ACell, a Current Review of Applications in Hair Transplant Surgery

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Originally Posted by gmonasco

I don't understand your response; it seems something of a non-sequitur.

The point seems to be that if FUE surgery could be consistently accomplished with little or no loss of donor hair, why would FUT continue to be used?

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Check out Dr. Hitzig's presentation (part 2):

http://www.iahrs.org/news/acell-matr...inary-results/

I'm still asking myself, whether or not Dr. Hitzig has consistent results with new strip or old scar removal --> "partial closure" for 8 - 10 days --> full donor regeneration after some month, including regrown/ingrown/sprouting out hairs within the former "scar".

If you remove 1 cm of tissue or more from a donor area, you are removing it in block excision. The entire dermis, follicle, and adipose come out. You close the area. This will result in a scar along with biological creep to some degree. The biologic creep will be greatest in the adjacent 0.5 cm on each side of the scar. As you move 2.5 cm above or below the scar, the biologic creep is less. The biologic creep does not result in more hair follicles or more follicular units. It does result in more skin with the same number of follicles and the same number of follicular units. In other words, the hair and follicular density decrease on either side of the scar. This has been documented many times including in studies that I have performed.

The application of Acell in this wound is not gong to replace the 1 cm (it could be more or less) of tissue that was removed. It might make the wound heal more like normal skin. It is not going to replace the tissue that was removed.

One other thing that Acell is not going to do is have any beneficial affect on the distortion of follicle growth direction that necessarily occurs with any strip procedure and increases with subsequent procedures. Often times it is not only the progressive widening of scars that make the consequences of subsequent strip procedures worse, it is the progressive negative impact on hair growth direction. At times the distortion of hair growth angles is the primary reason that strip procedures produce obvious evidence that a hair transplant was performed. Acell, God, genetic engineering, nor magic can overcome this particular deleterious consequence of strip surgery. Once you have it, you have it. It is nearly impossible to resolve. Sadly, too few recognize this complication of strip surgery. For these reasons, I consider strip excision non sequitur, as well especially considering that we are getting better donor area healing thus far from a combination of Acell and FUE.

I welcome clear evidence rather than fuzzy video photos that show a benefit from the use of Acell in the improvement of strip scars. Again, I’m all for it. I have not seen the evidence yet in clear photographs. I must say that I am listening and watching. Many are both doing some really cool stuff and merit keen interest. If you really want to impress me with your strip scars; however, treat the next 50 with Acell and then shave the donor area 6 months or longer thereafter. Take high quality images of each and present them in high quality format that anyone can enlarge rather than in grainy videos.

On a more positive note, I had a patient come back today 6 months after his procedure. We injected Acell into his strip scar and then grafted 50 beard hair that I extracted via FUE. The yield was 46 out of 50 beard hairs. I treated a different area of his multiple strip scars with 6 chest hair. Both were simply tests, which I prefer to perform with body hair these days. The 6 chest hair were not pre-treated with Acell. None of the chest hair was growing at 6 months. Of course one of his chief complaints was his strip scarring. When ever his hair is wet, the scars are evident. Like many of my patients he has multiple areas that need refinement and naturalization. I’ve devoted his limited donor area to resolving the pluggy, pitted appearance of his hairline. This leaves his body hair to treat his 4 donor scars, at least for now. He is physically active and spends a good deal of his time in physical activities such as cage fighting. Sweating results in wet hair that reveals not only his pluggy hairline, but also his multiple, wide strip scars. It is a complex scenario that requires good technique and a bit of luck.

I have been using body hair for many years now. The results are quite variable. Sometimes they are good. I call this good fortune. Sometimes the results are poor not only because of yields, but because they can produce poor cosmetic results even when the yield is good. Beard hair tends to have a better cosmetic impact than other sources, but the typical yield from beard hair is about 60% in ideal situations. Here we had a yield of 92%. That’s good in my experience. Not only that, the lengthy was really good for 6 months follow up. Thus far we have a bit more than good fortune at hand.

That is not to say that chest hair or leg hair have not worked well in many instances. Still the number of poor results is unacceptable. We really need to increase the potential donor area so I hope we can get better results from other sources of donor area.

