• 12-06-2010 04:54 PM
    John P. Cole, MD
    ACell, a Current Review of Applications in Hair Transplant Surgery
    I’m issuing this response because I am beginning to get phone calls requesting treatment with plucked hairs that are tainted with ACell based on presentations by Dr. Jerry Cooley and Dr. Gary Hitzig along with irrational exuberance on the part of some physicians who incorrectly feel these presentations represent a clinical breakthrough in the treatment of hair loss.

    My Use of ACell

    I first looked at ACell in the spring of 2007. In June of 2007, I began to research it in terms of treating horses for their lacerations since I own several horses. Horses are somewhat hirsute critters sort of like mice. Mice seem to grow hair when you apply butter. While ACell can regrow hair in horse wounds, it may simply be their predisposition to hair growth in general that is a work. I waited until ACell became FDA approved prior to considering it for use in humans.

    I will begin by relaying my experience with ACell and then discuss the presentations of Dr. Cooley. When I began using ACell, I really did not expect much other than improved donor extraction site healing. Obviously, I knew there was a potential for regeneration of extracted follicles, but since only the ectodermal stem cells would be residual in the donor area, I did not consider them to have a enough regenerative capacity by themselves. I started to apply it into extraction sites from FUE. The greatest challenge was how to deliver the product. The product originally came in two versions that were FDA approved for use in humans. One was a thin sheet and the other was a cluster of tiny particle that poses attractive electrostatic charge to one another and most any other object they come in contact with as described by Coulomb’s law.

    More recently Acell offered a fine powder. The real challenge was how to get the small particles into extraction sites because the particles have a good bit of static electricity on them as previously described. This makes them somewhat sticky to the jeweler forceps, one another, hair, or anything else in the universe. Subsequently, I began cutting the thin sheets into small pieces and putting a small piece in as many extraction sites as possible. The greatest difficulty was noting which extraction sites had already been treated because you have to constantly look away to pick up another piece of ACell and it is often difficult to see the small pieces once you have placed them in the extraction sites. I’m quite sure that many sites were not treated as a result of this difficulty. Similarly, many sites were most likely treated more than once. Suffice it to say that I did the best I could given such a challenge. Later, I began mixing the small particles in a hyaluronic acid gel and forcing a small drop of the gel mixture to the extraction sites using a 1 cc syringe and an 18 or 19 gauge needle that I ground the sharp tipoff of.

    When the fine powder became available, I switched to using this in the hyaluronic acid gel. The fine particles were a major breakthrough in terms of delivery. I found the ideal mixture was 60 mg of powder in 2 cc of the hyaluronic acid gel or 30 mg per cc of hyaluronic gel. One cc will usually treat well over 800 extraction sites. I often pre-treat the extraction sites with PRP and then drop the gel in to the extraction sites. Once again treating a non-shaven donor area with ACell particles is very difficult due to static electricity.
    The particles want are attracted to the hair, as well as the jewelers forceps. The gel mixture facilitates the delivery of ACell to these tiny individual extraction sites. One question that remains is whether ACell will become active once the gel sets up and “hardens”. The premise is that the hyaluronic acid will be degraded and leave the ACell to do its job. Will the hyaluronic acid degrade fast enough for the ACell to be affective? I tried mixing the ACell in PRP, but it just clumped and was impossible to administer to my extraction sites. Thus, the optimal option to date is the Acell/hyaluronic gel suspension at this point. Currently, I am working on a superior suspension of Acell in hyaluronic acid, as well as a better delivery method.

    I also began mixing 30 mg of the tiny particles in 30 cc of normal saline and injecting this into the recipient areas to include donor scars. I often treat these areas with PRP and microneedling, as well. I then activate the PRP by making incisions in the scalp or by injecting the patient’s thrombin or bovine thrombin into the recipient areas as taught by Joe Greco, PA, PhD. I have often added the ACell ECM to areas treated with PRP without grafts as Joe Greco has noted an improvement of pre-existing hair coverage in up to 70% of individual treated with a combination of ECM and PRP without grafting. I have noted the same in some of my patients, but follow up is difficult due to the distance between my clinic and the homes of my patients. Joe Greco has his own proprietary ECM that he obtains from the patient. Joe Greco has not released this ECM to other physicians yet. Joe is a wealth of knowledge and research with regard to PRP and eager to share this information.
    I often add ACell particles to my grafts by placing 25 grafts at a time in a ring cup that we hold on our finger during placement of the grafts along with particles of Acell in the cup. This way the grafts are directly exposed to Acell and many pick up a few particles during storage in the ring cup due to attractive electrostatic forces. The hope is that such exposure and tainting will improve survival of transected hair and possibly improve the survival of the grafted hair in general. We have not seen any documented benefit of this procedure yet, but we are still evaluating it.

    What I’ve noted so far is that ACell has the capacity to eliminate hypopigmented spotting in some FUE extraction sites. Those extraction sites that remained hypopigmented might not have responded or we might not have treated them with ACell. Again, it is impossible to know if all the sites are treated with ACell when you are using the powder or the cut up pieces of Acell. This is why I more recently began working with a gel because it is much easier to administer he gel suspension and it is far easier to verify that we have treated all the extraction sites. Acell also may have the ability to induce hair regrowth in some FUE extraction sites. I did not expect this to occur, but we were able to achieve some regeneration. For example, in a patient who had over 2000 grafts extracted, the number of hypopigmented spots were significantly fewer than the number of extractions, many extraction sites exhibited normal skin tone, and there were not as many empty extraction sites as one would expect following over 2000 extractions. In other words healing was better and some evidence of follicle regeneration was exhibited. Not all patients exhibit hypopigmentation with FUE, but those that do generally have hypopigmentation in all the extraction sites. The presence of both hypopigmented extraction sites and normal skin tone extraction sites suggests, but does not confirm, that Acell played a hand in improving the appearance of many extraction sites. Based on my experience in FUE, I also noted far fewer empty extraction sites than I would have expected following extraction of over 2000 grafts. This suggested, but did not confirm, that Acell may play a role in regeneration of hair follicles in extraction sites. I have also noted in other examples that an injection of a PRP and ACell combination can induce improvement in coverage of native hairs affected by androgenic alopecia in the absence of grafting. We also often treat these native areas with microneedeling and add thrombin to help activate the platelets in the PRP in areas of native hair that are not grafted. Again this practice has improved coverage in some, but we do not have statistically significant data to support our findings yet. A study in Korea showed that the PRP treated side resulted in faster graft growth than the untreated side of the grafted recipient area. Though I have not specifically evaluated this Korean finding, I have not seen confirmation of this Korean PRP study in my anecdotal evaluations.
    As another example I had one patient who underwent a large session of body hair transplantation. He had excellent growth of his beard hair, but his chest hair did not grow well. In a follow up procedure, I treated his donor scars with chest hair, but this time injected the scars with ACell/Saline 1mg/cc and PRP. The chest hairs grew well this time and grew faster than areas treated with PRP alone with chest hair as well as beard hair. Did the Acell, PRP injections promote a better yield of body hair and did they promote faster regrowth of the body hair? This is yet another question that needs to be answered.

    I have been slow to release my findings simply because it is too early and I do not want to stimulate irrational exuberance. We may not be able to confirm these findings though I feel very comfortable stating donor healing will be better with FUE extraction sites treated with Acell.

    In summary, I have found the following, but I have not clinically confirmed them:

    1. ACell plus PRP can induce improvement in coverage of native hair. Further evaluation is needed though Joe Greco’s findings combining PRP and an ECM are similar in terms of improved coverage.

    2. ACell in the donor extraction sites can improve the healing of these extraction sites, reduce hypopigmentation, and induce follicle regeneration of follicles in extraction sites. This will require further evaluation and study. These are simply preliminary findings without scientific confirmation as yet.

    3. I have not seen any benefit yet from treating grafts with ACell prior to implantation, but it may improve the survival rate of some grafts and some hair. This will need further evaluation.
    4. A combination of ACell and PRP seems to help speed up body hair growth and improve body hair yield in some patients though this needs further evaluation and confirmation.

    Despite these initial findings, it is too early to make any firm decisions regarding ACell with respect to FUE. While initial findings are impressive, we still need to discover a better deliver method to the extraction sites.


    I remain highly skeptical of all this. Body hair has taught me to be careful with any predictions with regard to new treatment modalities. My single criticism of Dr Woods is that he practiced body hair transplantation for many years, but did not reveal that the results were not consistent. Such a revelation would have been important information to both physicians and patients. His failure to report this was negligent in my opinion. If he has a method, which I can not imagine, that results in consistent yields from body hair, then he has an obligation to present such a method. My first body hair transplants were a great success, but some follow up transplants resulted I poor yields and a poor coverage. Perhaps a combination of Acell and PRP will improve results, but it is too early to make any predictions based on a limited number of results. PRP alone does seem to speed the healing of body hair extraction sites including the beard, however.
    I have no way at this point of determining if the ACell results are simply anecdotal findings. I need more patient follow up, which is difficult when most of your patients come from out of state. For this reason, I have been very cautious in my reports on ACell because I know all to well what can happen from irrational exuberance. All patients with limited donor areas want the Holy Grail. This is what body hair was supposed to be. It turned out that it was not.

