Regenerative Medicine 2021: Applications in Skin, Hair, & Sexual Rejuvenation

Amy Killen, M.D.

Yeah, so first of all, thank you for having me. My journey began as an ER doctor for about 10 years. I boarded in emergency medicine, worked in super busy ERs. And just about 10 years ago, I started becoming interested instead in learning about kind of longevity medicine, integrative medicine, age-management medicine, like whatever we’re calling it these days, anti-aging medicine. And eventually over the course of several years, ended up transitioning out of emergency medicine, and since then have been full-time doing what I’m doing. And then I kind of became very interested in that field, in the specific part of it, which is this sort of skin health, and sexual health, and using both integrative therapies, as well as regenerative therapies like stem cell therapies, to improve those two things. So I say I’m all about skin and sex, and how we can use those things and we can improve them as we also work towards, you know, living a longer life.

Joseph M. Raffaele, M.D.

Yeah, so that’s interesting skin and sex. I mean, after sex, your skin should glow a little bit, so that’s good. But is there some sort of a mechanistic thing, or just kind of- what made you put those two together? I mean, besides those being probably the two most important things to patients when they come to see us.

Amy Killen, M.D.

Well, that’s part of it. So what happened was I, you know, I opened the practice. I was doing a lot of hormone replacement, bio-identical hormones, lifestyle, you know, things like that, in Oregon. And I was starting to see patients and they would come to me with, you know, whatever their main complaint was, whether it was, you know, having difficulty losing weight, or lack of motivation, fatigue, depression, you know, all the things that we all kind of suffer from. And I would start them on a program of some sort, and some hormones, and then they would come back, you know, three or four months later. 

And they’re starting to feel a little bit better. They’re kind of out of that survival mode, hopefully, and starting to really, you know, enjoy life a little bit more. And then they would often ask me, at that point, “Okay, I’m feeling better, now can you help me, with either my sex life, or my skin?” Which also included hair, so skin, sex, and hair. And so I got this question enough times that I started realizing that this sort of skin and sex was almost like this kind of next level of health, where once you had the foundations kind of dialed in, you were out of survival mode. You’re feeling pretty good, that people start to actually want to improve those other aspects of their life. And you know, and frankly, helping people with these areas makes them very happy, and I love having happy patients. So that’s kind of how it evolved.

Joseph M. Raffaele, M.D.

So from a sort of starting out in a diagnostic standpoint, what are the things that- and are they connected, that make your skin age and not look as good as it used to? And then also- I think you’re talking primarily about performance, but also about libido. You know, those- I mean, those two are linked hormonally, of course, but then even when you fix libido, you don’t always fix performance, and you know, skin definitely helps. I mean, hormones definitely helps skin in females and males, but you take the next step beyond that for, you know, rejuvenating, really, instead of sort of slowing down the aging process, and maybe helping a little bit, you’re really about rejuvenating those tissues.

Amy Killen, M.D.

Yeah, exactly, and I think that, you know, to your point, there are so many things that are going to contribute to healthy aging in general, that are going to, you know- what that’s going to affect your skin aging, and your sexual aging. So whether that’s eating, you know, low kind of anti-inflammatory diet, to making sure you have good cardiovascular health, which is gonna be important, both for glowing skin, you gotta have blood flow everywhere, you know, and sexual function, to making sure your hormones are dialed-in, you know. 

Hormones like estrogen is, you know, extremely important for skin, especially as we get older for women, obviously all the hormones are important for sex drive, and for sort of sexual performance, if you will. You know, there’s so many things like that, which we can just kind of try to prevent any problems over time by living a healthy life and doing those things. And then, you know, once we get to the point where we’re ready to start adding in some therapies, there are many of the same kinds of things that actually work for skin health, that also work for sexual health. 

So things like, again, optimizing hormones, getting them where they need to be, and then using, you know, regenerative therapies, whether that’s like stem-cell therapies, exosome therapies, cellular therapies. Or other things, like light-based therapies, lasers, you know, photobiomodulation, red-light therapy. A lot of these same kinds of therapies will work for skin health, for aging skin, as well as to improve sexual health. So I’ve kind of put together some programs that use all of these different modalities, and they use them, you know, for skin, hair optimization, and sexual health.

Joseph M. Raffaele, M.D.

Yeah, that’s what’s been sort of interesting to me, is that you have a- almost like the way Dale Bredesen has for Alzheimer’s Disease, is a multi-modality approach to it. You want to fix the base of the pyramid, which is diet, stress, et cetera, and then hormone optimization. And then beyond that, you do work with delivering sort of growth factors and anti-inflammatory factors directly to the tissues. Because, you know, perhaps you aren’t gonna get the same levels at the blood, through, you know, going through the bloodstream. Tell me a little about that, which- well, let’s talk first about, you’ve mentioned some terms, “exosomes”, ’cause I don’t know that we’ve talked about them much on this show yet, exosomes, stem cells. Tell us a little bit about the cellular, and sort of partly cellular, or products of cellular stem cells that you use in your practice.

Amy Killen, M.D.

Yeah, so I mean, as you know, as, as most doctors know, the stem cells are the, you know, cells that you have, all over your body, that are responsible for the upkeep of all the different organs and tissues. So they have the ability to replicate themselves, and they have the ability to differentiate into different types of cells, whether that’s skin cells, or bone- you know, bone cells, cartilage cells, et cetera. So as we get older, our stem cells become less functional, but we still have them, but they’re not sending out as many messages to other cells, to help with this health of those cells, as they did when we were younger. So that’s something that we’re trying to kind of improve with the therapies that we do. So when we’re talking about using stem-cell therapies, there’s a couple of different things we can use. 

We can use actual stem cells. So we can use stem cells from the patient, for instance, from their bone marrow, or from their fat, in some cases. Or we can use, you know, there are products available like umbilical cord stem cells that you can purchase from companies, although that’s recurrently an FDA no-go. And then there are other products that you can purchase, like exosomes. So exosomes are kind of like the messaging arm of the stem cell. So when a stem cell communicates with other cells, one of the ways it does it is it releases these little, teeny, tiny bubbles, bubbles of information, almost. 