A single case! It means nothing really unless you are the recipient, in which case you can be elated. It is impressive and suggests that further study is warranted to see if we can improve body hair yields in general along with the potential to improve the yields from scalp hair. Today we grafted over 900 beard hair to the donor area. We treated all the grafts with Acell powder and also injected the donor area with Acell. He refused PRP, but I recommend it. I also grafted another 8 chest hair, but this time added Acell to them. Let’s see what we have in another 6 months. I hope it is good. With body hair, I always tend to sit on the edge of my seat and pray.

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Originally Posted by drcole

If you remove 1 cm of tissue or more from a donor area, you are removing it in block excision. The entire dermis, follicle, and adipose come out. You close the area. This will result in a scar along with biological creep to some degree. The biologic creep will be greatest in the adjacent 0.5 cm on each side of the scar. As you move 2.5 cm above or below the scar, the biologic creep is less. The biologic creep does not result in more hair follicles or more follicular units. It does result in more skin with the same number of follicles and the same number of follicular units. In other words, the hair and follicular density decrease on either side of the scar. This has been documented many times including in studies that I have performed.

The application of Acell in this wound is not gong to replace the 1 cm (it could be more or less) of tissue that was removed. It might make the wound heal more like normal skin. It is not going to replace the tissue that was removed.

One other thing that Acell is not going to do is have any beneficial affect on the distortion of follicle growth direction that necessarily occurs with any strip procedure and increases with subsequent procedures. Often times it is not only the progressive widening of scars that make the consequences of subsequent strip procedures worse, it is the progressive negative impact on hair growth direction. At times the distortion of hair growth angles is the primary reason that strip procedures produce obvious evidence that a hair transplant was performed. Acell, God, genetic engineering, nor magic can overcome this particular deleterious consequence of strip surgery. Once you have it, you have it. It is nearly impossible to resolve. Sadly, too few recognize this complication of strip surgery. For these reasons, I consider strip excision non sequitur, as well especially considering that we are getting better donor area healing thus far from a combination of Acell and FUE.

I welcome clear evidence rather than fuzzy video photos that show a benefit from the use of Acell in the improvement of strip scars. Again, I’m all for it. I have not seen the evidence yet in clear photographs. I must say that I am listening and watching. Many are both doing some really cool stuff and merit keen interest. If you really want to impress me with your strip scars; however, treat the next 50 with Acell and then shave the donor area 6 months or longer thereafter. Take high quality images of each and present them in high quality format that anyone can enlarge rather than in grainy videos.

On a more positive note, I had a patient come back today 6 months after his procedure. We injected Acell into his strip scar and then grafted 50 beard hair that I extracted via FUE. The yield was 46 out of 50 beard hairs. I treated a different area of his multiple strip scars with 6 chest hair. Both were simply tests, which I prefer to perform with body hair these days. The 6 chest hair were not pre-treated with Acell. None of the chest hair was growing at 6 months. Of course one of his chief complaints was his strip scarring. When ever his hair is wet, the scars are evident. Like many of my patients he has multiple areas that need refinement and naturalization. I’ve devoted his limited donor area to resolving the pluggy, pitted appearance of his hairline. This leaves his body hair to treat his 4 donor scars, at least for now. He is physically active and spends a good deal of his time in physical activities such as cage fighting. Sweating results in wet hair that reveals not only his pluggy hairline, but also his multiple, wide strip scars. It is a complex scenario that requires good technique and a bit of luck.

I have been using body hair for many years now. The results are quite variable. Sometimes they are good. I call this good fortune. Sometimes the results are poor not only because of yields, but because they can produce poor cosmetic results even when the yield is good. Beard hair tends to have a better cosmetic impact than other sources, but the typical yield from beard hair is about 60% in ideal situations. Here we had a yield of 92%. That’s good in my experience. Not only that, the lengthy was really good for 6 months follow up. Thus far we have a bit more than good fortune at hand.

That is not to say that chest hair or leg hair have not worked well in many instances. Still the number of poor results is unacceptable. We really need to increase the potential donor area so I hope we can get better results from other sources of donor area.

A single case! It means nothing really unless you are the recipient, in which case you can be elated. It is impressive and suggests that further study is warranted to see if we can improve body hair yields in general along with the potential to improve the yields from scalp hair. Today we grafted over 900 beard hair to the donor area. We treated all the grafts with Acell powder and also injected the donor area with Acell. He refused PRP, but I recommend it. I also grafted another 8 chest hair, but this time added Acell to them. Let’s see what we have in another 6 months. I hope it is good. With body hair, I always tend to sit on the edge of my seat and pray.