    A Review of Dr. Cooley’s Reports on Acell
    I called Dr. Jerry Cooley in September to discuss his results and to relay my experience. I also published some of my findings in September on the Internet. Dr. Cooley was very helpful. My understanding from that conversation was that he noted the strip scars were not as wide when treated with ACell. Interestingly, he did not mention this in his published Internet presentations, but he did say that it made a good closure better presumably because the scar was softer and easier to excise in follow up strip procedures. He did state that ACell will not save a bad closure, but fails to note that the majority of strip scars are not ideal, fine lines. Rather they are usually 2 to 3 mm wide with a hairless gap. This is normal healing and ACell will not prevent or treat it based on his findings. The bad closures he refers to are simply bad technique. In other words, if you take out too much tissue such that you are forced to close under excessive tension, the scar will be wider than 5 mm in width. Scars up to 5 mm in width are completely normal and simply reflect the unpredictability of strip scars in terms of width even when closed properly by skilled physicians. He also relayed that they scars were more normal in consistency (softer) in punch scars and in strip scars. He did not discuss hair plucking with me during this phone call.

    I did review Dr. Cooley’s abstract for Boston. I did not see any results in this manuscript. I then fastidiously reviewed what he has published on the Internet. I studied all his photographs and presentations carefully on both HTN and Bald Truth. I also considered his conclusions based on the results he presented. I would like to express my thoughts with regard to what he has published. First, I do not feel he has shown that plucked hairs grow better with ACell or without ACell. He has not shown that plucked hairs that result in growth in the recipient area also regrow in the donor area. It is impossible to show that the donor area heals better to feel and he has not shown that scars heal better in other regards due to ACell. He has not shown that transected hairs in a punch wound grow better with ACell. He has shown that plucked hairs do produce some yield, but we have known this since the Dr. Hitzig presentation in 2004 in New York. We have also known that plucked hairs don’t always grow and that this method of treatment was never popularized due to the inconsistencies in growth. He has shown that plucked hairs often result in a finer hair diameter even with ACell treatment. He has failed to provide conclusive evidence that grafts tainted with ACell result in more “robust” growth. I do feel he has some evidence that punch biopsy healing is better in the presence of ACell. In other words, I fail to see any reason for irrational exuberance at this time with regard to “autocloning” as there is no evidence what so a thing occurs or exists. Furthermore, the yields from plucking hair may indeed be worse than transplanting hair. We already know the hair is finer so where’s the benefit especially if there is less than 100% regrowth in the donor area and less than 100% yield in the recipient area?

    If Dr. Cooley had wanted to show that plucked hairs treated with ACell resulted in better growth, he should have treated two boxes in a completely bald crown. One box should have contained ACell treated plucked hairs while the other box should have contained non-treated plucked hairs. He did not do this. What he did was treat plucked hairs with ACell and then implant them into hair bearing areas. The before photographs were over exposed with light, which makes the areas look more bald than they are. The after photos were less well exposed, which makes them appear to have more hair. This technique will always make the after photos appear to have more hair. In addition, because he chose to treat hairy scalps, one must be aware that that styling can make a difference. Therefore, I feel it is impossible to evaluate any of his plucked hair comparison photographs. This is not to suggest that there was no growth from the plucked hairs. Rather it is impossible to discern how much growth there was from the plucked hairs. Since Dr. Cooley did not perform a comparison study of ACell treated Vs. non-ACell treated plucked hairs, it is impossible to determine whether ACell had any effect on the growth of plucked hair. This is not to take away from the efforts of Dr. Cooley. Rather, I wish to attenuate the excitement of patients who are enticed by the unscientific findings of Dr. Cooley and Dr. Hitzig, whose presentations were directed primarily at the lay public. Furthermore, there are other physicians who have irrationally interpreted these results as a major scientific break through similar to cloning when in fact there is no scientific data to support such illogical interpretation by physicians.

    Dr. Cooley stated that his initial study on plucked hair treated with ACell resulted in a 20% yield. As he became better at plucking hair, his yields increased. I surmise that he became more adept at plucking intact follicles. Intact follicles or nearly intact follicles are known to grow in the absence of ACell. In other words, he has only reported that he is able to improve survival of the plucked follicles through improved technique in plucking. He has not shown that improved plucking technique and ACell result in a better survival. Again, he did not evaluate the results of improved plucking with Acell tainting in comparison to improved plucking without Acell.

    Dr. Cooley suggests that ACell will improve the survival of transected follicles. While I believe this is possible, transected follicles are known to survive in the absence of ACell. In other words, he has not proven that ACell will improve the survival of transected hairs. All he has shown is what we already know. Transected hairs are capable of regeneration. Whether ACell had any affect on this regeneration, we cannot predict, as he did not set up a study to evaluate the difference in survival rate for transected hair with and without ACell.

    Dr. Cooley suggests that ACell can improve the appearance of strip scars. He has not proven this. He does state that strip scars are pink following treatment with ACell due to angiogenesis. Well, strip scars are always pink following surgery with or without ACell. Moreover, strip scars can stay pink or red indefinitely or permanently without ACell. Therefore, I don’t have any idea what he is alluding to when he mentions an association between a pink scar following treatment with ACell. Dr. Cooley states that the line of hypopigmentation persists following strip surgery treated with ACell. Therefore, the only benefit appears to be a softer feel to the strip scar. Well performed strip surgery in the absence of hypertrophic scarring does not result in a palpable or noticeable difference in the donor area. Hence, I have no idea what he is eluding to with regard to a better feel. In fact, I often have a difficult time finding my strip scars and certainly cannot feel a change in “feel” as I run my fingers through the vast majority of my strip scars. There is a way to quantitatively assess the hardness of scars treated with ACell, but all Dr. Cooley offers is a subjective assessment that I do not understand with regard to most of my patients. What he needs to do is a force comparison test measuring the Newtons of force required for a sharp instrument to penetrate both the Acell treated and the non-Acell treated scars and then statistically analyze the data. He did not do this. Dr. Cooley suggests that ACell can make a poor closure better, but presents no evidence to support this conclusion.

    Dr. Cooley also states that strip scars tend to be wider with tight closures. Taking out a wider strip than the scalp allows does have a propensity toward wider scars. Never the less, patients with tight scalps and resulting tight closures based on their tight scalps tend to have the finest scars. In other words, as long as you do not over extend the width of your excision in a tight scalp, the scar will tend to be fine. Loose scalps on the other hand usually close with minimal tension yet such loose scalps are the ones most prone to a wide scar. This is a basic tenet to strip surgery. Acell should not have an overall impact on this biologic predisposition. The suggestion by Dr. Cooley to the lay public is that as long as the physician does not close with tension, a wide scar is not probable. Such a conclusion is inaccurate on his part as he implies that the width of a strip scar is dependent on physician technique and judgment. Loose scalps closed under minimal tension are the most prone to a wide strip scar. Tight scalps closed under acceptable tight tension are least prone to wide strip scars. Certainly, if a physician takes a 2 cm (almost one inch) wide strip when the donor area allows for only 1 cm due to the tightness of the scalp, the patient may form a wider strip scar. This would be poor physician judgement. Still a patient with a loose scalp may allow for a 2 cm wide excision that closes under minimal tension, yet the patient may form a wide strip scar. In other words, Dr. Cooley has not expressed all the factors involved in the width of strip scars to the lay public. Furthermore, Dr. Cooley did not discuss other parameters and their affect on the width of the strip scars in his presentation. For example, he did not discuss the tension of the scalp, the width of his excisions, the use of a double layer closure, or the use of a trichophtic closure. In essence, his lack of information makes his conclusions worthless to the medical community and misleading to the lay public.

    Dr. Cooley states that ACell in FUE extraction sites improves the healing, but there is no regeneration of hair. In my experience ACell can improve the healing of a FUE extraction site, regenerate some follicles, and reduce hypopigmentation, but Dr. Cooley has not evaluated FUE extraction sites in his presentation. He has evaluated 4 and 5 mm punch biopsy sites, which are 4 or more times larger than an FUE extraction site. In a presentation on the Hair Transplant Network he has taken an approximate 4 mm punch biopsy from the scalp and states that the healing is better with ACell, but there is no regrowth of the hair. He goes on to state that this is a typical FUE extraction site. This is not true. No one I am aware of performs FUE with a 4 mm punch. Frankly, he should retract this statement because it is misleading to the audience it is directed to, the lay public. FUE has never caused the carnage that resulted from this 4 mm punch biopsy. In attributing such donor damage to FUE, Dr. Cooley’s assessment of the healing of a 4mm punch biopsy site could alarm patients considering FUE because an enormous hairless gap was created in the donor area. I think he should correct this statement immediately. How do we know this is a 4 mm punch? We can only assume, but the punch size is approximately equally to one half the diameter of the black circle. The black circle is a 0.5 sq cm reticule that fits on a dermlite. The radius or one half the diameter of this circle is 4 mm. Thus, the punch is approximately 4 mm in size. It is far less likely that ACell will regrow hair in a full thickness punch biopsy where all the stem cells, follicles, adipose, dermis, and epidermis are removed, just as it is far less likely that ACell can promote hair growth in a strip scar where a 1 cm or wider full thickness excision of all the stem cells, follicles, adipose, dermis, and epidermis occurs. In FUE, we are removing only the upper portion of the surrounding tissue. We are not performing a full thickness extraction. The inferior portion of the follicles is eased out. Thus stem cells are left behind. This is most likely why we see some evidence of regeneration of follicles in the donor area using ACell in FUE extraction sites. Furthermore, in FUE only a single follicular group is removed unlike the extraction of multiple follicular groups demonstrated by Dr. Cooley. When you ask Acell to do a little, it can. When you ask it to do more than it is capable of, Acell will not. You can regrow the tip of your thumb, but you are not going to regrow an arm amputated at the elbow with Acell. Similarly with Acell, you might regrow a single follicular group extracted with a 1 mm minimally invasive FUE punch technique such as I practice, but you are not likely to regrow multiple follicular groups extracted via a full thickness skin biopsy using a 4 mm punch that harvests up to 15 follicular groups collectively at one time.