They come out of the one cell, and then they get taken in by recipient cells in the area. And those little exosomes have within them, messenger RNA, microRNA, proteins, you know, cytokines, things like that. And so when those messages get taken in by the recipient cell, the cells nearby in the area, it actually- those cells can actually be changed by the exosomes. Because they’re receiving new messenger and microRNA, so you’re getting new blueprints, essentially, for protein production and things like that. So you can almost take these exosomes, and turn other cells into more active versions of themselves, because they’re getting new messages to do so. So we use exosomes- I use them, primarily, topically at this point, and again, because of the FDA, but we can apply them topically, or kind of microneedle them in for scalp and skin, to increase the messaging to the cells that are already there. Like the fibroblasts to increase collagen, or elastin, or the hair follicles to increase hair, you know, hair production. So all of these things, we can either use them together, or kind of piecemeal to increase cellular signaling and get rejuvenation of the tissues.

Joseph M. Raffaele, M.D.

But I’m also- understand that not all exosomes are alike, I mean, it depends on what cell they’re derived from. Do we know when you’re giving us particular product, what, you know, which mRNAs, which microRNA are- you know, sort of which growth factors are, you know, predominantly within those exosomes, you’d sort of know which signal you’re kind of sending to them, and does it matter? I mean, people talk about exosomes generically all the time.

Amy Killen, M.D.

Right.

Joseph M. Raffaele, M.D.

And there aren’t too many companies that offer them, I guess there’s a couple of them, right? But they’re different- they’re different products, right, I would imagine?

Amy Killen, M.D.

Yeah, and that’s a great question. Right now, you know, the only amount of sort of differentiation we have is being able to choose where are the sources. So we can choose, you know, umbilical stem-cell exosomes, which is the type that I use. ‘Cause they’re gonna be the youngest, they’re gonna, you know, in theory, have changed the least in their-

Joseph M. Raffaele, M.D.

Long telomeres.

Amy Killen, M.D.

Yeah, exactly, long telomeres, able to do the most sort of messaging. So those are the types I use primarily, but you can get exosomes from, you know, bone marrow stem-cells of adults, or adipose stem-cells in adults. And there are products in the market that have those as well. They’re- as far as the what’s in the actual exosomes, that, you know, looking at the messenger RNA, the- yes, I mean, it’s certainly possible to look at- not for me, but for the scientists who make the exosomes, to look and see what kind of messenger RNA it is. 

And at some point, in the hopefully near future, we’ll be able to select specific, you know, types of messenger RNA, specific ones that encode for, you know, proteins that are gonna be better for one thing, versus the other. Right now that’s not available to us yet. But I think in the next couple of years, for sure, we’ll have the ability to say, “Hey, well, these exosomes- this product is better for skin. This one’s better for hair, this one’s better for joints,” just based on the proteins that are gonna be encoded by the messenger RNA.

Joseph M. Raffaele, M.D.

And you may well be able to choose those. I mean, whoever’s producing them can choose to put those in there, of course, you’d have to. Because I know that pharma is looking at exosomes in a big way. A couple of conferences that I’ve gotten emails about, about all this sort of- you can’t call it drug development, call it some sort of exosome development, but they’re working on it. But at the same time, there’s a parallel track going on in offices like yours, where people are using exosomes with good effect, currently. And I wanted to have our, you know, our listeners understand, you know, the difference between- so when you get one of those products, do they give you a list, is it done- is there analysis done on the exosomes of what’s in that product, or…?

Amy Killen, M.D.

Yeah, you can get a list. I mean, you can get a list of the proteins that are being encoded by that particular type of exosome. And you know, right now, for the way that I’m using them, we- that seams of the exosome, you know, they get taken up by the recipient cell, and it matters more about what the environment is. You know, if they’re in the environment of skin, then they are going to sort of boost the skin regeneration. If their environment is a joint, they’re going to boost the joint regeneration, because they can generally do that. 

But, yeah, I feel like- yeah, they’re using exosomes for everything; they’re looking at them for cancer therapies, and delivering cancer, you know, cancer therapies directly. There’s so many opportunities for that. And that’s- and recently, as of this last June, the FDA came in and said, you know, “Exosomes are a drug. You can’t just, you know, you can’t just give them as you wish. We want to know more about how it’s being done.” So they’re regulating exosomes like drugs now, which makes it a little bit more tricky for us, but we can still do it topically. And for the things that I do, that’s really powerful still.

Joseph M. Raffaele, M.D.

So the previous- I think I’ve actually- yes, I have, received systemic exosomes in the past from the doctor that was working on my shoulder as well. Currently that has been- the kibosh has been put on that?

Amy Killen, M.D.

Yes, I mean, yes, if you ask the FDA, that is not something that they are wanting to be happening. I will say it’s still happening, but it’s- because a lot, you know, a lot of people have been using these therapies, IV, for, you know, five- and using them for five years, and have not one time had a side effect or a problem with any patient that’s received any kind of exosome. Because they’re not- you’re not going to incite an immune response from exosomes; A, they’re too small, and B, any kind of mesenchymal stem cell doesn’t actually incites an immune response, in general. And so, you know, you have a lot of things going for you there, but so they’re very safe. And that’s why I think a lot of doctors are reluctant to give them up, but we’re trying to comply with what the FDA wants.

Joseph M. Raffaele, M.D.

Yeah, it’s likely that’s gonna be a little bit tougher to continue doing. Just while we’re on the subject of systemic, I’m curious, when you put them into a joint, or when you put them into a, you know, skin, you have the area that they’re going to, ’cause you’ve injected in there. If you’re giving them systemically, is there a homing to tissues specifically? And how does that take place?

Amy Killen, M.D.

There is, absolutely, and it’s- ’cause they have some of the same surface receptors that a stem cell has, or a cell has. There’s actually some interesting studies. There’s a mouse study that I like to talk about, that has- they took these little mice, and they, you know, put incisions on the backs of the mice. And so they have these little wounds on the mice and the backs. And then they had a control group where they didn’t do anything besides put in saline. And then they had an IV exosome group, where they tagged the exosomes with like a fluoroscopy, you know, a dye kind of tag. And they put the exosomes in the IV of the mouse’s tail. 

And then they had a third group where they injected the exosomes directly into the wounds on the back. And then they followed these mice out for a month. And what they found was, that within seven days, in all the groups that got exosomes, the exosomes were found in the wounds themselves. So they all kind of went to the wounds within seven days, and they stayed there up to 21 days. So that’s interesting, so they- we know they can home, just like stem cells can home, they can home to areas of infection, or inflammation, or injury. And then the other thing that was interesting about that study is the group that got the IV exosomes actually had better wound healing than the group that got the injections directly into the wound. And so now that-

Joseph M. Raffaele, M.D.

