Secrets about Sex in the City and Everywhere Else with Dr. Jennifer Walden

Dr. Furnas (00:02):
We pay attention to sex in the media and sex in the city, but we don't talk much about when things aren't going so great or when they could be better. Now with all the new technology research and increasing openness about intimate topics, we have something to talk about like Courtney Kardashian's, new lavender colored gummies for vaginal health called, wait for it: Purr. Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:37):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the non-surgical world to bring you what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:52):
It is a true pleasure to introduce our very special guest, Dr. Jennifer Walden. Dr. Walden is a plastic surgeon in private practice in Austin, Texas. She's a leader in surgical and non-surgical cosmetic procedures and lectures internationally. And she is the aesthetic societies first female president, now past president. Welcome Jennifer.

Dr. Walden (01:20):
Thank you so much, Heather and Josh. I'm so glad to be here.

Dr. Korman (01:25):
So we'll talk about both men and women in this episode, but let's start with women. Jennifer, you opened a vaginal rejuvenation center in your practice in Austin. Can you tell us why women would be interested in vaginal rejuvenation and what treatments you offer?

Dr. Walden (01:42):
Yes, up until about 2016 and around that time mainly we talked about male sexual health. And Viagra is one of the most, well-known, well-marketed drugs ever. There were no non-invasive options for women, and women were dismissed by about menopause. I think as doctors such as Heather Furnas and I came of age and came to the podium and did studies, and we started to actually see clinical trials with device technology that worked and hormone therapies that worked for women that are perimenopausal. Our industry responded to it. So we began to develop device technology to help with sexual health, all the issues we can get into, and once I started offering that in my practice, it really grew. Women are very responsive to that. We had no options. They're surgical for so long and fraught with complications, mesh, bladder, mesh, all that stuff. So that is kind of how this is all developed in my practice as a plastic surgeon. But we really owe people like Dr. Furnas here who's done a lot of studies on these things and labiaplasty a debt of gratitude. It's scientists, surgeons like her that actually help bring things to market and bring this into our view.

Dr. Furnas (02:56):
Thanks, Jennifer. Let's take a deeper dive into the complaints women have that can be addressed. Non-surgically like vaginal laxity, ability to orgasm sensation, vaginal atrophy, lubrication, stress, urinary incontinence. So what do you do that, you mentioned devices, energy devices, what are all the modalities that you can offer women?

Dr. Walden (03:22):
Usually what we do is we have them examined and we get a history from them. This can be done by myself or my nurse practitioner, and we make sure that there are no other comorbidities or masses, anything that they need to be treated with first. But then we usually can assign them into a treatment modality based on their symptoms, how quickly they want to get it done, what's their budget, how much time do they have? Are they just visiting Austin once or do they live there? But there's different technologies to treat different things. We have erbium laser, that's an ablative laser similar to the fractional laser we get on our face. We can do intravaginally for stress urinary incontinence and to help with lubrication and sensation. Radiofrequency microneedling you may have heard about before, again help to tighten the skin on the face. You may hear about some of these brands that the Kardashians are using.

(04:15):
Well, we also have that for the vagina. We do radiofrequency microneedling for the vagina, which is excellent for tightening and sensation. And most of these modalities that I mentioned, whether it's radiofrequency or laser therapy, usually require more than one treatment. But doesn't everything in the medical spa, I mean doesn't, Botox doesn't disport, doesn't filler doesn't laser to the face require maybe a maintenance time every year to two years. And so that is very true with vaginal health. I think it got criticized early on for not being permanent, but how could it possibly be permanent? Nothing we do in our nonsurgical medical spa environment is permanent and for a good reason.

Dr. Korman (04:54):
So I think that's a good point because radio frequency is like the energy of the decade and there are a lot of things that we can do. There's so many different machines that are advertised by doctors, by companies, and obviously they all need, as you point out, need to be done in a series. I think that one of the important questions is the permanence or lack thereof, meaning okay, people are okay necessarily to do a maintenance treatment maybe once every year, six months, but maybe not every month or two weeks or four weeks. So in your practice with all the technologies you do on average, would you say, how often do the maintenance after the series, whatever the series is, whether it's three or four or five, when and how often do you think that or you advise your patients that they would need to have a touch-up?

