you're not going to see before and after pictures on the web, just because that's, you know, that's sensitive for most people, but during the consultation process, we can show you lots of things and help.


Dr. Brahme: [00:45:06] And before and after pictures, because we have them for use in the office, but not on our web. 


Monique: [00:45:12] Right. So I think we got everything. This was so interesting. And I really thank you both for how open you are and how fun this is. You've made it a fun hour and we really appreciate your time. And thank you, Kara. And thank you, Dr. Brahme and


Dr. Brahme: It was a pleasure.  


Monique: Thanks. And so if you have any questions about. These services or want to contact us everything's in the show notes, but you can call us at (858) 452-1981. 


Oh. And one question before we leave, I just remembered. So our brand promise is “Where Dreams Become Real”, because we're helping people make their dream and turn it into reality. So for each of you, what's a dream of yours that became real. I'll start with Kara. 


Kara: [00:46:05] Okay. I was actually one of Dr. Brahme’s patients before I worked with you guys. And Christina was fabulous with me too. So that was many moons ago. And then my dream was actually to come back and work with you guys because it was such a great experience. And, I have to say, I've worked at a few offices in San Diego and this was by far my favorite. So just being able to work with such a great team, like, I feel like this has been like a real dream come true. Like a full circle. 


Monique: [00:46:32] That is so interesting. I did not know that you were a patient. 


Kara: [00:46:36] Yeah. And then Lauren's patient, and then now I'm here.


Dr. Brahme: [00:46:41] So my dream come true was that I started out my plastic surgery career as a solo practitioner in my own office. And I did that for about five or six years. And then I joined another group. And then I finally landed at La Jolla Cosmetic Surgery in 2004. And I've been here 17 years now. And that has been a dream come true. It is a wonderful place to practice. It is kind. It is sensitive to the patient. And as the thousands of reviews will attest, we do really good by our patients and they come back and we love them and they love us.


Monique: [00:47:24] Yeah, that's passionate. We are passionate. I think that's something that, you know, when you love what you do, you do it really well because you love it. And it's like a really wonderful little cycle and it is infectious, it is so. 


Anyway, well, thank you both. And everybody check the show notes for links. And if you subscribe to our podcast, wherever you subscribe or follow, you can come in and to our office and show us that you're a subscriber and you'll get $25 off a product of $50 or more, which is always fun or any procedure. 


So. Thank you all, and we will see you all next time. Thanks. Thanks. Bye bye. Thank you.


Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code podcast to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I 5 San Diego freeway in the Ximed building on the Scripps Memorial Hospital campus. To learn more, go to L J C S C.com or follow the team on Instagram at LJ CSC, the La Jolla Cosmetic Podcast is a production of The AXIS.