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Dr. Cole what is you opinion on partially extracting a portion of the hair follicle with 1 of the 2 sources of stem cells in the hair (Dermal papilla or bulge) that Dr. Gho is doing.

He claims that both sources of stem cells will result in a new hair follicle when implanted and that the donor hair will regow, so your getting 2 hairs from 1 hair.

Dr. Gho is probably right on a limited basis. If you look at hair follicle transection yield studies across the board, you will find that transected follicles can result in more than one hair. The problem is that neither fraction will produce a yield of 100% nor quite often the combined yield of 90%. Furthermore, there are many studies that show that fractionated follicles produce finer hairs. This is why many physicians do it at times to produce a finer hair result on the hairline or in the temple point region. Still, expect a lower yield than 60% from each fraction. I prefer to cherry pick finer hairs for these functions rather than throw caution to the wind and hope that I get an acceptable yield from fractionated follicles.

No one really knows what Dr. Gho is doing. He claims that he is extracting a portion of the follicle and getting two to grow. He probably is, but not on a consistent basis. It is up to him to prove that all the science pre-dating his claims is inaccurate. Many have done this for years without complete success. In other words, follicle transection rate studies result in lower than ideal yields from each fraction consistently in all studies to date. Perhaps something like Acell will change the playing field for all of us, but in the interim, I would not put my donor area at risk.

Enclosed is an image of a plucked hair follicle compared to an intact follicle. If most of the stem cells are located in the upper portion and you fractionated this follicle somewhere between the upper and lower portion, you might have stem cells in both halves. You would expect growth from both half. Unfortunately, you don’t get this in human trials. Furthermore, note how little tissue there is around a plucked follicle. Acell might improve the survival of the transplanted hair, but what is going to improve the survival of the limited amount of tissue that is residual in the donor area from the plucked follicle. I think you need to stimulate that too. Still, I’d put my money on the intact follicle on the left and stimulate both the recipient area and donor area with Acell. If Acell fails to work, at least you have the intact follicle working for you in the recipient area. Note the plucked follicle on the right. It is missing parts of the upper dermal sheath and the lower dermal sheath. Until we prove Acell stimulates the recipient area with the naked follicle to produce a full diameter hair and the non-stimulated lower residual fraction of dermal sheath in the donor area also produces a normal diameter hair, I have to back the intact follicle and stimulate the donor area. I see positive results in both the donor and recipient area doing the latter.

Recall the study by Dr. Jimenez where he noted the stem cells are in between 1mm and 2 mm from the surface of follicle (between L1 and L2 as defined by Dr. Jimenez). Why would we see growth from the upper portion and the lower portion, when you amputate a follicle at the lower portion of the follicle between L2 and L3? There must be stem cells at the lower portion, as well. Based on the study and the location of amputation, you get different yields. I’ve also enclosed a photo from Dr. Jimenez’s paper on the morphometics of the hair follicle. For the most part he says that the stem cells are located between L1 and L2. Still you can get growth from the upper portion and the lower portion when you amputate somewhere between L2 and L3. None of it makes total sense. What we do know is that in some studies the yield is better when you fractionate the follicle at the upper 1/2 from both portions. Other studies seem to refute these findings.

It is up to Dr. Gho to clarify his work. To date he has not. It does not make sense to me. That too often is the case in the field of hair transplant surgery, however.

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Originally Posted by drcole

Dr. Gho is probably right on a limited basis. If you look at hair follicle transection yield studies across the board, you will find that transected follicles can result in more than one hair. The problem is that neither fraction will produce a yield of 100% nor quite often the combined yield of 90%. Furthermore, there are many studies that show that fractionated follicles produce finer hairs. This is why many physicians do it at times to produce a finer hair result on the hairline or in the temple point region. Still, expect a lower yield than 60% from each fraction. I prefer to cherry pick finer hairs for these functions rather than throw caution to the wind and hope that I get an acceptable yield from fractionated follicles.