Dr. Walden (05:55):
Yeah, as you mentioned correctly, they're usually involved in a series of three spaced about six weeks to eight weeks apart. And then we usually will tell patients everything is based on their clinical exam before. If they have a large amount of laxity or stress urinary incontinence, it may involve more, but usually once a year would be a maintenance algorithm. Some women who swear by certain technologies, whether it's vaginal or muscle stimulation for the abdomen will come back religiously every six months and that's fine. We like that. I mean, I like that it works. I'm a business owner. I like retaining my patients and seeing 'em back, but some of 'em base it on just how tight do you want to be? How good do you want sex to feel? And I think women for so long never got even the question. So they kind of graded it based on their response.

(06:48):
And it's interesting to me with the radiofrequency and the laser treatments and that sort of thing, everyone responds a little differently. So someone who might not respond well to radiofrequency, we might then put into a category of laser vaginal treatment or vice versa because our bodies just respond differently to different energy. I, for example, respond very, very well to radiofrequency. I was showing my estheticians slides throughout the years of me doing radiofrequency and it takes your jawline back. Well, similarly I can respond to radiofrequency anywhere in the body. So some people will come back after a series of three and say, I didn't experience much of a difference at all. And those people might put into a surface ablative category meaning laser that's going to treat the surface epithelium or surface of the vagina, and that's just what they need maybe to get resurfaced and to feel a little bit tighter and to kind of strengthen and help with stress urinary incontinence and all those tissues right around the urethra that can provide structure there.

Dr. Furnas (07:47):
How does the heat help reduce the stress urinary incontinence? You mentioned the tissues. Tell us a little bit why women get stress urinary incontinence after it's typically after childbirth, would you say?

Dr. Walden (08:03):
Right, yeah. Typically after childbearing, it's not uncommon at all to have a little stress urinary incontinence, which is just leakage of urine with laughter or jumping or coughing. It's rather more common than not. And so we've lived with that for many decades, but now getting a couple of treatments involving radiofrequency or the laser heat energy can help tighten the muscles and it really helps contract the surface of the inner layer and then it causes what we call neogenesis or the induction of new collagen formation in the wall, the vagina. And some of these can stimulate different muscle layers as well. We do have a muscle stimulation technology called sula that you actually sit down on something and you don't have to remove your clothing, but as in a muscle stimulation technology that can help strengthen the pelvic floor muscles. And so that's even stimulating deeper within the pelvic floor for women who have severe stress urinary incontinence men or post prostatectomy that have some issues too. And so anyone that needs pelvic floor strengthening can benefit from that particular machine. But yeah, the heat can cause contraction of the tissues and new collagen formation basically.

Dr. Korman (09:16):
I mean, I realize both men and women carry each other's hormones, so we're more similar than we are different, but yet the anatomy and a lot of things are different. And also exactly how you market, because women often will go to events together, whereas guys are different. They'll go to a golf game together and a basketball game together, but they won't exactly go to a sexual wellness clinic together. So tell us how does that work?

Dr. Walden (09:49):
So I mean I think the basis starts, like you said, the hormonal axis. And as we age, men lose testosterone as well, and women can benefit from testosterone we've found and can be somewhat protective. So the foundation of this whole arm of my practice is me partnering with my nurse practitioner and she does hormone therapy. So she sees you, assesses symptoms, men or women, and I'll kind of go down the male pathway here in a minute, but diagnoses whether you have low T, low testosterone or not. And then she may prescribe pellets to implant to the tissues just to put subcutaneous pellet into the buttock, subcutaneous fat or creams, that sort of things or pills. But whatever it is that begins the basis for then what we'll then refer to as the next phase. And with men often it'll be erectile dysfunction and so she can prescribe medicines.

(10:48):
Of course we can. We've been able to do that a long time. But we also have other modalities that can help men. We have extra corporeal shockwave therapy. You may have heard Big D Wave or Gains Wave. Those are just brand names for a shockwave therapy that helps build new blood vessels in the penis and to help widen them, we also have what we call the O Shot for orgasm shot for the women and for the P shot for the men. And that is basically taking your own blood and using the platelets, injecting that into the corpus or the body of the penis, the muscle. And that thereby stimulates it to a little bit more sensation. It helps with erectile dysfunction. And those things have really grown a whole lot in my practice, very much so in the past five years I would say to where we have a very strong male contingency in our practice.