    Dr. Cooley has shown a reduction in the hypopigmentation that is characteristic with 4mm punch grafts or biopsies. He has demonstrated that Acell may improve the appearance in these biopsies. My findings suggest that Acell improves the healing of FUE extraction sites. Both Dr. Cooley’s 4 and 5 mm wide full thickness skin biopsies, as well as, my evaluations of FUE minimally invasive extraction site healing lack statistically significant data to support their findings. Never the less, they are corroborative findings in that hypopigmentation is reduced and the resulting scar is more normal in appearance. Both need more thorough study, however the cumulative data is positive.

    Dr. Cooley also states that the plucked hairs are finer in diameter. In other words, they will not cover as well as transplanted hairs that are thicker in diameter. Plucked hairs will more resemble body hair in their potential coverage as body hair tends to be finer. The only reason to consider plucked hair is if it were to increase the potential donor area hair. Has Dr. Cooley shown that successfully plucked hairs that grow in the recipient area also grow back in the donor area? No, he has not. In fact his one example of donor regrowth was on one of his staff members, a female who wanted eyebrows. How many hairs did he pluck for an eyebrow hair transplant? I did not see many grafts in his example, but lets assume it required 200 hairs in total, as this appears reasonable given Dr. Cooley’s presentation. The growth was quite good though and I think it was the most impressive example of plucked hair growth that he presented. It still does not mean that Acell had any influence on the growth. The improved growth might have been due to improved plucking (intact scalp hairs are easier to pluck than intact beard hairs). Unfortunately, we still do not know if the growth was better due to improved plucking technique or treatment with ACell prior to insertion of the plucked hair. We do know that plucked hair will grow in the absence of ACell as Dr. Hitzig demonstrated as far back as 2000. In the donor comparison shots for this female, Dr. Cooley shows an area at the top of the right ear and behind it. The photograph is so over exposed that they woman’s hair appears blonde. The entire region appears to be void of hair. In the center of this circle of hairlessness, is a needle holder that obscures the view of the central plucked region. When I first examined this photograph, my assumption was that the patient would have been upset to have so much hair plucked because it left a large bald area. Closer evaluation shows that the area really looks fully plucked only due to overexposure by the camera settings (F stop and ISO) and lighting rather than due to plucking hair. The follow up photo shows a woman with brown hair (as opposed to blonde hair) because the photograph is not over exposed. The region in the donor area that is depicted is above the area that was plucked. The two areas are entirely different regions in the donor area. Yet, we are to believe that the hair that was plucked grew back. Suppose that you pluck 200 hairs to transplant to the eyebrows. Do you honestly think you could identify the identical 200 hairs you plucked a year later so that you could verify that they grew back? Absolutely not! In other words, Dr. Cooley has not demonstrated that successfully plucked hairs that grow finer in the recipient area have the capacity to also regrow in the donor area. In other words, there is no demonstrated benefit from plucking hair. You may only deplete your donor area in an effort to grow finer hair in the recipient area. The whole concept of autocloning is merely an aberration or a slight of hand based on photographic manipulation.

    With regard to beard hair, I have evaluated Dr. Cooley’s photographs closely. Only a single hair in all his examples resembles a typical beard hair graft. The remaining examples have fine and straight hair. These are not typical for beard hairs and cause concern on my part as I have considerable experience grafting beard hair. Beard hair grafts tend to grow wavy and the hair is much coarser than scalp hair. If you put a beard hair graft beside a single scalp hair graft, you would see that beard hair is about twice the diameter of a scalp hair. Furthermore, the grafted beard hair wave or curl is quite distinguishable from finer straight grafted scalp hair even when the hair is wet. When I compare the beard hair side of Dr. Cooley’s photographs to his scalp hair side in the same patient, I do not see any difference in the quality of hair. As such I can conclude only three possibilities. One is that the beard hair he transplanted lacked the normal characteristics of scalp hair, which is unlikely as he presented several examples that lacked the typical appearance of beard hair. The second is that plucking results in a modification of beard hair such that it is finer and lacks the characteristic curl or wave. In this scenario the beard hair would produce less coverage than a typical beard hair graft. The final possibility is that the beard hair did not grow at all. Regardless of the possibility, it is clear that plucked beard hair does not cover as well as transplanted beard hair. Furthermore, there is no evidence that a plucked beard hair grows back at an acceptable yield. Dr. Cooley did present one patient with a bald vertex who grew a single beard hair. This would have been his best option to show that Acell had an impact on plucked hair survival. He also could have demonstrated the survival rate for both beard and scalp hair with and without Acell. Instead, all he did was biopsy the single beard hair that he depicted to show that a transplanted hair has a normal expected histological structure, which one would expect of any transplanted hair. It is a shame that he missed the opportunity to present more valuable information with this patient. One note for Dr. Cooley is that the non-growing beard hairs are foreign bodies. He needs to remove these as they will ultimately lead to cyst formation and can affect the yield of his transplant. These are dead hairs and need to be removed. There is no reason to wait for a growing hair to expel these dead hair, foreign bodies. These dead “whisker hairs” are potentially damaging to the transplant so Dr. Cooley needs to remove them as opposed to be intrigued by them.

    Finally, Dr. Cooley suggests that grafts treated with ACell result in more “robust” growth. He presented two examples. One appeared to have no hair loss and the follow up photograph after one year simply presented a different styling option along with roots that needed bleaching. The second example was of a gentleman who got a result consistent with the number of grafts transplanted. The before photos were with wet hair. The after photos were with dry hair. The before photos had the hair styled back to conceal a balding crown and expose loss in the front. The after photos had the hair combed forward, which exposed a balding crown and made the front look thicker. The overall result was consistent with the number of grafts placed. Moreover, the patient entered into the procedure with a retained frontal hairline and a retained frontal forelock, which always make amy result look better than it would had he started with no pre-existing hair on the frontal hair line. There was also a consideral amount of pre-existing hair in the entire grafted area, which is additive to any hair transplant result. His follow up comparison showed nothing to suggest more “robust” growth of the grafts.

    In final summary,

    1. There is evidence that ACell improves FUE healing and full thickness 4 mm punch graft healing in terms of skin color.

    2. There is evidence that ACell can regenerate hair in FUE extraction sites, but more work is necessary to insure this is not an isolated anecdotal occurrence.

    3. There is no evidence that ACell improves the growth of plucked hair.

    4. There is no evidence that ACell makes the growth of transplanted hair more “Robust”.

    5. There is no evidence that ACell improves strip scar appearance.

    6. There is qualitative evidence that ACell improves the feel of a strip scar in some instances, but it is difficult to understand how Dr. Cooley arrived at this conclusion .

    7. There is no evidence that ACell induces transected hairs to regrow, but it might.

    8. There is no evidence that plucked hairs regrow in the donor area, but they might.

    9. There is evidence that plucked hairs will grow finer and result is poorer coverage than transplanted hair.
    10. There is no evidence to conclude that “autocloning” occurs.

    What Can We Expect from the Use of Acell with Plucked Hair?

    There currently is irrational exuberance with regard to ACell. We need some real scientific data to support the benefits. In the interim, patients need to exercise caution with regard to plucking hair and the use of ACell. Such efforts may not result in more hair and may even jeopardize the potential coverage you can get by reducing the diameter of the hair shafts and reducing the regrowth of follicles in the donor area. IN OTHER WORDS YOU COULD BE IN WORSE SHAPE BECAUSE YOU UNDERWENT A PLUCKED HAIR SESSION OF “AUTOCLONING” USING ACELL. There are no studies yet to document the yield you can expect from plucking hair in the recipient area and no studies to show that it is safe to the hairs that are plucked from the donor area. Until Drs. Cooley and Hitzig can produce more scientific and statistically conclusive data, patients should proceed with caution with regard to plucking hair. My recommendation is that they avoid the plucking session with or without Acell altogether.