No one really knows what Dr. Gho is doing. He claims that he is extracting a portion of the follicle and getting two to grow. He probably is, but not on a consistent basis. It is up to him to prove that all the science pre-dating his claims is inaccurate. Many have done this for years without complete success. In other words, follicle transection rate studies result in lower than ideal yields from each fraction consistently in all studies to date. Perhaps something like Acell will change the playing field for all of us, but in the interim, I would not put my donor area at risk.

Enclosed is an image of a plucked hair follicle compared to an intact follicle. If most of the stem cells are located in the upper portion and you fractionated this follicle somewhere between the upper and lower portion, you might have stem cells in both halves. You would expect growth from both half. Unfortunately, you don’t get this in human trials. Furthermore, note how little tissue there is around a plucked follicle. Acell might improve the survival of the transplanted hair, but what is going to improve the survival of the limited amount of tissue that is residual in the donor area from the plucked follicle. I think you need to stimulate that too. Still, I’d put my money on the intact follicle on the left and stimulate both the recipient area and donor area with Acell. If Acell fails to work, at least you have the intact follicle working for you in the recipient area. Note the plucked follicle on the right. It is missing parts of the upper dermal sheath and the lower dermal sheath. Until we prove Acell stimulates the recipient area with the naked follicle to produce a full diameter hair and the non-stimulated lower residual fraction of dermal sheath in the donor area also produces a normal diameter hair, I have to back the intact follicle and stimulate the donor area. I see positive results in both the donor and recipient area doing the latter.

Recall the study by Dr. Jimenez where he noted the stem cells are in between 1mm and 2 mm from the surface of follicle (between L1 and L2 as defined by Dr. Jimenez). Why would we see growth from the upper portion and the lower portion, when you amputate a follicle at the lower portion of the follicle between L2 and L3? There must be stem cells at the lower portion, as well. Based on the study and the location of amputation, you get different yields. I’ve also enclosed a photo from Dr. Jimenez’s paper on the morphometics of the hair follicle. For the most part he says that the stem cells are located between L1 and L2. Still you can get growth from the upper portion and the lower portion when you amputate somewhere between L2 and L3. None of it makes total sense. What we do know is that in some studies the yield is better when you fractionate the follicle at the upper 1/2 from both portions. Other studies seem to refute these findings.

It is up to Dr. Gho to clarify his work. To date he has not. It does not make sense to me. That too often is the case in the field of hair transplant surgery, however.

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Thank you for your response, i know your probably tired as it is late at night, but i just have one last question that is slightley off topic.

I've seen scientist grow organs in vitro using cells and a scaffold. Organs ranging from Livers, ears, fingers, arteries and blood vessels.

ie. Dr. Anthony Atala from Wake forest University.




Although a hair follicle is complex, relative to other organs its actually quite simple. So why cant scientist grow hair follicles using dermal fibroblasts and bulge stem cells using a 3d biodegradable scaffold of a hair follicle?

Westonci, could you please stop quoting multi-paragraph responses in their entirety? It's really annoying to have to scroll through all of that for no purpose.

Wow! I suppose it has something to do with life and death along with insurance. Well, you probably have to consider the complexity of the hair follicle, which derives from both epidermal and mesodermal stem cells. Take a look at those labs. Who do you know in the hair restoration industry that has anything like this?

Like it or not, the loss of a liver or both kidneys will kill you. Too few recognize that hair loss is the equivalent of killing you to a small fraction of people. Most consider it a normal occurrence that you should not be upset about. No insurance is going to cover it. Thus, where is the money for invested research backed by our government? There in lies much of the problem, perhaps.

We are fortunate to have dedicated researchers such as Dr. Cotseralis dedicated to the problems at hand. i still recall his excitement when i told him i had noted that follicles around a healed strip excision had the capacity to increase in hair diameter following strip excision in 1999. i suspect this was his first exposure the potential of perturbation of hair follicles. All of us are lucky to have him.

i suspect we all just need more money and more rational to overcome hair loss. No one is going to die from hair loss based on the rational of most. Still it impacts many people in horrific ways. i think we need to get this across to politicians and researchers.

i recall my next door neighbor who needed a single kidney. Her husband, who was a federal judge, and she were careful with their money. They never bought a cell phone. One day they got a call that her matching kidney was available, but they were our of town. The kidney went to the next person and she died of kidney failure months later even though they finally bought a cell phone. That memory has never left me. Hair loss can be devastating to so many people. We just need more awareness that hair loss, though not life threatening, can severely impact the lives of so many. Therein lies the problem. No heart...you die. No liver....you die. No kidneys...you die. No hair....what are you worried about? Well, the loss of hair has a tremendous impact on otherwise healthy individuals. We simply need more awareness of the impact and a tremendous amount of financial backing.