I can see how that- if they’re getting there, they’re probably getting there in a more nicely distributed pattern. ‘Cause they’re using, you know, the highway system of the capillaries, to get in there, rather than just a needle injection.

Amy Killen, M.D.

And they probably didn’t lose as many to injection as well. I figured that was probably-

Joseph M. Raffaele, M.D.

Right.

Amy Killen, M.D.

part of it. But yeah, so we can use them IV, just like you could with stem cells, they definitely can home. And because they’re so small, they do pass the blood-brain barrier, and they don’t get trapped in the lungs the same way that stem cells do. When you give stem cells in an IV, you know, 80% of them go to the lungs, and just hang out there. And you can still get benefits from that, because they’re still messaging and doing their stem cell things, but they’re not getting quite as widely distributed. But exosomes, actually, can pretty much go everywhere, which is unique to them.

Joseph M. Raffaele, M.D.

 Sounds like, though, they’re going to places where there’s damage, or where there is inflammation, or something, because of the receptors they have in their surface. So I didn’t know that about them, and well, I guess I’m glad I got them.

Amy Killen, M.D.

Yeah, yeah.

Joseph M. Raffaele, M.D.

So speaking of stem cells, I mean, I’ve heard that stem cells don’t… And, you know, that’s why I’m speaking to you, don’t- correct me if I’m wrong, but I’ve heard that they used to think that the stem cells go to the tissue that you’re looking at, even if you inject it into that tissue, and then start to multiply and replace that tissue. But now they think that that’s less likely what’s happening, and more that they’re just delivering paracrine factors to the tissue. Is that your understanding at this point?

Amy Killen, M.D.

That’s exactly right. So, you know, in culture studies, and they use pee in petri dishes, they, you know, obviously stem cells are capable of replication and differentiation, so that you can turn those stem cells into actual different types of tissue. But what’s been found in the human body, is when we moved stem cells from one place to the other, they don’t tend to engraft. So they don’t tend to become- you know, if I take some cells from your bone marrow and put it in your skin, the cells don’t tend to become skin cells, or give rise to skin cells. They stick around for, you know, days to weeks, depending on kind of where you’re putting them. 

But they’re sending out these- all these signals, including exosomes, to the cells around them, which is called the paracrine effect, as you just rightly said. And that’s what’s doing, you know, all the good stuff. And so they’re also sending out signals to the immune system, there’s immune modulation happenings, and you have the immune system kind of ramping up or down, depending on what’s needed. You have anti-inflammation, you have antioxidant effects, you have anti-apoptosis, anti-fibrosis, like you have angiogenesis, you have all these things kind of happening locally in that area, as well as systematically, as well. But it is- it does all seem to be about the signaling. 

In fact, there’s been the idea that they should change the name from mesenchymal stem cell, to mesenchymal signaling cell, because they’re really all about signaling. And that’s- it’s like nature’s sort of, you know, medicine box that you’re just moving from one place to the other.

Joseph M. Raffaele, M.D.

And the benefit of using a mesenchymal stem cell over just the exosomes, is that- is there a wider variety of exosomes that the mesenchymal stem stem-cell releases?

Amy Killen, M.D.

Yeah, there’s a wider- there’s a wide variety. And you know, we don’t know for sure, there’s a lot of debate still going on, whether actual stem cells are better, or just things like exosomes. There’s a lot of benefits to exosomes, because again, they’re small, you can get them off- you know, you can get them kind of from a lab, you can freeze them, versus having to have them like hyper-frozen, like stem cells. There’s good viability, they’re not gonna generally die in their vials. So you have the ability to give them to more people. And- but they’re also pretty new on the scene. Like we haven’t had enough time to do a lot of studies to see, you know, if you compare using mesenchymal cells versus exosomes for X, Y, and Z, you know, which one works better? 

In the few studies that I’ve seen, like for instance, in sexual health, there was a rat study where they did this- they did that. They did mesenchymal stem cells from fat, I think. And then they did exosomes from those same stem cells. And they did them in a study that looked at that, essentially, erectile dysfunction model. And they found that the exo- they both performed well, but actually in that case, the exosomes did a little bit better. And so, you know, I think there’s still debate out there about what the best way to do it is.

Joseph M. Raffaele, M.D.

What is the model of a rat erectile dysfunction?

Amy Killen, M.D.

They actually have- they have a few different models. It’s a great- I love that question. They will do like little- they’ll cut the cavernous nerve to the rat. And they’ll do like a post-prostatectomy model, or they’ll use drugs like streptomycin, and it’d be like a post, like, diabetic model. So they have like these different like posts, you know, hypertensive model, diabetic model, prostatectomy model, depending on what we’re looking for.

Joseph M. Raffaele, M.D.

We’re just wiping out the rats’ erectile function, okay.

Amy Killen, M.D.

It’s very sad, it’s very sad.

Joseph M. Raffaele, M.D.

So… Well, I guess that’s a relatively good segue into your whole body stem-cell makeover that you do. Tell us a little bit how you got into that. And I’m really curious to hear about what kinds of results, and whether I’m gonna hop on a plane and head out to Park City.

Amy Killen, M.D.

Yeah, so Dr. Harry Adelson, who was my partner, it’s his practice up in Park City where we do this procedure. And we’ve been working together for about seven years, he only does musculoskeletal pain. So he does, you know, spine, he’s a big spine guy, full spine, joints, musculoskeletal pain like that. He’s been doing that for a number of years. And then I’m, you know, I’m sort of skin and sex. So it’s just- that’s skin, hair, sexual stuff. And a few years ago, we- about four years ago at this point, we had a lot of patients ask, you know, coming in saying, “Hey, you know, my shoulder hurts. 

My knee hurts, my hip hurts, my ankle hurts. And also I want, you know, skin rejuvenation, and hair restoration.” Essentially, can you do all of these things at one time? Because we were already going in, and at the time, we were doing bone marrow aspiration on the patient, we were doing fat aspiration to use their cells. We were also adding in exosomes. And so, you know, we’re sedating the patients so that they’re not awake and uncomfortable. And so what we realized is we could actually do it at one time. 

If we took enough volume from all the different sites, if we added enough other things to make it a good, effective procedure, we could sedate the patient, and in three hours, we could inject every single joint in their body, all the major joints, at least. Including every major joint in the back, you know, including epidurals, transforaminal epidurals, as well as facets and all those things. And I could do all of my cosmetic injections, microneedling, hair injections, sexual injections, et cetera. And we could do all of that in about a three-hour period of time. And so we’ve been that now for three or four years, we’ve done over 200 patients, and we call it the full-body, stem-cell makeover. And it is- it’s pretty spectacular. It’s pretty big, but a lot of people really like it.