    Now that I’ve discussed the scientific conclusions one may draw from the use of Acell, we should consider the limited probability that a successfully plucked hair will regrow in it’s donor region. Recall that Dr. Cooley stated his initial plucked hair success rate was only 20%. He noted an improvement in his yield as he improved his plucking skills. He also demonstrated the difference between a good plucked hair and a poor plucked hair. Essentially, a good plucked hair encompasses the entire follicle with the exception of 1/6th of the external internal (lower) portion of a follicle. The plucked hair is almost a completely intact follicle. What remain behind in the donor area are the lowest portion of the external root sheath, a very thin sheet of the internal root sheath adherent to the external root sheath, and the dermal papilla. At best only 1/6th of the entire follicle remains behind the donor area. With “autocloning” the nearly intact follicle is tainted with Acell. The residual tiny fragment of the follicle that remains in the donor area is not treated with anything other than nature’s magic wand. Why would anyone think that this tiny residual fragment of the follicle would result in nearly 100% regrowth? Perhaps if they treated the donor area with Acell, as well, we might see an improvement in the yield. Unfortunately, Dr. Cooley has already shown that plucked hairs that regrow in the recipient area are finer than transplanted hairs and finer than the original hair. The most important factor in terms of coverage is the diameter of the hair because diameter has an exponential affect on coverage. Consider that doubling the diameter of a hair quadruples the volume a hair provides at any length of growth. Halving the diameter reduces the volume to 1/4th of the donor hair. Doubling the number of hairs grafted simply doubles the volume of coverage. Thus, the last thing we want to do is reduce diameter except on in some instances on the hairline or specialty grafting such as the temple points because coverage is adversely affected in an exponential manner.

    Now let’s turn our attention to the data with transected single hair grafts obtained by FUE and their growth in the recipient area, as well as their regrowth in the donor area. Suppose you transect a follicle at the lower 2/3 such that you transplant the upper 2/3 and leave the lower 1/3 in the donor area. The growth rate of the transplanted upper 2/3 without Acell would be 41.3% with a range of 33.3-53.3%. The growth rate of the lower 1/3 would be 53.3% with a range of 46.6-80%. In hair plucking you are removing more than 3/4ths of an intact follicle. You are leaving behind only the lower 1/6th of the ectodermal portion of the follicular sheath and the dermal papilla. In other words, you have at least a 41.3% chance of regrowth of the transplanted portion without Acell. With Acell tainting you might increase this yield, but the hair would grow in finer and may lack curl or wave. Transection at the lower 1/3rd will result in a yield of 53.3%. With plucking however, you are not leaving all the cellular components of the lower 1/3rd. Rather, you are leaving only the lower 1/6th of the external root sheath and the dermal papilla and you are not adding Acell to the donor area. In other words, you should have less than a 53.3% chance of regrowth of hair in the donor area. Why do I say less than a 53.3% probablility? Simply because survival of a single hair scalp follicle in the donor area decreases as you reduce the residual fraction of an amputated hair follicle, which is based on this same single hair transection study in FUE. If you leave a residual lower 2/3rds of the follicle in the donor area the survival rate is 84% (range 66.6-93.3%). If you leave the lower ½ of the follicle in the donor area, the survival rate of the lower ½ is 68% (range 53.3-86.6%). Again, if you leave the lower 1/3rd of the follicle in the donor area, the survival rate of the lower 1/3rd is only 53.3% (range 46.6-80%). With plucking you are leaving only the lower 1/6th of the external root sheath, a tiny layer of adherent internal root sheath, and the dermal papilla. This suggests that you might regrow a fraction of the plucked hairs (perhaps only 50% of the plucked hair) and what regrows in the recipient area will be finer. You also might regrow at best 50% of the donor hair and it might be finer too. Alternatively, in the donor area you might regrow far less of the hair that was plucked from the donor area. With beard hair, Dr. Cooley has suggested that the yield of plucked hair is less than with scalp hair and what grows is finer. We might assume from this finding that the yield of regrowth in the beard donor area is even less than the yield of scalp hair in the donor area.
    Suppose you pluck 100 hairs, taint them with Acell, and transplant them to your totally bald recipient area. You could expect approximately 50 or more finer hairs to grow in the recipient area. You also might expect fewer than 50 finer hairs to regrow in the donor area where no Acell is applied. You very well could wind up with 50 finer hairs in the recipient area and 40 finer hairs in the donor area. Of course you very well could wind up with a much lower yield in the donor area as so little formative tissue remained in the donor area. In essence you might expect to have no more the same number of hairs as you started with (100) with ½ in the bald recipient area and less than ½ in the donor area. Unfortunately, you could expect that all remaining hairs would be finer. As such, you would be worse off than had you done nothing what so ever because the remaining hair would be finer. Since you might not even regrow 50% in the donor area in, you would be much worse off than had you practiced traditional FUE or strip surgery.

    Beard hair obtained by FUE heals remarkably well with little evidence of extraction when proper technique is followed. Beard hair transplanted to the scalp from FUE has a mean survival rate of about 60% though higher and lower yields are possible. Therefore, you are more likely far better off to obtain beard hair from FUE than from plucking beard hair because the survival rate is acceptable and because the quality of the hair is far better than is possible from plucking. Of course tainting beard hair obtained by FUE with Acell and pre-treating the recipient area with PRP might improve the survival rate of beard hair. This is something that should be studied. In addition, the healing along with the potential for regeneration of the donor hair by adding Acell to the extraction sites seems to make this modality a far superior route.

    The physicians who are enamored with plucked hair tainted with Acell are the same ones who have worried about the survival rate of “skeletonized” follicles obtained by FUE. What they fail to recognize is that there are minimal requirements for follicle growth. This includes an intact dermal sheath surrounding the follicle. FUE grafts are not skeletonized follicles. They are the components required to produce a hair follicle. Surrounding adipose that is present from strip surgery only adds to the volume of tissue that is extracted from the donor area and the volume of tissue implanted in the recipient area. This adipose adds nothing to the potential for follicle regrowth. With “autocloning” you are disassembling the follicle such that it not longer has the minimal requirements for growth and praying that Acell will make up the difference. What is left in the donor area is a mere fragment of the original follicle, yet these FUE skeptics feels this tiny residual fragment will routinely regrow hair in the donor area. Their conclusions defy logic. My suggestion for those considering “autocloning” is for them to proceed with caution at this point. I would not have more than 500 grafts placed in the initial procedure. Then you should evaluate the results both in terms of your expectations and those expectations of your physician twelve months later. Only if you are both happy with the results, should you enter into a follow-up procedure of “autoclonning”. My personal feeling is that “autoclonning” will result in unacceptable results, however. I hope I am incorrect in this assumption, but logic and experience dictate that my predictions are accurate.
  • 12-06-2010 05:10 PM
    wolvie1985
    Hahahahahaha. With respect, please take your infamous ego and sour grapes somewhere else, doctor.

    Rather than try to help advance the science of using plucked hairs with ACell yourself, you have chosen to sit in the backseat and criticize the driving of others without having taken the wheel yourself. Your 'experience and knowledge' is based on old methods and science that predates the application of ACell to plucked hairs, or combining the ACell with arterial blood.

    You say: "With “autocloning” you are disassembling the follicle such that it not longer has the minimal requirements for growth and praying that Acell will make up the difference. What is left in the donor area is a mere fragment of the original follicle, yet these FUE skeptics feels this tiny residual fragment will routinely regrow hair in the donor area."

    First of all, what is left in the donor is the follicle that has simply been plucked. Not a fragment. Unless you know something that the entire hair removal industry has yet to discover, plucked hairs grow back. Ask any woman who has had a brazillian.

    Secondly, no need to 'pray' that Acell makes up the difference. It DOES. Cooley and Hitzig have DONE IT. And they say it works and have proven it works. You have not even tried their methods, and yet you think you are entitled to say they are wrong.

    You also suggest that the Acell hairs that grow in the recipient area are thinner than regular hairs. Cooley and Hitzig have never said this.

    CIT is the new laserdisc. Please deal with it instead of crapping all over your colleagues' ingenuity and courage.
  • 12-06-2010 05:40 PM
    tbtadmin
    Quote:

    Originally Posted by wolvie1985 View Post
    Hahahahahaha. With respect, please take your infamous ego and sour grapes somewhere else, doctor.

    Rather than try to help advance the science of using plucked hairs with ACell yourself, you have chosen to sit in the backseat and criticize the driving of others without having taken the wheel yourself. Your 'experience and knowledge' is based on old methods and science that predates the application of ACell to plucked hairs, or combining the ACell with arterial blood.

    You say: "With “autocloning” you are disassembling the follicle such that it not longer has the minimal requirements for growth and praying that Acell will make up the difference. What is left in the donor area is a mere fragment of the original follicle, yet these FUE skeptics feels this tiny residual fragment will routinely regrow hair in the donor area."

    First of all, what is left in the donor is the follicle that has simply been plucked. Not a fragment. Unless you know something that the entire hair removal industry has yet to discover, plucked hairs grow back. Ask any woman who has had a brazillian.

    Secondly, no need to 'pray' that Acell makes up the difference. It DOES. Cooley and Hitzig have DONE IT. And they say it works and have proven it works. You have not even tried their methods, and yet you think you are entitled to say they are wrong.

    You also suggest that the Acell hairs that grow in the recipient area are thinner than regular hairs. Cooley and Hitzig have never said this.

    CIT is the new laserdisc. Please deal with it instead of crapping all over your colleagues' ingenuity and courage.

    We understand that this is a very passionate topic, and all opinions are certainly welcome, however, we ask that our forum users post all commentary in a respectful manner.