(11:38):
And about three or four years ago, I started to offer on my end what I do, which not many people, but I offer male enhancement with fillers. So hyaluronic acid filler into the male penis. I did one today, I mean today was like the crown jewel because we did a case where my nurse practitioner came in and she did the P shot for him. He had different things he wanted treated. So P shot, he had banding. So I came in and did a little collagenase and broke up some banding in the penis with an injection. And then I did the J shot. We call it the J shot, but that's male enhancement with HA filler. They're all in different layers and treating different things. But the last part that I did enhances the size and the girth. So mainly girth and width of the penis, but also can help with the length as well as it telescopes out. And that has been incredibly popular too. You'd just be amazed. And my male patients, like you say, they don't come in groups, but they are the most appreciative low maintenance people in my practice. So I really enjoy my male patients. It wouldn't be the same without 'em. And I do that that J shot probably about two or three times a week.

Dr. Furnas (12:46):
And what is the recovery? What are the instructions you give them?

Dr. Walden (12:51):
Usually just ice, similar to I always compare things to women, something they can understand because their wives or girlfriends have all bought lip filler or breast implants. So I just compare it very much like take it easy for the next two to three days ice just as you would've swollen lip. It's going to be bruised and swollen in the next two to three days. I ask 'em not to have sexual intercourse for about seven to 10 days just because you want all those little needle holes to close back up and not have any bacteria environment surrounding them. So no sexual intercourse, they can manually do what they need to do to help spread the filler. If for some reason, just like you tell someone who got a little filler in their cheek, if you feel a little lump, if you want to just go ahead and just smooth that, you can smooth that a little bit because hyaluronic acid is moldable in the first two to three days.

(13:39):
And so they can do that if they'd like manual, but otherwise it's pretty low maintenance. They go home and they rest the weekend and not a lot of concerns. They usually will come back if there's a little asymmetry or a little lump or bump, they may come back at about, we have 'em wait for about four to six weeks. We can dissolve a bump just like you could in the lip or the cheek. And then if they want more, it's definitely a foundational procedure that you can enhance the size, but it grows, it gets foundational, it gets bigger as we go along, for lack of a better word, you can do that. And so I may begin with 18 to 23 syringes on the first visit, and then maybe the next visit, which is a quarter and three or four months away, we may just build upon that foundation with about eight syringes to 10 syringes. And each syringe of those fillers, as you probably have heard, is just like a teaspoon. It's one cc, one cubic centimeter. So that's why it sounds like a lot, but into the male penis, it actually spreads very nicely and it doesn't look too big or unnatural.

Dr. Korman (14:43):
And are there risks that people should know about?

Dr. Walden (14:47):
I think the risks would be lumps, bumps, asymmetries. I personally have not had, I guess if we went through the litany of things like erectile dysfunction, urinary tract infection, I've not had any of those issues with this. Just I think it would be extremely important to go to someone who does this and that knows anatomy, ie, like a board certified plastic surgeon doing it or urologist that does a lot of 'em because it's not something you would enter upon lightly. But I think avoidance of complications is about knowledge of the three-dimensional anatomy, which is what we're pros at. Really that's what plastic surgeons are, specialists of the face, breast body and genitals really.

Dr. Furnas (15:33):
We've been talking about non-surgical treatments, but sometimes non-surgical treatments may not be sufficient. So for example, let's say a mother comes in saying she doesn't feel anything with intercourse after she had her children. When would you decide to perform a vaginoplasty versus doing something? Does that depend on her anatomy, her workup, her goals? How do you approach that?

Dr. Walden (16:02):
Yeah, usually I would say nine times out of 10, those patients arrive in my surgical clinic like my clinic, and they're a candidate for vaginoplasty. If they say I had children, vaginal childbirth can't feel much anymore gaping. Those are the people, and when you examine them, they have a large hiatus to their vagina, maybe a episiotomy tear. And as you know, that's more of a layered muscular mucosal closure that we redo with perineoplasty and vaginal tightening and that can help a lot. So that's one category. And then if on exam they really have a good, I mean some of those women have good vaginal tightening and the anatomical reason is not quite as transparent, then I'll put them into the category of my non-surgical where we have them, they have to fill out three different surveys, they're standardized surveys, sexual satisfaction, vaginal laxity and urinary issues.