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Originally Posted by drcole

When I extract a full intact hair follicle, I ease it out. I do not cut around it and remove it. Easing the follicle out means that bits and pieces of the dermal sheath are left behind in the dermis and adipose. These bits and pieces leave potential stem cells behind. These stem cells have the potential to create new hair follicles.

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Doctor thank you for answering my question. One follow on question, do you have plans to refine your extraction in order to consistently regenerate follicles at the donor following extraction or is it simply too unpredicatable at the moment.

We ask that all users of BTT forums act in a respectful and civil manner when posting their questions, concerns and opinions. This is a place to learn from each other, share ideas and information and to communicate with experts in the field, not a place to voice unfounded personal attacks.

Thank you for your cooperation in this matter.

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Originally Posted by tbtadmin

This is a place to learn from each other, share ideas and information and to communicate with experts in the field, ...

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The answer is - NO.

That is a tough question, but a good question, Rapunzal.

In the 20 years I’ve been restoring hair the one constant is change in my personal technique. I made some huge changes back in the early years when I began transitioning from the standard of plug grafting to follicular units. Back in 1991, I termed them pilosebaceous units and I still think that term is more applicable to what we do surgically as opposed to follicular units. I invite anyone to research the orign of the term follicular unit in 1984 as a histological term. Back in 1991 all my mentors called me crazy for changing. I could not help but listen back then. Today, I don’t listen to my ears. I listen to my eyes and think with my mind. That is not to say that we should not consider what we hear and read. We simply cannot be boxed in by what others say. We need to take a rational approach and follow what our eyes reveal. Results are simply results. If you don’t try to build on them, you are going to be stagnant. If you try new things, the results disclose the consequences - good or bad.

In this thread we are focusing more on theory than on concrete evidence. Theory is a great thing simply because it implores us to try new things. Reality is a quite different avenue. If the results are poor, we abandon the road. If the results are very good, we stay the course. If the results are suggestive, we wander in one foot at a time. In many instances of hair restoration surgery the previous freeway leads us to a new exit. The previous freeway makes us feel comfortable exiting because the road has been safe thus far. This is what occurred in the transition from plugs to follicular units. Other roads are new. We exited a jungle and followed a new road. Sometimes that new road is dangerous and full of peril. Such was the road with body hair. Today we are discussing new highways. We have some suggestive evidence, but we do not have complete faith in the new opportunities. There are signs along the road imploring us to continue without concern that we are going to drive off the cliff. The problem is that we still do not know the veracity of these signs. Is it marketing or is it the land of opportunity?
The bottom line is that things that have worked in the past several years are likely to work well in the future with few modifications. Breaking plugs into follicular units was a small but obvious exit. Stem cell enhancement is not something that is old, tried, and true. This is new! We all must step tepidly as the consequences are yet uncertain.

To more directly answer your question, I must say that I don’t think I have a new solution for extracting grafts even with the new biologic enhancement tools at our disposal. I don’t think there is a better way. As I mentioned my procedure over the coming months or years will certainly change. I don’t sit and wait for modifications. I constantly look for them. Sometimes I sit in a comfort zone on fractions of my procedure such as how I extract follicles while looking in the other direction for improvements in other aspects of my procedure. Your comments, however, cause me to contemplate because perhaps there is a better way. We must all be on the look out for ideas that jar our creative side. This is still not to suggest that I can think of a better way at this time. It is simply a reflection that I hear your wake up call and I will contemplate the possibilities.
Every day I go to work I think about how I am going to treat my patient. I actually begin this the day before by reviewing the patient chart and the procedure. I often change the start time to encompass what I want to do. Then I modify it once more while I evaluate the patient in person. Then as I progress, I often modify the procedure once more as I begin to focus on the individual follicular units under 6X magnification. I think about my work from the before I go to sleep until the time I sleep. Then I often dream about it. You’d be surprised what you can learn from your dreams. I feel that if you are ever going to improve, you must be constantly focused on improvement and vigilant of what your colleagues are doing. There is always something to learn or modify based on your own reflections or the advancements of your colleagues.