    Thank you.
  • 12-06-2010 06:00 PM
    wolvie1985
    You're right. I apologize for the tone. But I stand by the substance of my comments.
  • 12-06-2010 07:03 PM
    Westonci
    Im also wondering where dr Cole got his info from regarding the "supposed" plucked scalp hairs being thinner than normal scalp hair. Im sure that Doctor Rassman or Doctor Bernstein as well as others who attended the ISHRS meeting in Boston and spoke with Jerry Cooley would have heard about it and mentioned it in their analysis, but they have not heard of this yet.
  • 12-07-2010 08:12 AM
    Winston
    I think it’s good to have a balanced perspective and not to over hype any of these new breakthroughs, but in my mind there is only minor scientific data coming from either side of this discussion. So far we have some decent data coming form Dr. Cooley and Dr. Hitzig, and more of an opinion, based of his observations, coming from Dr. Cole. I guess only time will tell.
  • 12-07-2010 08:41 AM
    Bakez
    Unfortuntely, what Dr Cole has posted is what I suspected. Obviously he has backed it up, but just based on pure logic I feel as though this won't work, and I sort of doubt that 'A-Cell' even does anything at all - is there actually any proper evidence at all that is has been used anywhere succesfully?
  • 12-07-2010 01:11 PM
    wolvie1985
    "The whole concept of autocloning is merely an aberration or a slight of hand based on photographic manipulation."

    The only thing manipulative is Dr. Cole's manifesto which I suggest is designed to undermine this massive advancement and slow down the massive stampede away from his own techniques. I'm sorry, it's hard to standby and let this go unchallenged.

    Dr. Cole: tell us where and when Dr. Cooley told you that the autocloned hairs grow back thinner. That is a very serious claim and needs to be substantiated.

    Either confirm this claim or apologize for this misinformation.
  • 12-08-2010 07:04 AM
    CIT_Girl
    Wolvie1985, Dr. Cole does not have a whole lot of extra time to check-up on the forums but I think I can answer that question for you.

    If you look at the 4th in the series of Dr. Cooley's video presentations http://www.iahrs.org/news/dr-jerry-c...tion-part-3-4/, around 6:40, he shows a photo of a combination of FUE and plucked grafts and says verbatim "If you look at the photograph on the left, the close-up photograph, some of those thicker hairs are the FUE grafts and then some of the finer hairs within it are the plucked hair grafts".

    Plucked hairs are essentially transected follicles and though transected follicles can grow when transplanted (as long as they are nearly intact), the resulting hair will generally grow in finer due to the damage. Despite all the hype over 'autocloning', there is nothing truly novel about this.
  • 12-08-2010 11:42 AM
    wolvie1985
    Dr. Cole has manipulated this section of the presentation. Those hairs were finer because they were just starting to grow in - like all transplanted hairs do. Dr. Cooley has confirmed repeatedly that those fine hairs mature into normal thickness and that 'you cannot tell the difference between an autocloned hair and a regular one'. Dr. Cole should have done some further research into the matter, or further discussed his 'concern' with Dr. Cooley, rather than cherrypicking a slide and twisting it to suit his agenda. Your contention that there is nothing novel about this is both hilarious and disturbing.
  • 12-08-2010 12:44 PM
    Gubter_87
    CIT_Girl:

    Okay so if we all agree that plucked hairs can actually form functional follicles in rare cases.
    Wouldn't you agree that if A-cell can be used to raise the rate of success to about 75 %, that it would definately be a major breakthrough.

    I am 23 and am about NW4, with thinning in a NW6-7 pattern, not the average ideal candidate for a traditional hair transplant.

    However if plucked hairs can be used (even if they grew in thinner than regular hairs, which is something that Dr. Cooley does not seem to have observed) maybe even in conjunction with a regular transplant - that could change everything especially for all the young balding guys out there.
  • 12-08-2010 02:13 PM
    CIT_Girl
    Gubter_87, I didn't mean to come across as flippant about the potential that this could be an amazing breakthrough for hair loss sufferers- I personally would love that as much as anyone. I just don't have my hopes up, with the evidence that has been presented so far, that this will be THE answer to everyone's prayers. By saying there was nothing 'novel', I meant in the notion that transacted follicles (plucked hairs) can regrow. We'll have to see side-by-side studies (on a bald head) to know for sure whether ACell actually has the ability to affect the survival rate of plucked hair. Further studies (or explanation from Dr. Cooley) are also needed- for example, to determine what constitutes a viable plucked hair: how much of the formative tissue must be left behind to achieve regrowth in the donor area and how much must be removed to actually get it to grow in the recipient area?- before people get too emotionally invested in this 'breakthrough'.
  • 12-08-2010 02:31 PM
    Gubter_87
    Unless Dr. Cooley is lieing, he has been able to achieve a survival rate of 75 % for plucked hairs. If it is because of A-cell (which is probable) then great. However if this has nothing do to with the use of a-cell, and the good succes rate is just because of Dr. Cooleys plucking technique - then even better! I don't really see the issue.

    Fact is if Dr. Cooley technique achieves these results - it is a major breakthrough for hair loss sufferers as it greatly increases the donor making it basically infinite.

    Sure - we need to see more evidence. But I see no reason to doubt Dr. Cooleys initial findings as he is a reputable hair loss suregon.
  • 12-09-2010 04:11 AM
    ejj
    just my opinion , if i only got 75% growth i would be pretty upset !
    regards
    ejj
  • 12-09-2010 06:05 AM
    meridius
    Quote:

    Originally Posted by ejj View Post
    just my opinion , if i only got 75% growth i would be pretty upset !
    regards
    ejj

    Really? I would be thrilled if I got 75% growth from plucked hairs. That would be much more valuable than 100% growth from FUE or strip because the donor reserve would still be intact.

    As long as the vast majority of the plucked hairs grow back which they should, I really cannot see a reason to be this dismissive of the new approach.

    And I certainly cannot understand how someone can justify that it is okay for the donor hairs to be taken out in FUE not to grow back ever again in the donor area, and then make such a big deal about the plucked hairs coming back weaker. Is it because the survival rate is higher for FUE? What if this new method comes close or even better catches up with it? Given that it already achieves 50-75% despite being so new, why not?
  • 12-09-2010 09:56 AM
    wolvie1985
    The autocloned hair does not come back weaker. A simple email or phonecall to Dr. Cooley's office would confirm this. The donor grows back and the recipient grows in approx. 75% of the time. These are the facts that Dr. Cole is trying so desperately to muddy.
  • 12-09-2010 01:04 PM
    Winston
    I don't know why you guys are so up in arms about Dr. Cole’s post, it’s simply his point of view. It doesn't change the fact that Dr. Cooley is still experimenting with Acell and it doesn't change what Dr. Cooley believes about it’s effectiveness. Time will tell if this is the breakthrough that we have all been hoping for.
  • 12-09-2010 02:37 PM
    HairRobinHood
    Quote:

    Originally Posted by Winston View Post
    I don't know why you guys are so up in arms about Dr. Cole’s post, it’s simply his point of view. It doesn't change the fact that Dr. Cooley is still experimenting with Acell and it doesn't change what Dr. Cooley believes about it’s effectiveness. Time will tell if this is the breakthrough that we have all been hoping for.

    Just for instance: A comment like that …

    Quote:

    Originally Posted by drcole View Post
    He did not discuss hair plucking with me during this phone call. He did relate his own personal experience by having his nurse punch into his scalp in an ACell treated area of scar and a non-ACell treated area. He said the punch crunched into the non-ACell scar site while it slid softly into the ACell scar site without making a characteristic crunching noise that is audible to the patient. The ISHRS has issued a position paper. The position paper clearly states that it is the opinion of the ISHRS that only licensed physicians should be punching into the scalp or performing FUE. This is simply food for thought as Dr. Cooley is now the ISHRS president.

    … has absolutely NOTHING to do with “it’s simply his point of view”. Absolutely nothing!

    By the way: Dr. Cole is talking here (quote/comment) about this subject:

    http://www.baldtruthtalk.com/showthread.php?t=3528

    But here I’m talking about that subject – the ISHRS called it “unprofessionally cat fight”:

    http://www.ishrs.org/articles/position-1.htm
  • 12-09-2010 03:16 PM
    HairRobinHood
    "food for thought"
    Quote:

    Originally Posted by HairRobinHood View Post

    But here I’m talking about that subject – the ISHRS called it “unprofessionally cat fight”:

    http://www.ishrs.org/articles/position-1.htm

    "This is simply food for thought", Mr. Cole!
  • 12-09-2010 03:46 PM
    John P. Cole, MD
    New grafts do tend to grow in finer initially, but often take on a thicker diameter as they mature. I would expect a similar course with plucked hair. We’ve had enough time to evaluate hair diameter, but like much of the material Dr. Cooley has presented, he has not taken enough time to draw any conclusions with respect to diameter, and he has not assessed diameter in a scientific manner. Dr. Cooley has not presented any evidence that plucked hairs are as coarse as the donor hair. In fact, one of the few comparison he’s made at all is the scalp plucks to the beard plucks. Here the beard plucks were much finer than traditional beard hair and as fine as the scalp hair plucks. This simply does not occur based on my considerable experience grafting beard hair. In other words, the direct comparison photographs clearly show a finer nature to plucked beard hair grafts. Measuring hair shaft diameter requires specialized equipment if you are going to get reliable results. I own it and would be more than happy to assist Dr. Cooley in a scientific study that evaluated hair shaft diameter. Thus, far, however, Dr. Cooley has presented no scientific evidence that indicates that plucked hairs typically grow in as coarse as the donor hair source. What he has done is say that plucked hairs grow in finer than FUE hair. If he wants to alter this statement, he would need to provide me with scientific evidence that supports his conclusions.