(16:58):
And that helps me to quantify where is the issue originating from? I want to know. And there's so many issues that go, as we all know, that go into sexual satisfaction and the ability to feel an orgasm and be happy with sex. There's so many, you know, brain from here on down, right? So we want to really go to the core of that issue and find out what can help them. And that's really going to end up being more of the noninvasive root and the hormonal root. Getting 'em back on hormones is step number one, like estrogen and progesterone, even testosterone. Testosterone helps women with libido more than anything I've seen. I mean it just has helped a lot for women to repark their marriage when they've been super tired, worn out, had the kids, did a lot of the work, but once they got back on some Biot for example, is what we use implant a testosterone pellet, they have energy again, better physique looking better and then more libido.

Dr. Korman (17:54):
So one question in this hormone replacement therapy zone. It's kind of all over the map a little bit. And if people are somewhat scared about the hormone concept, and especially as people get older, and there's a lot of patients who are in this post-menopausal women category that are really trying to figure out what can they do not just for their face but for all of their bodies. And so would you, and this is true for both women and for men, I mean there's andropause as they talk about and menopause. So for that age group, which I think is clearly an important and growing age group, how would you relate to them? Is it still the same testosterone and that's how it works or is there a different version for that aged group?

Dr. Walden (18:47):
Well, I mean whether menopause or andropause, it still is going to be being evaluated. Clinical symptoms, their history, past surgeries, if they've had any past surgeries, any past for women, we want to know, have you had any uterine cancer, breast cancer, pap smear has to be negative or normal within the last year for men. We need to make sure your PSA is not high. We do an exam of the genital region, and when I say we, I mainly mean my nurse practitioner. Cuz I'm in the operating room and the nurse practitioner is the one that is really good at sitting and talking and delving into these areas and getting a really good history and physical. As you know, surgeons are great in the operating room, right? Not so much with the talking for a long time. But yeah, no, so my nurse practitioner really delves into that. So we don't want to put some people on hormones cuz it's contraindicated, you got prostate cancer, we're not going to put you on testosterone, you're not cured yet.

(19:44):
Or you have estrogen receptor positive breast cancer history. So we would get medical clearance from your doctor, your primary care doctor or oncologist if you had any of those issues in the past and wanted to be treated. Cuz we want to be on the same page with your primary care doctor. But I would just say it's just a very detailed exam and a very detailed hormone panel that we assess not just the standard hormones, but ones we don't think of and vitamins and minerals and all sorts of things and amino acids in your body, B12. There are a lot of reasons, underlying reasons why we start to decline in our energy level and the way our skin looks and our hair feels and our sexual libido. It's not just testosterone and estrogen. There's so many other reasons.

Dr. Korman (20:27):
I just wanted to ask one last question about nitric oxide for male enhancement. What do you think about that? Do you prescribe it something you recommend or not?

Dr. Walden (20:36):
So, you know, just Viagra or a different pill like Cialis, pills like that, that help to stimulate erection. Those usually we'll prescribe like a low dose Cialis, which is a vasodilator, opens up the blood vessels with anytime we start to do any type of erectile dysfunction treatment, like the extra corporeal shockwave with PRP, the P shots interposed like every four weeks. It only helps, those medications only can like help as a foundation to help open up those blood vessels. And we'll come in and stimulate new blood vessels, what we call angiogenesis within the penis, but we need that nitric oxide or the Cialis sildenafil to help open up the blood vessels. So those do have a place in our practice as well. Again, my nurse practitioner who that's her background are these things, is usually the person prescribing those. I don't particularly prescribe those in my clinic. I'm dealing more with cosmetic surgical, but that is part of our sexual wellness arm of our practice.

Dr. Furnas (21:44):
A few years ago, I think it was 2018, the FDA came down hard on some of the lasers and I think maybe one radiofrequency device as far as using these for cosmetic reasons, non sort of cancer reasons. And the FDA has been pretty quiet. There are complaints about burns and whatnot and lack of study. Is there a reason the FDA has been quiet and do you feel that we're studying these things more, these devices better?