Joseph M. Raffaele, M.D.

So what kinds of things do you see afterwards? I mean, we’ll start with the joints. And a lot of these people, from what I understand, are not necessarily suffering from major, like, presurgical types of problems, but they have aches and pains. They’re limited- maybe they’re athletes, and they, you know, they want to keep functioning. It’s almost not quite prophylactic, but really to try to sort of change the crankshaft in your car after, you know, 50,000 miles kind of thing. And so they- I mean, I’ve listened to some of the testimonials, but they get quite a bit of a beneficial effect from it.

Amy Killen, M.D.

Yeah, it depends on what they’re coming in for, obviously, but, you know, we have people who, you know, some people have pretty severe pain and problems. And then some people don’t really have a lot of pain, they’re just sort of these longevity-seeker, kind of bio-hacker people, who are just trying to do everything that they can to stay on top of it. So we have, you know, everyone from 35-year-olds, to 75-year-olds, who are doing these procedures. And, you know, I think it depends on what they come in with. Obviously, if they have no problems coming in, which some don’t have a lot of problems, then they don’t tend to have- you know, afterwards, they feel really good. 

A lot of them just feel like they kind of had like a full body massage that just kind of stays with them. A lot of people report a lot better sleep, and just kind of general movement. Of course, with my stuff, you know, you’re just looking for improvements in skin health, you’re looking for improvements in skin texture, tone, color, fine lines, over the course of the first few months. And that continues out for at least a good year that you keep getting more and more and more improvements. With hair, we’re trying to, you know, improve hair counts, and as well as thickness of the hair follicles. And then with sexual function, I have a lot of patients who don’t really have- again, don’t have a lot of problems, but what they find is that even if you’re, you know, if you’re 45, 50 years old, even if you don’t have a lot of problems, things have changed in terms of blood flow, in terms of the cellular health-

Joseph M. Raffaele, M.D.

Yeah, for sure.

Amy Killen, M.D.

and the tissues. And so, you know, if we can kind of turn back the clock, even just a little bit, things feel different. And people are always very grateful that, you know- a lot of times they’re surprised, they’re like, “Oh, I didn’t even know that I had, you know, any aging problems going on, but it turns out that things are actually a lot better than they previously were.” So, you know, the idea of being- at least for that, you’re increasing blood flow, you’re trying to increase the health of the cells in the tissues, and actually just kind of create, you know, more youthful tissues.

Joseph M. Raffaele, M.D.

Be really interesting to see if you- ’cause a lot of people are doing things like this, like a pre- and post-MRI of the spine, or of- you know, a lot of people do a whole-body MRI. But I mean, specifically of the joints, if there’s anything going on there, that would be kind of- are you looking to publish any of this stuff? You’ve got 200 now.

Amy Killen, M.D.

I know, we should. We haven’t- you know, the problem with MRIs are that you don’t- a lot of the things that we’re doing are happening on them, you know, micro-cellular level, it’s happening in the microcellular circulation, and the, you know, on the nerve level. So you may not see structural changes. You know, you may not see- certainly, the bones probably won’t change. You may or may not see cartilage change. You know, you certainly could do things with skin. If you had a good camera, you could do this before-and-after skin. And you could certainly do Doppler, and things sort of for the penis. So, the short answer is, we haven’t done all that research. We always- we certainly keep track of our patients, and we follow up with them, you know, every three months out, through at least the first year or two, and surveys, and all of that. But it’s- you know, a lot of it’s just about funding, and that’s-

Joseph M. Raffaele, M.D.

Oh, yeah, of course. You know, I’m just thinking out loud, it would be kind of cool to see. So there’s the new kid on the block that we had talked about a little bit, you and I, in the past, I guess over Instagram, is the VSELs. Tell us about the VSELs, and how they may be sort of the right thing between the iPS, and the embryonic stem cells, that sort of gets rid of the two undesirable effects that those can have, and why they’re probably not gonna be used?

Amy Killen, M.D.

Yeah, VSELs were discovered in about 2008. And what- that stands for Very Small Embryonic-Like stem cell, so that’s what the VSEL stands for. And they’ve been, you know, looked at for a number of years, and kind of found in everything from bone marrow, to even just peripheral blood. And basically they’re these little, very primordial cells, that are in-between an embryonic stem cell and like a mesenchymal stem cell, or a, you know, a hematopoietic stem cell. They’re not differentiated yet. And they can actually become both the hemo- hemo- hematopoietic, sorry, hemopoietic stem cells, or mesenchymal stem cells, or some of the other types of stem cells. But they’re not as primordial as an embryonic stem cell. So they don’t see problems with like, you know, tumor formation throughout, you know, the teratomas and things with VSELs. And they also have preserved telomerase activity, which I know that it is interesting to you.

Joseph M. Raffaele, M.D.

I’m excited now.

Amy Killen, M.D.

“You said ‘telomere’, you said ‘telomere’!” But what happens is, these cells are- they’re hanging out, we have them our entire lives, but they live in this quiescent state. So they’re really turned off, and they’re not subjected to aging like other cells. So they actually aren’t influenced by IGF-1, or insulin, or any of the things that can cause other cells to age faster, which is very interesting. They’re like cocooned off, and they can be turned on, or activated, by pretty severe traumas. So if you were in, you know, a car wreck, or a stroke, or things like that, there’s some- at least supposition, that they can be turned on by extremes of heat, and cold, and such, as well. But for the most part, they’re just in your body, kind of hiding out, and they’re just there as like a reserve. And it was hard for a number of years, to figure out, “Well, how can we activate these cells?” 

There was a number of protocols out there, over the years that have come out, that have shown, “Well, if you heat them for this long, and cool them for this long, and talk to them in this way, like, you know, for X-many days, then you can activate them.” But it was never something that was approachable enough for us, as doctors, to be able to actually do those things. 

But there’s now a laser, there’s a doctor, kind of physicist, out of Texas, Dr. Todd Ovokaitys, who has come out with a special photo-acoustic laser that he designed, that basically, within three minutes, you can activate PRP. And you can increase the VSEL proliferation, and activity in that PRP, just with this laser. So we’re starting to use this laser on our PRP, trying to activate the VSELs. And we’ve just been using them about two months now, but we’re doing so- we are doing some testing on that, looking at, you know, at least epigenetic testing before and after. And we’ll eventually try and add-in some other testing, like it’d be great to do a telomere testing before, you know, before, and maybe six months or a year after, to see if we’re gonna see any improvement in that. And then, of course, we’re keeping track of our- how we’re using them. We’re using them with our joint injections, and skin injections, and things like that. But very new, very, very untested and new, but pretty exciting stuff.