    Many of the results depicted were in their infancy. If something changes in their appearance over time, I would be the first to accept this as an improvement in the technique, but there still would be a complete lack of scientific data. In the mean time, we have direct comparison of grafts obtained by FUE and grafts obtained by plucking. In Dr. Cooley’s own words, the FUE hairs were thicker than the plucked hairs. If the grafts were placed at the same time, then you would expect them to be on a similar maturation schedule. We can leave it to Dr. Cooley to follow his results and evaluate the diameters over time. He can then report them. His goal should be to measure the diameters before transplantation and then again after transplantation. I do not know if he has the equipment to perform this study in his office, but as I stated, I have it in mine.

    What is missing from all these presentations is reputable science. I’ll discuss this as it relates to “autocloning”.

    1. A study must include an introduction, methods, results, and a discussion. The conclusions in the discussion should be based on the results and they should answer the questions you create when you design the study. When you start the study, you must determine what you want to prove. Then you must design a method that will allow you to gather results that will support or disprove your hypothesis. Both Dr. Cooley and Dr. Hitzig skipped the methods, presented unconvincing results, and came to conclusions that were not supported by their results. Their entire effort was flawed from the beginning due to poor scientific method.

    There is no direct comparison of plucked hairs treated with Acell and plucked hairs untreated with Acell in a bald crown. Therefore, not only do we have no idea whether Acell impacted the growth of viable plucked hairs, we also do not know if Acell alone impacted the growth because the grafts were predominately place in hair bearing zones. Isn’t possible that Acell alone induced growth? One must isolate variables if they want to evaluate them individually.
    There is no evidence that hairs plucked from the donor area regrow in the donor area. In order to have cloning, you need to create more than one hair. Not only have the physicians failed to verify this, we have no evidence what so ever that a single hair re-grew in the donor area. Am I the only one who finds this comical? From my perspective I see the advocates eulogize their logic this way. They plucked some hair, put some Acell on it, put the pluck in the recipient area, showed them some growth, and told them it grew back in the donor area. They’ll be too trusting or too stupid to ask Dr. Cooley to show them the proof because of the physician’s reputation. Sure they’ll have to pluck 200 hairs to get 80 that grow, but who cares. Let’s toss in the word cloning and they’ll be so excited that they won’t care that they did not follow a scientific method or prove a single point they made. Bernie Madoff would have loved some guys who swallowed this stupid pill. You might still be able to invest money with Intercytex too. Even body hair works better than their potions, but some people simply become delusional when they hear the words, “hair multiplication or cloning”.
    What are the methods. You can’t have a study without first defining the methods. This includes the technique you use to pluck a hair and what constitutes a viable plucked hair. How are you going to verify that a plucked hair actually regrows in both the recipient area and the donor area? How are you going to identify the plucked hair in the donor area. Suppose you have a two hair follicular unit and one hair is resting in the exodus stage. All you see is a single hair. You pluck it. You come back 3 months later and see a hair. Was that the hair you plucked or the hair that was in the exodus stage.

    Other questions I’d like answered would be the yield. You can’t simply throw out a number and say, I wish I knew the specific number, but I think it is 75%. That’s not science. Furthermore, some cases might have good yields and some might have poor yields. I learned this the hard way with body hair. The same could occur with plucked hair. How many plucked hairs survive with Acell and how many survive without it. If you pluck 100 hairs, how many will regrow in the donor area and in the recipient area. How many hairs do you have to pluck in order to get 100 viable hairs. Do we need to pluck 500 hairs to get 100 that are viable plucked hairs? What happens to the non-viable plucks. What percentage of these non-viable plucks survive in the donor area? Sure we know that plucked hairs can grow back, but we also know that they do not always grow back. Why do women often need eyebrow transplants? Their plucked hairs did not always grow back! Why do people with a compulsion to pluck their hair, trichotillomania, often present for hair transplants? Their plucked hairs did not always regrow. Don’t mislead yourself. Plucked hairs do not always regrow!

    Here is another example of an unscientific study that lacked methods designed to evaluate a hypothesis. With regard to scar width, Dr. Cooley presented one example of a 2 cm wide scar that resulted from another physician. The other physician excised the scar once more and it returned to a 2 cm wide scar. Then Dr. Cooley excised the scar and added Acell. The resulting scar was 6 to 7 mm at 4 months with Acell. The plan was to excise the scar again and hope for an even finer result due to the affects of Acell. My comments are as follows: An acceptable width for a strip scar is 0.5mm to 5 mm. A strip scar that is 2 cm wide is the result of poor physician technique, it is iatrogenic. Dr. Cooley feels that the reduction in the width of the scar to 6 to 7 mm in his hands was due to Acell because the original physician’s attempt at revision failed and produced another 2 cm wide scar. There are multiple factors that can affect the width of a scar revision. In 1993 I began closing my revisions in two layers. In almost all instances, the width of the scar decreased by 50% or more. With every scar revision that I’ve done, I’ve told patients that the scar may resume it’s original width, be wider, or finer. Usually they are 50% their original diameter or less. In fact, I have never revised a scar left by another physician that did not reduce in diameter though I tell every patient the scar could be the same width or wider. The point is that there are multiple factors that can affect the width of a scar other than Acell. If you don’t know the technique used by another physician, you can’t compare your technique to that of the other physician. Examination of a strip scar that was 2 cm in diameter immediately tells me that the other physician did not use excellent technique. Thus you can’t compare the two scar widths based on Acell alone. Furthermore, I can tell from the photos that the revision performed by Dr. Cooley was in multilple layers. Otherwise, the wound would have been much wider than 2 cm rather than finer when he was placing the ACell. Might the use of two layers alone have decreased the scar diameter? Of course. In addition, some physicians attempt to get additional grafts out with a revision. Perhaps rather than excising the scar alone, the original physician excised more than 2 cm and put unacceptable tension on the wound at closure. In other words, we don’t have enough information to make a determination if Acell improved this scar. Closing one side with Acell and the other without Acell using the same method of closure other than Acell would have given us an idea, but we would have required a minimum of 6 months to make the initial observation. Once again, no methods were mentioned and no comparison was performed. The methods were not designed properly to evaluate the hypothesis. We can’t evaluate this result. Never the less, Dr. Cooley drew the conclusion that Acell improved the width of the scar even though the results did not verify the conclusion. All we can do is be happy for the patient as the scar is finer. This too is an immature result, however. Scars do not begin to widen until the 3rd month usually. When they do widen, they continue widening out to the 6th month. We need to wait until at least 6 months to evaluate the results of this closure.

    As an example suppose I want to reduce blood pressure. I could surmise that the sugar in the gum a patient chews is elevating blood pressure because it has more calories, elevating his weight, and increasing resistance on his vasculature. Therefore, I start my patient on sugarless gum and 6 months later we find that his blood pressure drops from 160/110 to 140/80. We then present our findings and conclude that sugarless gum lowers blood pressure because it has fewer calories. What we failed to disclose was that we also routinely put our hypertensive patients on a 1800 calorie per day diet and hire a personal trainer for each patient. Would the drop in pressure be the same without the diet and exercise? Who knows, but we certainly can’t attribute it strictly to sugarless gum once we know all the variables that were not disclosed in the study. The only way to evaluate a single variable is to isolate it and study it under a strict scientific methods. The lack of a scientific method is exactly what we find in all these examples. There are no independent variables. Without isolating the variables we cannot evaluate them.

    I can go back to every example that Dr. Cooley presented and show a disconnect between the results and the conclusions based on a lack of scientific method. The presentation is interesting and nothing more. The conclusions are humorous.

    In the mean time there is no evidence that autoclonging exists. If it did, I would expect Dr. Cooley to cease performing strip surgery altogether and simply pluck hair. I suspect he is a long way from that point as there are simply too many unanswered questions. The most important question is whether anything grows back in the donor area when you take an almost completely intact follicle or of the donor area. What we do with FUE is take out completely intact follicles. In the absence of Acell, they do not grow back in the donor area. In the absence Acell an almost completely intact follicle has about as much chance of regrowing in the donor area as a fully intact follicle. One question he is seeking is whether these nearly intact follicles that would have grown without Acell might not regrow the next cycle. They will follow the same cycle as a fully intact follicle most likely. I’m not sure he understands exactly what he is doing, which is transplanting nearly intact follicles. Acell might improve survival in the recipient area of nearly intact follicles, but Acell is not going to affect the life cycle of a nearly intact follicle, because it is essentialy a normal transected follicle that grew on transplantation and will continue cycling most likely. There is no magic here.

    Now, wolvie, let me make something clear to you. There is no scientific data to prove a single conclusion you allude to. There is no evidence that the plucked hairs grow back at the same diameter as they were in the donor area. There is absolutely no evidence what so ever that anything similar to autoclonning occurs. Dr. Cooley performed no survival studies so there is no evidence that the survival rate is 75%. You seem to have a great deal of difficulty connecting the dots. Read my lips...Dr. Cooley presented no data what so ever to indicate that even a single viable plucked hair grew in both the donor area and the recipient area. I have no idea what your agenda is, but your conclusions are simply a leap of logic or hallucination. We all want to believe hair plucking works including myself, but no one can draw scientific conclusions based on faulty studies. Now, if you want to pull the Dr. Cooley card on me, feel free to have him give me a call or debate me on a forum. We’re not enemies or competitors. We’re colleagues who are both interested in making lives better. I welcome evidence that refutes my position simply because it will improve the possibilities for all individuals with hair loss. If it does not pan out, however, the impact on the finite donor area would be deleterious. Don’t count me to be on the bridge of that ship. In other words, show me the science.