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Originally Posted by drcole

That is a tough question, but a good question, Rapunzal.

In the 20 years I’ve been restoring hair

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... someone like you has now clue whether or not a plucked hair has the ability to regrow?

Hair Robin Hood, i have no idea what your point is. What i can say without reservation is that there is no one who is not walking on thin ice with regard to Acell. Acell is a new modality with unproven benefits.

So far no problem with direction--it is a great question though.
FUE transplants require extensive shaving of the donor area causing a long downtime to the patients. Strips offer the ability to transplant "coupled follicular units" allowing for better central density and a quicker more cost effective procedure. Downtime is minimal.
That being said, each patient and Physician needs to choose the procedure that they are most comfortable with after reviewing the options. ACell seems to even the field.

Thank you very much for all your input. I can only speak for myself, but to me the FUE downtime is not that much of a problem because in the end its just a few month. But due to some operations back in my youth days (not hair related) i am really really afraid of a strip procedure.

Thats why i like the idea of only plucked hair to be transplanted and the idea to creat infinite donor hair with FUE. I know every surgeon has his speciality when it comes to terms of transplantation. But i am still afraid of a strip operation. So as rapunzal i would be very happy to see further efforts to create an Acell FUE technique with regenerating donor hair.

I would accept the downtime without hesitation. In the long run it wouldn´t even make no difference between FUT and FUE in terms of infinite donor hair.

@Dr Hitzig : Acell is not even the field its more then that its a real game changer :-) so thanks again to you and Dr Cooleys efforts to reach out to the baldie community, your efforts are very much appreciated

what effect does acell have on the donor scar?

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Originally Posted by ejj

This is my donor scar where acell has been used , I had a procedure 13 months ago . For me its a little dissapointing , the scar is not like a ` normal ` scar there is no hard tissue, so I suppose thats a positive !.... however its now just a `hairless ` piece of scalp that I think defeats the object of having a transplant in the first place ,

Hope this helps with your qs montrose

Regards

Ejj

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That was a good one :-) i think you should ask to Dr Hitzig and or Dr Cooley they can surely help you. Also your scar is "new" which should make things easier then an old one

Hey ejj, sorry to hear that you didnt get the outcome you wanted. dont give, hopefully someone can help you out.

i have a couple of questions if you have a moment and are willing to share the answers.

when you went in 13months ago did you go in for scar correction only or was it part of a hair transplant ?

what was your scalp laxity like when you had it done ?

do you know what type of closure was used and stitching ? it might be on your procedure report if you have one

do you know how the acell was applied ? powder, sheets and where is was applied

sorry for the questions, but this information helps everyone ask the right questions when they go to see a surgeon for a consult

Who performed the surgery?

ejj why did you delete your post?

Guys
I appreciate the time you both take to answer questions and provide your thoughts. Please continue to take time from your busy schedules to visit these forums to answer questions and provide your thoughts because with something like Acell that is very new there simply isnt enough information available.

pioneers can often be rediculed, dont be disheartened if you really believe you are making a difference because the satisfaction from eventual achievement will make the journey worth its while
cheers

I agree with this statement. It is important to get deeper in this Acell thing and also to go one step beyond.

For Example, Dr Cole is sceptical about autocloning, but maybe he can conduct some trials with patients and see if plucked hairs will grow and he can also put further effort in FUE and infinite donor reserves.

If FUE infinite donor is possible, my plan would be really simple, go for a FUE procedure and use Dr Hitzig and Dr Cooleys Plucked hair autocloning for do a little bit more fine tuning in my frontal area.

I am currently saving my money till someone will come up with "Yes i managed to get infinite donor with FUE"

But thanks again due to those results and the encouraging effort put into this, it is the first time i can gladly say " Well hairloss is only temporaire messing around but not in the long run"

Keep up the good work

I have been doing non-shaven FUE for many years. i strongly feel this is the future in FUE for all patients. It requires more preparation time, but it does allow the patient to return to work the next day without shaving. There still are many physicians who are unaware that patients do not need to shave their donor area. i've done well over 3500 grafts on a patient in one day without shaving the donor area of my patient. i think a good mark is about 2000 to 2500 grafts in one procedure non-shaven, however.

if you have a strip scar, you often do not want to shave your donor area. Who could blame you? in these instances, i am careful with how much donor area i trim. The last thing we want to do is expose the strip scar whenever possible.