Dr. Walden (22:18):
Yes. I think like I'd mentioned in 2016, 2017 when they started to come on the market, so every laser device as you know, or radio frequency device in our whole field, if you went into a trade show, they had just developed a new vaginal wand that goes on it and were selling it and marketing it, and I think they put the cart before the horse and more clinical studies needed to be done. We needed to tamp down. So the FDA really kind of put a damper on the marketing of the manufacturers and said that they had to kind of put a proper label and had proper disclaimers on the marketing of these devices because they were coming on so strong in this wellness aesthetic market, right, not treating patients who are medically ill. And so that's what happened. And those companies, they responded pretty quickly and did those things. And they did studies with me, with you with a lot of well-known doctors that were in the space.

(23:17):
And I think that helped to gain legitimacy for these devices. And I think some of the warnings that were off, if FDA cited warnings off the MOD database was a self-reporting. I could go in tonight and say five years ago I got a little burn and it turned red on my cheek. And that's a burn, right? That's reported as a burn to the FDA. So, it's self reporting, so the MOD database had some reports.And when you really look back into it, there was maybe 15, 16 reports we really looked back in, a lot of 'em were kind of self-explanatory, like there were two employees playing with a device after hours and they were trying it out on themselves and one actually burned the other. They hadn't been properly trained. So if you really looked into the history of some of those MOD database complaints, they were not, or it wasn't quite fair to us. We were providing real treatments and we were researching it and making sure we were being safe for our patients. So I think we think they kind of got quiet after that.

Dr. Korman (24:13):
If you were going to get out your crystal ball and what innovations, we talked about radio frequency being the energy of the decade, but can you sort of envision innovations seeing in the future? One thing that I'm still trying to understand is between the non-ablative, meaning the non burning devices and the ablative, which is more recovery but potentially longer lasting. What do some of these therapies that we know now that would be nice to have, wish to have, that you could potentially see in the innovative space to improve going forward?

Dr. Walden (24:56):
I think, you know I always kind of look at what are the predecessors coming down the pipeline for other areas of the body. So I think of without the heat or thermal injury, there's micro coring. So we have devices that are used for creating tiny non-thermal channels in the skin to help contract. So micro coring might occur. There's a device called Ellacor that does that. And so could they make a component for vaginal health? Well, they might be already making one, but that might be an idea there. Otherwise, I think ultrasound, ultrasonic technology is good and not quite used in the vaginal space. So we use ultrasound, like for example, soft wave is an ultrasound technology that's helped me kind keep my jaw line, it helps lift in the middle age and helps contract. And so maybe an ultrasound version, ultrasonic tightening version. You might've heard it earlier, iterations called Ultherapy.

(25:54):
So maybe that perhaps. And then I always think what's really interesting to me is I got an IPL laser hair removal sent to me so I could do a video for this company and it's a do it yourself at home device. Now I'm not saying go on TikTok and make these devices or anything like that. All I'm saying is the idea of that they are now, they're starting to make safe do it yourself laser hair removal devices, right? Because I've been buying 'em, I've been kind of trying 'em out. Cuz I recommend them to my patients when they're like, what do I do in between all these 16 appointments for laser hair removal? You have to keep doing it. But I would think there are some good, do-it-yourself devices for vaginal tightening involving LED light therapy, low energy radio frequency. And so I just think that the safe vetted DIY are do-it-yourself treatments at home probably have a lot of appeal to the TikTok generation.

Dr. Furnas (26:47):
And do you see a role for exosomes in the future with the

Dr. Walden (26:52):
Yeah. Exosomes? Yeah, that cause a stimulation of growth factors to be released, that sort of thing. We do use those in our practice currently for P shots, O shots and some hair restoration. I think that that's an area that again, the FDA has smartly said, let's research this before we start making wild claims. So I think that's newer treatment, but I do think that shows promise from what we're seeing and how it's working for some people.Not everyone, it doesn't help, I mean, again, these things, some people are non-responders. You might do PRP if they don't respond to exosomes or vice versa.