    Suffice it to say that if he is proven accurate, we are all going to stop traditional harvesting methods and start plucking hair. The aesthetic benefits are as valuable as the potential for an unlimited donor supply. There are about 100,000 hair transplants in the USA each year and the majority of them will be plucked hair. They will certainly benefit from technology that expands their donor area while minimizing scar formation. Until then, patients should proceed slowly with this technology. I think 200 plucked hair is a good number for a procedure at this time. We need conclusive science before anyone becomes more aggressive with this technology.
  • 12-09-2010 04:08 PM
    mlao
    It's good to hear both sides of the conversation. I think we should sit back and wait for more results from Doctors Cooley and Hitzig. In addition lets see how the studies that Doctors Bernstein and Rassman are entering into go. I had a consult with Dr. Bernstein once and he seemed to be a very pragmatic individual so I'm pretty sure if he sees promise in the procedure he will say so.
    Until then I will keep on my meds.
  • 12-09-2010 04:53 PM
    gmonasco
    Realistically, this scenario is exactly what you want to see when it comes to medical breakthroughs: researchers who are testing out a new treatment to see if it has potential, and skeptics who are asking the tough questions about whether (and how well) that treatment is actually working.
  • 12-10-2010 02:16 PM
    Jerry Cooley, MD
    I thank Dr Cole for his interest in our work. As I’ve stressed repeatedly, my work consists of preliminary ‘anecdotal’ observations about the use of ACell in hair restoration surgery. Of course it would be nice to have large clinical studies with control groups which would provide a higher level of proof. Any physician who has participated in formal clinical studies knows the difficulty and complexity involved in such work. These are especially difficult with hair restoration surgery, and there are almost no such studies done in our field. The bulk of what we do has developed over time based on the ‘anecdotal’ observations of forward thinking surgeons who went on to share these results with their peers.

    With a product like ACell that is entirely new to our field, most physicians would be lost as to where to begin looking at possible applications within the spectrum of hair restoration procedures. Hopefully our work will provide a starting point for others to do controlled studies. I’m glad Dr. Cole is now working with ACell and is able to share his anecdotal observations with us. That is how progress occurs in our field.

    In reference to “autocloning”, our work continues. As each new patient comes in for followup with positive results, I become more excited about the future of this procedure. None of our patients have complained of thinning in the areas that were plucked, and none of my test sites with plucked hair without ACell subsequently grew hair. Dr. Cole is right that occasionally Dr. Hitzig had success with plucking alone, but the fact that he saw a big difference after he began using ACell and only does it this way now is rather convincing to me that ACell is making a difference. The hair diameter certainly appears normal but I have not scientifically tested that.

    In reference to the many points raised by Dr. Cole, I can sum up my answer by saying, 'time will tell'. I know he has faced similar criticisms over the years in regards to body hair transplants; nevertheless he has tenaciously carried on. That is our intention too.
  • 12-10-2010 04:26 PM
    Gary Hitzig MD
    Skepticism is healthy
    I too thank Dr. Cole for his detailed skepticism. When analyzing his extensive report, one should not miss that he too saw impressive results with ACell in some of his body hair patients. I think Dr. Cooley's message is on target.
    It is very important that ACell be used correctly to achieve optimal (and even satisfactory) results. Suspending ACell powder in saline is not optimal. One of the advantages of PRP and related mediums is that they have high concentrations of Adult Stem Cells. These are the cells that ACell, when in direct contact, converts back to the Active Progenitor Cells and are instrumental in taking over the healing process by duplication instead of scarring. ACell is unique in that it is the only ECM (Extracellular Matrix) that is Bi-Modal and incorporates the recruitment of both Epithelial and Endothelial Cells needed for skin and hair duplication. It also provides a scaffold for the process to occur which is temporary and then disappears allowing the newly recruited cells to do their work.
    ACell also contains a multitude of Growth Factors as well as proteins needed to support Hair Growth-this is most likely why it has dramatically increased plucked hair survival. Plucked hairs do not grow thinner-at least not in my experience of over 10 years with them.
    Let me also make it clear that my original and still use of plucked hairs has been for repair of old transplants with depleted donor areas or small areas of transplant fill-ins. It is a tedious procedure although improving as our techniques do.
    My greatest fear has been the worry that judgements will be made of a discovery based on improper employment of it. Sometimes it is easier to shoot the product than the surgeon.
    I applaud Dr. Cole for his intense scrutiny, but the "empirical" results, as Dr. Jerry Cooley has said, are very real and multiplying daily.
  • 12-10-2010 05:58 PM
    Westonci
    Quote:

    Originally Posted by Jerry Cooley, MD View Post
    I thank Dr Cole for his interest in our work. As I’ve stressed repeatedly, my work consists of preliminary ‘anecdotal’ observations about the use of ACell in hair restoration surgery. Of course it would be nice to have large clinical studies with control groups which would provide a higher level of proof. Any physician who has participated in formal clinical studies knows the difficulty and complexity involved in such work. These are especially difficult with hair restoration surgery, and there are almost no such studies done in our field. The bulk of what we do has developed over time based on the ‘anecdotal’ observations of forward thinking surgeons who went on to share these results with their peers.

    With a product like ACell that is entirely new to our field, most physicians would be lost as to where to begin looking at possible applications within the spectrum of hair restoration procedures. Hopefully our work will provide a starting point for others to do controlled studies. I’m glad Dr. Cole is now working with ACell and is able to share his anecdotal observations with us. That is how progress occurs in our field.

    In reference to “autocloning”, our work continues. As each new patient comes in for followup with positive results, I become more excited about the future of this procedure. None of our patients have complained of thinning in the areas that were plucked, and none of my test sites with plucked hair without ACell subsequently grew hair. Dr. Cole is right that occasionally Dr. Hitzig had success with plucking alone, but the fact that he saw a big difference after he began using ACell and only does it this way now is rather convincing to me that ACell is making a difference. The hair diameter certainly appears normal but I have not scientifically tested that.

    In reference to the many points raised by Dr. Cole, I can sum up my answer by saying, 'time will tell'. I know he has faced similar criticisms over the years in regards to body hair transplants; nevertheless he has tenaciously carried on. That is our intention too.

    Dr. Cooley why not add WNT proteins to the mix of Acell/PRP. Its been shown by Dr. Cotsarelis and Histogen and Angela Cristiano and others that injury+WNT proteins cause new hair growth.
  • 12-10-2010 06:11 PM
    HairRobinHood
    Quote:

    Originally Posted by Westonci View Post
    Dr. Cooley why not add WNT proteins to the mix of Acell/PRP. Its been shown by Dr. Cotsarelis and Histogen and Angela Cristiano and others that injury+WNT proteins cause new hair growth.

    And wherefrom should he get Wnt proteins? In a supermarket? :rolleyes:

    http://en.wikipedia.org/wiki/Wnt_signaling_pathway
  • 12-10-2010 06:29 PM
    Westonci
    Quote:

    Originally Posted by HairRobinHood View Post
    And wherefrom should he get Wnt proteins? In a supermarket? :rolleyes:

    http://en.wikipedia.org/wiki/Wnt_signaling_pathway

    http://www.genwaybio.com/all_protein...77386bc323cca2

    Scroll to the bottom to see the WNT proteins. I think doctors would have access to such material.
  • 12-10-2010 07:46 PM
    HairRobinHood
    Quote:

    Originally Posted by Westonci View Post
    http://www.genwaybio.com/all_protein...77386bc323cca2

    Scroll to the bottom to see the WNT proteins. I think doctors would have access to such material.

    Ok. And which one should he choose and add? All availabel Wnt proteins? Or just a specific combination/mix thereof?

    Concerning "Wnt proteins" - basically you're right; Dr. George Cotsarelis (Follica) brought this subject up in this field, followed by Dr. Gail Naughton (Histogen) and so on. BUT none of them ever discussed "adding" of any "Wnt proteins" to mammals for any therapeutical purpose. It's just all about "Wnt SIGNALING" and not about adding any "Wnt proteins". But feel free to read it yourself:

    http://www.wipo.int/pctdb/en/wo.jsp?...DISPLAY=CLAIMS
    -------------------------
    EXCERPT
    "79. A method for producing pigmented hair on a subject, said method comprising comprising (i) generating a hair follicle on said subject according to the method of any of claims 47-78; and (ii) suppressing an expression of a Wnt protein in said hair follicle.