Joseph M. Raffaele, M.D.

So you treat them after you’ve taken the platelet-rich plasma out, and you give it a little bit of a buzz, there’s- is that considered treatment, or is that…? ‘Cause I know when you sort of manipulate something afterwards, the FDA gets unhappy about that sort of thing. Is there they’ve not spoken to that yet, I guess.

Amy Killen, M.D.

They’ve not spoken about VSELs, but really we’re- it’s just a light, you know. People have been using different types of light; red light, and other kind of photobiomodulation-

Joseph M. Raffaele, M.D.

That’s true, psoralens, and for-

Amy Killen, M.D.

Yeah, for a long time. And to me, that’s still minimal, very minimal manipulation. But you know, they’re so new, that the FDA, as far as I know, hasn’t spoken about them yet.

Joseph M. Raffaele, M.D.

Have you seen anything clinically? That’s- in terms of responses you’ve seen?

Amy Killen, M.D.

We just started using it. The main thing we’re seeing is that when we started using the VSELs during our full-body stem cell procedures, that the patients were waking up in almost no pain. Like, it just seemed like- you know, we do- we’re doing hundreds of injections, and you’re doing, you know, bone marrow aspirations, and all of these things. And so they’re- if they’re not- you know, they wake up generally in some discomfort, but in the last month or so, we’ve been noticing that the patients are just waking up extremely comfortable, which is really interesting. And we’ve never had them- they’re always in such, you know, the pain is always fairly low when they go home, and we never use opiates or things like that, when they go home. But that this has really helped a lot. So we’re hoping that, you know, it takes usually two or three months to start seeing benefits from any stem-cell therapy. So we’re hoping that we’re really gonna start seeing some benefits, but we don’t know, we’ll see.

Joseph M. Raffaele, M.D.

Yeah, that’s really nice, that the telomerase activity, it’s not like an embryonic stem cell, it’s somewhat preserved, but- or is it at full level?

Amy Killen, M.D.

I don’t know exactly the level, I just know that it’s preserved, at least much more than any other cells in the body. So it’s- you’re not getting the decreasing activity like other- which makes sense if these cells are not, you know, they’re not dividing, and they’re not like- they’re just- or maybe they’re dividing, I don’t know how they work, because I haven’t- they’re so new, but they’re just like, you know, kind of hanging out, they’re not subjected to all the stresses in the body otherwise. So, I don’t know.

Joseph M. Raffaele, M.D.

Well yeah, one wonders, evolutionarily, why they’re there,

Amy Killen, M.D.

Right.

Joseph M. Raffaele, M.D.

And, you know, if they get activated with extreme trauma and things like that, that makes sense. But still, more and more, definitely more research to be done on those. I’m also very curious about your techniques that you always do, all of these great Instagram videos that show, you know, sort of- very generously showing techniques to everybody about how to apply therapies to the skin and to the scalp. There was a guy in France many, many years ago, that used to do microneedling with vitamin C and other things like that. But it was sort of like a much cruder way of doing it. You’re delivering these various therapies with these microneedling, and you get- how far deep do you get? And I would imagine it’s a lot more effective than topical.

Amy Killen, M.D.

Yeah, absolutely. Well, you know, many of these things like stem cells, don’t go through the skin. Exosomes, actually, will go through the intact skin, but it takes about 18 hours. So it’s-

Joseph M. Raffaele, M.D.

You can’t wash your face?

Amy Killen, M.D.

They’re very slow moving. You just sit there with them on your face. So you’re creating-

Joseph M. Raffaele, M.D.

A long mask.

Amy Killen, M.D.

It’s a very long mask. Creating some microtrauma, A, it’s gonna allow entry into the skin. And B, you’re also gonna- you’re gonna have this sort of homing, you know, mechanism, that, just from the trauma itself, that kind of helps to keep them there. So I’ll do a few things, I will inject directly, and I don’t do deep injections, usually, although I can, but I’ll inject just, you know, intradermal injections, which are gonna go, you know, four millimeters or less, usually into the skin, or just subdermal. And then I’ll do the microneedling, which is going to usually go about one to two millimeters deep. 

And that’s just the little device that has the needles that just go up and down really fast. And you can do- you can treat the entire face, neck, you know, decolletage, backs of the hands. Like you can treat literally anywhere on the body, it just creates a little redness. And then you have these little micro channels that are open for about 30 minutes. And so whatever you apply topically, then gets pulled, you know, all the way down into the deep dermis of the skin. So I love microneedling, that’s fantastic. 

And then I’ll also sometimes use other things, like a laser, like a non-ablative fractional laser, or even like a CO2 laser. Those are other things, you know, the thermal damage is gonna increase collagen and elastin production on its own. And then you’ve also created this homing mechanism so that when you apply the stem cells, that they’re going to stay there, or the exosomes, they’ll stay in place. And we know from multiple studies now, that if you use these kinds of cellular therapies after laser treatments, that you’ll have much faster time to healing, much less pain, redness, swelling, and then overall, a better aesthetic response. So they’re great in combination with any kind of other facial procedures. I don’t do plastic surgery, but a lot of plastic surgeons I know will also use them, you know, with their plastic surgeries. So they’re pretty great.

Joseph M. Raffaele, M.D.

Yeah, so do you have any specific devices that you- I mean, is it like a roller for the microneedling, or how does that work?

Amy Killen, M.D.

It’s a- there’s a couple- there’s a bunch of different micro-pens out there, like literally pens. I use one by- I just blanked on the name of the company. But I’ll tell you if I remember it. There’s one by SkinPen, there’s a couple different ones out there that doctors can buy. You can buy cheap ones, you know, on the internet, which I wouldn’t recommend just for random people to do. But the other thing you can do, which I- I send patients home with, is I also like derma rollers, which are- they’re gonna be just like little manual- like, almost like little rolling devices that you can roll over your skin. And that’s not-

Joseph M. Raffaele, M.D.

They’re needles?

Amy Killen, M.D.