Dr. Korman (27:28):
Do you think there's any role in, maybe this is a question more for you're nurse practitioner, but there's like you said, a lot of sexual health starts with the brain and the talking part, the helping people to understand, obviously they want results, but I think results come from a multifactorial place. So is that part of how she treats the patients and with the follow-ups, or just wondering how there's got to be some component of psychology here?

Dr. Walden (28:04):
I think there is in every facet of my practice too, aesthetic practice. How do I look back to myself when I look in the mirror and am I happy with that? That is prevalent. And even Heather, in your and mine, practice is psychology, but particularly in the sexual wellness, yes. Ashley and I have both dealt with patients who are having problems or issues, and she's very, very good at empathy and sympathy. I've had patients come to me privately and tell me that they feel like they can talk to her because she's not judging them. And that was so great to hear, even from a family member of mine who is having hormonal, she's came to me and told me she's not judging me, I can open up to her and thereby she can help me and she's helping me by the way. And so that's why it's important to pick the right provider, I think. But I think as you know, we know from our own plastic surgery practices, when it might be appropriate to refer someone to a professional psychologist, and that might be someone with body dysmorphia where they see something that just, we don't see it all, but they're seeing it themselves. And we've had a couple of patients that we've had to get with their primary care doctor and talk about those types of referrals when we can't help with what we have to offer.

Dr. Furnas (29:21):
How would you recommend people find somebody who really is a true professional? You mentioned board certified plastic surgeons, urologists, there's a lot of marketing out there and a lot of people, and it varies by state who can do what, and sometimes people don't care. They aren't legally able to do something. So what do you recommend or what would you recommend to people to look for?

Dr. Walden (29:49):
So I mean, I think 10 years ago, the plastic surgeon on this would say, just don't go to any med spa, don't go to a med spa. So I own med spas. So it's very confusing. I would say a medical spa is just a standalone practice that does sexual wellness. So we don't necessarily say that anymore because we actually own and run them now. And so I would say you look for a board certified plastic surgeon that does sexual health or a medical spa that they direct the functioning and the operation of, and the hiring of. And so for example, in that, I have a medical spa in New York. Here's just an example of one, right? My medical director there is, she's a Mount Sinai trained internist, but she did integrative and functional health and now she knows more about hormones than I do.

(30:37):
I go to her to help me with my hormones. Right? She's so smart and she's up to date on the literature. And that's an example of a medical spa you should feel safe going to. So you have to research and vet in about us or meet our staff on the website. And when you talk to them and make the appointment and meet someone, kind of verify those credentials. And that's a good way to do that is just make sure that this is what their specialty is. They've likely spoke about it and lectured about it. They've likely studied it and maybe written a paper or two about it at least. And they're board certified in plastic surgery.

Dr. Furnas (31:13):
Yeah, I think with gynecology it's interesting. There's been a lot of resistance to anything dealing with cosmetic vulva, vaginal treatment, surgical or non-surgical. I think that's slowly changing. The Women's Health Initiative also sort of put a damper on hormone therapy. And I think that is slowly changing.

Dr. Walden (31:36):
Yeah. Yeah. I mean I think when you look at OBGYNs for so long, the way, and they'll probably be mad I say this, but the way they were trained was kind of patriarchal and, in that you don't really need to worry so much about the aesthetic appearance of your labia and your genitals. That should not be a worry for you. And that was the way I think that many of them were trained and the way the logic was because they're dealing with function, they're dealing with childbearing, there were much, very weighty issues, right, very important issues. And so it was dismissed for so long. And I think that's where we've been able to kind of help out because aesthetics is our thing. So we don't feel bad or frivolous validating a woman saying, I don't like the appearance of my labia. They look awful. They produce camel toes, it hurts to have sex. So all those things we've validated now, I think that the lot of gynecologists are now coming on board.

Dr. Korman (32:32):
Well, Jennifer, this has really been very enlightening for me personally and also too, I'm sure has been very useful for our listeners. Is there anything else you'd like to add?

Dr. Walden (32:46):
No, I think we hit all the high points. Thank you.

Dr. Furnas (32:49):
Well, thank you for listening to this episode of Skintuition. Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Korman (33:05):
So follow us, subscribe, send us questions, any suggestions for guests, we'd be happy to listen. And we look forward to seeing you in two weeks.