    80. The method of claim 79, wherein the step of suppressing an expression of a Wnt protein comprises inducing an expression of a Dkkl protein.
    -------------------------

    So as you can see, they do not mention something of "adding" of any Wnt proteins. They just talk about "suppressing" an expression of a [specific) Wnt protein.
  • 12-11-2010 08:57 PM
    HairRobinHood
    Wnt vs. growth factors
    @Westonci – My previous post (yesterday) about the “Wnt” subject, was just a quick response out of my memory. I just read it again and checked what I wrote. But besides some grammar mistakes (I guess), everything I mentioned is basically – correct:

    Quote:

    Nilofer Farjo, MBChB Manchester, England
    Wnt signaling: a review
    One of the current buzz words in the literature, in meetings, and on the Internet is “wint”; but, what exactly is wnt and how does it fit into our understanding of hair follicle physiology? And, more significantly, will it lead to a new generation of treatments for alopecia?
    When we talk of “wint,” we are in fact referring to two different things: the wnt gene family and wnt proteins. Wnt genes are structurally similar genes (19 wnt genes in humans have been identified on different chromosomes) that produce signalling proteins also referred to as wnt. These signaling molecules regulate cell-to-cell interactions during embryogenesis and control normal physiological processes in adults; some of these wnt proteins are specific to certain cells and tissues.
    Histogen Inc. has been conducting studies using the concepts of increasing wnt signaling to promote hair growth in clinical trials. Below I interview their founder and CEO, Dr. Gail Naughton, on these recently completed trials.

    Source: Hair Transplant Forum International, Jul/Aug 2009, page 120
    Dr. Gail Naughton (Histogen Inc) mentioned in this interview, that they “produce” specific types of Wnt proteins (e.g. Wnt 7a) in their own labs, as well as “other hair-regeneration-related proteins” (e.g. follistatin) under specific and controlled conditions. Thereby specific cell types (fibroblasts) INCREASE their production of specific Wnt proteins, and during the production of these Wnt proteins, the cells also “secret a variety of wound healing growth factors” (e.g. KGF, VEGF etc). All in all results in a special medium which they simply call “Hair Stimulating Complex” (HSC). That’s all – isn’t it?

    Concerning “abnormalities in Wnt signaling” or formations of tumors/cancer, particularly related to Wnt 5a proteins, Dr. Gail Naugthon mentioned in this interview, that they have to adapt the growth conditions to down-regulate Wnt 5a proteins and to up-regulate Wnt 7a proteins and so on.

    So I ask you once again: Which Wnt protein type should Dr. Jerry Cooley “add” to the mix of Acell/PRP, and finally, for what reason? Wnt 7a proteins? Down-regulated proteins or up-regulated proteins? How much should they be “up-regulated”? Is it possible that too much “up-regulated” Wnt 7a proteins “signal” other proteins in your body to be e.g. Wnt 5a proteins or to be any other (“risky”) protein type, simply with the intention “just for fun”?

    How about just adding of the mentioned “growth factors” ?
  • 12-12-2010 07:33 AM
    Jerry Cooley, MD
    Role of WNT
    Westonci and HairRobinHood

    Thank you for the lively discussion of WNT. Doubtlessly the WNT pathway is critical in the formation of hair follicles. In fact, I wouldn't be surprised if the WNT pathway is activated when ACell coated plucked hair is implanted in the skin. However, I would be very cautious about adding exogenous WNT proteins as this may disturb the delicate balance of stimulatory/inhibitory factors present in this context. For example, it is well known that activation of WNT/beta-catenin is associated with tumor formation, which is why Cotsarelis' approach is requiring such careful animal studies and will be subjected to close regulatory scrutiny. In the past, some thought that Sonic Hedgehog stimulation had potential for hair loss treatment, but I believe that tumor formation occurred which shut down any further work on this. It may be that the Histogen approach, which uses a mix of embryonic proteins secreted by neonatal fibroblasts, is more desirable because that stimulatory/inhibitory system is already built in.

    Regardless, use of either approach would require FDA supervised studies and should not be done by the surgeon at this time just to 'see what happens'. ACell is already FDA approved for wound healing and can be safely used as an adjunct to transplanting plucked hairs.

    Thanks again for the thought provoking discussion.
  • 12-12-2010 10:25 AM
    Westonci
    Quote:

    Originally Posted by Jerry Cooley, MD View Post
    Westonci and HairRobinHood

    Thank you for the lively discussion of WNT. Doubtlessly the WNT pathway is critical in the formation of hair follicles. In fact, I wouldn't be surprised if the WNT pathway is activated when ACell coated plucked hair is implanted in the skin. However, I would be very cautious about adding exogenous WNT proteins as this may disturb the delicate balance of stimulatory/inhibitory factors present in this context. For example, it is well known that activation of WNT/beta-catenin is associated with tumor formation, which is why Cotsarelis' approach is requiring such careful animal studies and will be subjected to close regulatory scrutiny. In the past, some thought that Sonic Hedgehog stimulation had potential for hair loss treatment, but I believe that tumor formation occurred which shut down any further work on this. It may be that the Histogen approach, which uses a mix of embryonic proteins secreted by neonatal fibroblasts, is more desirable because that stimulatory/inhibitory system is already built in.

    Regardless, use of either approach would require FDA supervised studies and should not be done by the surgeon at this time just to 'see what happens'. ACell is already FDA approved for wound healing and can be safely used as an adjunct to transplanting plucked hairs.

    Thanks again for the thought provoking discussion.

    Sorry for bombarding you with millions of questions, but Im wondering how much you are charging per plucked hair. Even if you are not sure, could you estimate how much it would cost so that we could have an idea how much we should be saving for such procedure (and yes im aware that the results may or may not be permanent at this time).

    Having said that, God bless you Dr. Cooley for your hard work, and I know that your name and Dr Hitzigs will go down in the history books for your contributions in this feild.
  • 12-12-2010 11:55 AM
    wolvie1985
    Westconi, I may be wrong but I get the sense that pricing questions are probably best directed to Dr. Cooley's office directly. It is just a phonecall after all! :) Dr. Cooley, thanks again for your participation here as well as your patience. Class act all the way.
  • 12-13-2010 12:23 PM
    wolvie1985
    I forgot to shout out to Dr. Hitzig as well! Sorry, Dr., I didn't see that you posted on here too. You're truly a pioneer in your field and given new hope to millions.
  • 12-15-2010 09:24 AM
    cim98mk6
    New upcoming article from Hitzig
    http://www.prweb.com/releases/haircl...web4840684.htm

    In an upcoming article submitted to the Hair Transplant Forum International, Hitzig states, “Early results in transplant patients (where it is easier to obtain arterial blood from the surgical donor area) have shown that when MatriStem plus spun down arterial blood plasma or PRP are combined and then injected in thinning areas of the scalp that have not previously received a hair transplant, miniaturizing hairs appear to re-grow. The results are still very early, but make sense in light of previous reported PRP injection results.”


    I haven't seen anyone discuss this press release in the forum yet. Increase regrowth in thinning areas seem to be another area where ACELL can be applied.
  • 12-15-2010 11:04 AM
    Gubter_87
    I've been in contact with Dr. hitzig earlier and he recommended that if I have a transplant to use an injection of A-cell and PRP to prevent further loss.

    I've never heard of these two being used as a preventative treatment before? Does anyone have anymore information about it? Does it work better/worse than propecia?
  • 12-15-2010 02:06 PM
    Gary Hitzig MD
    ACell plus PRP/Arterial Serum with Buffy Coat
    Whenever our Plastic Surgeons perform a Transplant utilizing ACell, we automatically inject the surrounding thinning areas with the combination of ACell mixed in PRP or Arterial Serum plus Buffy Coat (where the Adult Stem Cells and Platelets plus nutrients are). We of course inform all patients of this addition and why we are doing this (preventative or possible regrowth of miniaturizing hairs). There is no extra charge for this either. By adding this to the transplant procedure since the patient is numbed anyway, we are getting good clinical feedback of it's efficacy. We have been very excited with the early (8 month) results, and are now performing independent injections of PRP plus ACell to those candidates with early or moderate thinning but obviously no shiny bald area. Propecia is an adjunct to this procedure and should not be stopped until we learn more about the mechanism of it's action. We hope this will be a better answer to thinning as we have not had to repeat any of these injections to date. Time will tell!
  • 12-15-2010 02:41 PM
    Gubter_87
    Thank you for your reply Dr. Hitzig.
    Are you planning on displaying the results from these injections anywhere soon?

    I always think it's encouraging when people actually take steps to develop the field of hair loss treatments. Because to be honest, for someone like me who is 23 years old, NW4, thinning in a NW6 pattern and possibly aiming for a full NW7 - there basically do not seem to be many options.

    So I'd just like to say thank you to you, Dr Cooley and everyone else who are actually trying to come up with innovative new solutions.
  • 12-15-2010 04:11 PM
    Gary Hitzig MD
    Yes, I will post results.Give me until after the holidays as people are very engaged and unavailable. In January you will start seeing the "early" 9 month injection results. As I have combined transplants with injections in the thinning areas, I will point out the transplants vs. the injection only sites. Please bear with me, January will be here very soon.
  • 12-17-2010 03:18 PM
    tbtadmin
    Dr. Gary Hitzig Responds To Recent Concerns and Criticisms About The Use of ACell MatriStem In Surgical Hair Restoration.

    Listen To The Segment
  • 12-19-2010 03:22 PM
    Don'tDoIt
    With all this talk about Acell, I am surprised that no one on this forum, including Spencer, has brought up the news this week about stem cell research.

    I am referring to the report that stem cells have been used, for the very first time, to create a living hair follicle. This report comes from Ronald Lauster at Berlin Technical University. The news has been reported in the popular media during the past few days. Spencer, what do you think about this news?

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