Yeah, they’re needles, but they don’t go very deep. So I have my patients go home with a derma roller that has needles that are about 0.25 to 0.5 millimeters. So not enough- no bleeding at home, not enough to cause any of that, but enough to cause a little bit of damage so you can still get products and things on to the top part of the skin. So I have my patients go home with derma rollers and have them do that once or twice a week after my procedure. So that I’m continuing to, kind of again, keep the stem cells and the cells homed in on the skin that I just treated, and in hopes that they can get better results long-term.

Joseph M. Raffaele, M.D.

So with your treatments, being at- whatever, as deep as four millimeters, you obviously make the skin look better, and so the fine wrinkliness and stuff, but things like folds, or things that fillers treat, can yours- are you making fillers obsolete with your therapy? Or is that something that- you know, do you see that?

Amy Killen, M.D.

They’re not- you know, these therapies right now are not as good as like a hyaluronic-acid filler, like the Juvederm or Restylane, for actually filling. So we can see some improvements in skin volume. And there’s been some studies with looking at nasal-labial folds, and using like- even just with PRP, we know that that can help a little bit, but it’s not as good as filler. I think that there’s coming- there’s some placental matrix products coming, that are made from placentas, that are essentially kind of ground up, and they get the cells out, and just keep the matrix part, the extracellular matrix. 

There are some products that have already come out, actually. And there’s some more that will come out, that I think if we were to pair some of those matrix products, which are a little thicker, with something like exosomes or even PRP, then we would probably see more of a filling result. But right now I still use fillers, also. I use them for filling, I still use Botox for, you know, stopping muscles from moving. And then I use the regenerative procedures for, really, the skin itself, and improving the glow, and the texture, and the tone, and such of the skin.

Joseph M. Raffaele, M.D.

And for hair, it’s pretty much the same therapies, just on the scalp, right?

Amy Killen, M.D.

Yeah.

Joseph M. Raffaele, M.D.

Or is there some- something different about it in terms of…?

Amy Killen, M.D.

Yeah, we can- you know, scalp actually seems to really benefit from the cellular matrix products, like the placental matrix or exosomal matrix products, because it’s kind of like a scaffolding that you can inject into the scalp, and then injecting like exosomes or PRP on top that, is the growth factor part of it. So you kind of get like the one-two punch. So those two seem to work really well together. But yeah, we can use stem cells, we can use exosomes. PRP has been well-studied for hair, and can be effective, although you have to do multiple treatments with PRP. And scalp injections are- they can be painful if they’re not done, either on your skin-

Joseph M. Raffaele, M.D.

Oh, I’ve had them, yeah, they’re not fun.

Amy Killen, M.D.

They hurt, right?

Joseph M. Raffaele, M.D.

Yeah. 

Amy Killen, M.D.

They’re not good.

Joseph M. Raffaele, M.D.

But do you do a sort of a microneedling as well for the scalp? And that delivers-

Amy Killen, M.D.

Yeah, you can do microneedling over as well. I usually will inject, and then microneedle, if I can get to that part of the scalp. But if someone’s- you know, with women, for instance, and they have a decent amount of hair, then it’s kind of hard to microneedle sometimes.

Joseph M. Raffaele, M.D.

Right, true.

Amy Killen, M.D.

But for men, we’ll microneedle over on top as well.

Joseph M. Raffaele, M.D.

Have you ever thought about- ’cause I know there’s literature on it- I actually gave a lecture, maybe six or seven years ago, about the effect of shortened telomeres in the skin, and telomerase-activation, potentially turning on fibroblasts, and decreasing production of the metalloproteinases, and those sorts of things. And TA Sciences has a topical product. I’d be curious, ’cause like- you know, little lights went off when you said you do the microneedling first, and then you put the cream on top, and so it might be able to get that- could you- does it have to be a serum, or would a cream get in as well?

Amy Killen, M.D.

A cream can get in as well, it has- it depends on how thick it is, but yeah, we will use creams as well. Like if it’s a pretty thin cream or serum. But yeah, I mean, anything that’s trying to- you know, the cream gets through the skin eventually, right? Like it has to, or it won’t work.

Joseph M. Raffaele, M.D.

Yeah, but probably not as much as if you put holes in the skin.

Amy Killen, M.D.

Well yeah, I think- you know, we know that like, with hair, for instance, we know that if you do, like microneedling or derma rolling at home, and then you apply your minoxidil, for instance, on top of it, then you’re gonna have better results, than if you just apply your minoxidil topically. And so when we can do this- we can do the microneedling and derma rolling with, you know, everything, from vitamin C serums, or creams, to just regular skincare creams, as long as they’re pretty thin, they’ll still kind of go in those little channels, at least to some degree. But yeah, I like your idea, we’ll use some TA Sciences topical, and some microneedling, and that’s gonna- that sounds great.

Joseph M. Raffaele, M.D.

Yeah, I mean, that’s what I think I’m gonna get, get a pen, or if I don’t, get out there to see you, and try that myself. ‘Cause I think- there is a really pretty good molecular pathways worked out for why that might be beneficial. So I’m gonna avoid using any puns and say, “Let’s talk about erectile dysfunction,” at this point. I have a propensity towards that. So you have a multi-modality approach there, as well, with both, you know, the injectables, and then you have the shockwave therapy, et cetera. I’d love to hear about, you know, sort of what kinds of results you get, and what- I know that a lot of your patients are healthier and bio-hacker types, I have patients like that, majority of my patients. And then another set of patients post-prostatectomy, that- or radiation therapy that, you know, are unfortunately not having much in the way of erections, or using TriMix, or something like that. Tell us about the range of your success with the kinds of approaches that you take.

Amy Killen, M.D.

Yeah, so again, like injections, like you said, I’ll use injections like stem cells, PRP, exosomes. I’m also a big fan of making sure the patient has a- some kind of nitric oxide booster on-board, like, you know, a Neo40, or some other kind of nitric-oxide products, ’cause that’s obviously super important for erectile function. Testosterone, obviously, very important as well. So I kind of make sure that they have their foundations in place. And then I also like to use, like a shockwave therapy, like GAINSWave or other- some kind of other low-intensity shockwave therapy, which is gonna require, you know, multiple treatments, but that can be really effective, especially when you add it to some of the injections. And then the other thing that I’ve recently discovered, and become excited about, is using bio bioelectricity for ED. 

I’m working with a company now, actually, that has a device that’s not painful, that you essentially can wear for like 30 minutes, twice a week. And it’s essentially, they discovered the electrical signals that specifically activate certain proteins. And so they can essentially create, you know, different signal maps where they’re, you know, they’re first- they’re increasing stem cell homing, then they’re increasing angiogenesis, then they’re increasing, you know, muscle regeneration. Then- like essentially kind of marching through all the things you would need to actually repair a penis. And you’re getting all those signals kind of in order, noninvasively, non-painfully. And they’ve been having, you know, the early studies are about 90% of patients are having improvements, with just, you know, a series of maybe eight of those treatments.

Joseph M. Raffaele, M.D.

Is this available? Or is it- you’re still working with them on that?

Amy Killen, M.D.

It is, the technology’s available, they’re not out to consumers yet, but they’re working on getting a consumer device, I’m working with them and doing some clinical studies- some further clinical studies on that technology. But they’re using it, the same kind technology, for skin rejuvenation, for hair restoration, because really, once you know the signals that you need to create the proteins, it’s just a matter of putting them in the right order, you know, and the right delivery device.

Joseph M. Raffaele, M.D.

Right, you might be able to actually use it for muscle building, too, I would imagine.

Amy Killen, M.D.

Oh yeah, they have applications for muscle building, for increasing klotho, which is a longevity protein, that they’re talking a lot about.

Joseph M. Raffaele, M.D.

That would be fascinating, klotho’s a super powerful longevity.

Amy Killen, M.D.

Exactly.

Joseph M. Raffaele, M.D.

What’s the name of the company?

Amy Killen, M.D.

So it’s part of a business accelerator program through Leonard- Leonhardt Ventures, and I just became an advisor for them, so just full disclosure, but I’m pretty excited about some of the things that they’re doing. And so I’m gonna be adding that- those kinds of things into the therapies that I’m doing, too. But to answer your question, you know, when we use a combination approach, obviously gonna have better results with ED, than if we’re just using one thing at a time. The post-prostatectomy patients are some of the hardest to treat, but, you know, we’ve seen studies with, for instance, with stem cells, in combination with shockwave therapy. And they’re seeing, you know, 65 to 75% of patients with post-prostatectomy ED, are having some improvements, at least. And we’ve seen the same kind of numbers coming out of the early bioelectricity trials, 65 to 70% of even post-prostatectomy patients having improvement. So I don’t think that that’s a lost cause, but that is a harder one to treat, than just, you know, just ED from aging, or from diabetes, or high blood pressure, or things like that.

Joseph M. Raffaele, M.D.

So you don’t yet see, like, guys that are not able to have penetrative sex, having penetrative sex after a prostatectomy?

Amy Killen, M.D.

I do, yeah, in fact, one of my favorite stories was a patient that I treated about five years ago now. Post-prostatectomy four years, no erectile function, you know, nothing- the PDE5-I’s didn’t work, TriMix didn’t work, like nothing really worked. His doctor had- his urologist had told him that he needed to get an implant if he was gonna have any return of function. But otherwise healthy guy, like it was, you know, doing all the right things. And so he came to see me, and- just kind of as a last ditch effort, we did- I did stem cell and exosome injections, we did shockwave therapy, I think we did 12 sessions over the course of a couple of months. Got his testosterone even better, and put him on some nitric oxide. And within four months, he and his wife had been able to have sex for the first time in four years.

Joseph M. Raffaele, M.D.

Wow!

Amy Killen, M.D.

And he said it wasn’t perfect, he was like, “You know, we think we can still work on some things,” like, there’s still some things to work on. But it was able to happen, and that was a pretty big victory for both of us.

Joseph M. Raffaele, M.D.

Yeah, absolutely. So I’m gonna just turn to a little bit of a theoretical question, because I- it’s something I think about. In terms of- so you’re taking these stem cells, out of the bone marrow, out of the fat, probably out of the fat, not as much of an issue, but just curious about how the bone marrow, I mean, we have a set number of stem cells in the bone marrow. Telomerase is activated, to a certain extent, but not that much. Do you ever worry about reducing the, you know, the level of stem cell reserve that you have, by, you know, what- is it a, paying Peter to rob Paul, kind of thing? Or, I mean, obviously, potentially with TA-65 or some other telomerase activator, you could do that to, you know, turn on telomerase, to get them going again. Is there any talk about that in the literature, or anything like that?

Amy Killen, M.D.

You know, I haven’t seen a lot of talk at all, although I do, you know, when you and I saw each other last time in Las Vegas, I know that we talked about this a little bit. And we are careful not to go into the bone marrow very often. So that’s one thing, is just making sure that, you know, we’ll go in there, we’ll get what we need, but not, you know, not keep going back to that well. ‘Cause I think that’s a good point, and nobody wants to deplete any cellular supplies. It’s making it- it’s become a little harder because the FDA doesn’t like us to go to fat anymore. They don’t- you know, they’re only comfortable with bone marrow. And so even though fat is so accessible, and nobody wants it, and it’s- you know, anyone who has it is like, “Get rid of it, please.” It’s teeming with cells, way more stem cells in fat than bone marrow, that the FDA has said that that’s somehow a drug, but the cells from your bone marrow are not.

Joseph M. Raffaele, M.D.

‘Cause it’s an easily accessible drug, as opposed to the bone marrow.

Amy Killen, M.D.

An easily accessible drug that no one is- yeah, that we’re not even using, and it’s just sitting there. But they- yeah, so they recently have said that we can’t use the stem cells from fat, so it’s become a little bit of problem. So I think, you know, where we’re going- and I think where the field is probably gonna go eventually, is using occasional bone marrow, especially with musculoskeletal pain, those cells seem to be really good at healing musculoskeletal pain.

Joseph M. Raffaele, M.D.

That’s what the guys at HSS and all the regenerative guys here say. So I’m like- because I got joints, it needs to be injected, obviously, I’m like, “Can we use fat?” They’re like, “Just doesn’t work as well, quite as well, as bone marrow,” although, you know…

Amy Killen, M.D.

What we’ve found- what Harry, my partner found, is that bone marrow works consistently, for most people, for healing musculoskeletal. Like not everyone, but most people have some results. Fat, when he was using them, he was getting better results, but for not quite as many people. So it was, you know, more robust results, but not everyone responded to it, which is why he eventually went to doing both. So he was getting, you know, great results in almost everyone, or at least most people. 

But I think that what we’ll start to see is many more of these allogeneic therapies coming in, that we don’t have to use the patient’s own cells as much in the coming years. Where we can use, you know, off-the-shelf, you know, whether it’s umbilical cord stem cells, or whether it’s the exosome products or, you know, other things like that. That will become more and more personalized and specific for what we’re trying to treat, and also require fewer and fewer procedures on the patient. Because I think that, you know, the less we can- that we have to do to get, you know, to make you better, and the less pain it’s causing you, the more likely people are able to do it. And the more accessible it is to more people, and the cost comes down.

Joseph M. Raffaele, M.D.

Yeah, ’cause I mean, you don’t have to do anesthesia. I mean, some people don’t do anesthesia for just taking bone marrow, but it’s the kinder, gentler way to do it.

Amy Killen, M.D.

Yeah.

Joseph M. Raffaele, M.D.

And you’re doing it also for the injections that you’re doing.

Amy Killen, M.D.

Right.

Joseph M. Raffaele, M.D.

Do you have any idea? I mean, I guess, I don’t know the answer to this, and that’s why I’m gonna ask you. Do you have any idea, like what percentage of the bone marrow you’re taking out when you’re aspirating, doing a single bone marrow aspiration?

Amy Killen, M.D.

I don’t know the percentage. I mean, when a Harry does the big, big cases, he’s getting about 100 cc’s of bone marrow, so it’s a fair amount. Like the patient’s definitely anemic for 24 hours. But for smaller procedures, it’s not nearly as much. And I don’t know overall percentage what that is, it’s a good question, he would know. I just don’t know, ’cause I don’t do that part of it.

Joseph M. Raffaele, M.D.

Yeah, just curious about that. Because, you know, they’re starting now to look at, in sort of people with idiopathic pulmonary fibrosis, some of these people that are stratifying the way in which they’re going to treat them, based on their telomere length. Because if they give them too much ablative therapy, then they, you know, they can have a problem, ’cause they don’t have the reserve. You know, if somebody has really short telomeres, that would be something to think about, potentially. Do you do anything in a- since, you know, it sounds like you’re adding growth factors, but part of the process, part of the problem, in, you know, these tissues that are aging, is senescent cells. And is there a role for removing senescent cells, to do anything with senolytic therapies, to sort of make it- more room for the healthy tissues?

Amy Killen, M.D.

Yeah, I’m very interested in the senolytic therapies, and I’ve experimented on myself a little bit, for sure.

Joseph M. Raffaele, M.D.

Oh, really?

Amy Killen, M.D.

I’ve taken some things myself, but yeah. But yeah, I haven’t done a whole lot with patients, you know, aside from having them do, you know, like some of the supplements that are a little gentler, that might be helpful for that. But yeah, I think it’s a good point. I think that it’s something that- it’s so intriguing, and yet, you know, I also don’t want to kill off too many senescent cells and- you know, there’s a kind of a balance in it. But yeah, I think that that’s where- that’s one of the next things that I’d like to get into, is being able to give those kinds of therapies.

Joseph M. Raffaele, M.D.

Yeah, they’re interesting studies going on it, you know, there’s some caveats, again. My friend and colleague, Michael Fossel, who’s done a lot of work in telomere biology, is probably one of the- two of the smartest people in the field of telomere biology around, talks about synolytic therapies being of concern. Because if you’re gonna take out a cell, it needs to be replaced. And so you go into then mobilize other stem cells, to replace it, and thereby shortening the stem cell pool in that, and then ending up being, perhaps, worse off. And maybe the better idea is rather than having synolytic therapies, is to have cell therapies that can reset cells back from a senescence, to a- and none of them, as far as I know, do that just yet, which is why I’m now a little concerned about using them. People talk- there are some doctors that are doing a fair amount of it, and then they’re- it’s in a licensed light, and there’s dasatinib, and rapamycin, which is not. But I think they’re-

Amy Killen, M.D.

Right, right.

Joseph M. Raffaele, M.D.

they’re kind of all tied together in some way. So that’s a really- I mean, fascinating work that you do out there. And is there anything else you’d like to tell our listeners about, you know, what’s coming down the pike, what’s next for Amy Killen?

Amy Killen, M.D.

You know-

Joseph M. Raffaele, M.D.

I have trouble keeping track of you as it is.

Amy Killen, M.D.

I’ve had some great opportunities to work with some really, you know, interesting people. And my main- the thing I love the most is learning about new things that are going on in the field, whether it’s stem cells, or in this sort of, sex and skin field, and then trying to figure out how to bring those to patients in a safe way. So I do love like traveling, and going to conferences, and meeting, you know, people like yourself, and having hard questions and all that. So I’m going to hopefully do more of that and keep traveling. And then I have some stuff going on with our clinics, and they’re just kind of expanding and building more clinical space and such. So, you know, I’ll be around, and you’ll still see me on Instagram.

Joseph M. Raffaele, M.D.

Oh, yes, yeah, I mean, you should tell people what your Instagram- what do they call it, handle, or whatever?

Amy Killen, M.D.

Yes, it’s a handle.

Joseph M. Raffaele, M.D.

You have such great information up there. You post a lot, but it’s all- you know, unlike a lot of people, it’s, you know, almost always very interesting information. Occasionally, it’s Amy doing crazy things. That makes it fun.

Amy Killen, M.D.

There’s a lot of me, yeah, a lot of me hiking, or like me and my dog, or…

Joseph M. Raffaele, M.D.

No, you put a lot of thought, and a lot of time, I don’t even know how you have time for that stuff, you must have a nice team, you’re just super-

Amy Killen, M.D.

Oh, it’s all me, I need it. I should have a team, because some of the things I post, I’m like, “I don’t know what I did that.”

Joseph M. Raffaele, M.D.

You’re being too modest. It’s really great information up there. So just tell us, tell us what it is.

Amy Killen, M.D.

It’s Dr. Amy B Killen.

Joseph M. Raffaele, M.D.

Okay. All right, so- and any other addresses or information about your clinic out there? ‘Cause this is not CME, this is just for information for people to learn about where they can go, places, and send their patients.

Amy Killen, M.D.

Yeah, so the stem cell clinic, where we do the full body, is at doscereclinics.com, which is D O C E R E clinics.com. That’s sort of the main one that people travel in for. I have several other websites and things, but I’m most active on Instagram. And then I also have some YouTube videos with Amy Killen, MD, I think as well.

Joseph M. Raffaele, M.D.

Well, great, as always, it’s always fun to have conversations with you. And I’m sure our listeners, as I have, learned a whole bunch of new stuff, and look forward to seeing you at the next conference, or sooner, or maybe out at your clinic.

Amy Killen, M.D.

That sounds good, it was good seeing you, as well.

Joseph M. Raffaele, M.D.

All right. Thank you.