Now here are some pearls of wisdom if both patients and physicians are reading. When i was doing strip procedures, i would often trim the donor area that i planned to take in patients who had existing strip scars. In my hands you can typically anticipate that a strip scar that is 3 mm wide is going to be 3 mm wide with the subsequent procedure. in other words, the width was based not on technique, but rather on individual patient healing characteristics. Knowing that the scar would be the same, i would let the hair down and step back away from the patient. i would then look at the donor area under bright lights. if i could see the strip scar even with the upper hair laying over the scar, i would not take as wide of an excision. often times the strip scar is most apparent over the mastoid process. if you measure 7 cm lateral to the midline of your scalp in the back donor area, you are over the mastoid process. that is the boney protrusion that sticks out between your ear and the mid-line of your rear donor area scalp. This is where strip scars are first evident. i think the bony prominence makes the scar most prone to be wide there. Also the donor area density is lower there than in the mid-line scalp. If i could see the scar i would reduce the width of my strip so that i could insure more hair was there to help conceal the strip scar.

Back in 1992 I noted that my first strip procedure produced a fine scar. I would often then make a second procedure and produce a second fine scar above or below the first scar. The problem was that the multiple scars would make the donor area appear thin with all the scarring. This was how physicians taught me to do the procedure. Then i got the idea to harvest from the same scar in the second procedure so that my patients still had one scar. That was a good idea. The problem with harvesting from the same scar was that the extra tension on the subsequent procedure tended to make the scar wider. That's when i came up with the idea to close in two layer. My colleagues thought it was ridiculous to close in multiple layers because there was no firm tissue to hold the deep suture. Well, the adipose was firm enough to hold either individual sutures or a running suture. Guess what? the scars reduced by 50% when i did this. Today, multiple layer closure is quite common. I could take a 5 mm wide scar and get it to 2.5 to 3 mm in width. Then i noted the big problem was an alteration of hair growth angles. The more tissue you take out, the greater that problem became. Furthermore, the more tissue you take out, the greater the reduction in follicular density around the scar. Finally, even the best of techniques cannot always stop a strip scar from going from 2 or 3 mm to 5 mm. Now you have a wider scar, less density around the scar, and distortion of hair growth angles. All these complications simply create headaches for physicians and patients. Today there are options available that allow you to avoid these complications.

With a non-shaven technique of FUE, we can trim the donor area first and see what the donor area would look like if we take all the follicular units that we trim. Of course I sometimes over trim to see what the donor area would look like if i took all the follicular units that i trimmed. if i don't like what I see, i can reduce the number of follicular units that i take. This is very important with patients who have prior strip scars. We need to insure that patients can conceal their strip scars following a procedure. When i was doing strip procedures (I've done over 8000 of them), we could only estimate what the donor area would look like. With the non-shaven FUE we can actually see what the donor area will look like if we take everything. if i don't like the coverage that is left following individual follicular unit trimming, I simply reduce the number of grafts that i take. This is yet one more advantage to the non-shaven technique.

I began doing this non-shave technique is 2004. Prior to this i would shave small patches of hair. It turns out that the shaven patch is the worst way to do FUE. Avoid it at all cost. Either go with the non-shaven technique or the shaven technique. The shaven patch is a bad protocol. Patients will not prefer this method even though many physicians still do it. This method thins out patches of hair. It is far better to stretch your follicle removal out over the entire donor area than to do it in patches.

Shaving is a faster way to proceed. Shaving is the preferred way if your transplant surgeon is a novice. If your surgeon has not done much non-shaven, don't let him experiment on you with a large procedure. He needs to start small and work his way up.

The non-shaven route takes more time to master. I remember doing it early on. i went home with a headache every day. Now i simply fly through it with no problem. It just takes time to get really good at it.

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Originally Posted by RichardDawkins

I agree with this statement.

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Does it mean you agree that conversations with yourself?

@ Dr Cole : Ok this has its advantage but my point is, and i think anyone would agree here. That we would switch a full shaven head for infinite donor any time :-)

As i said before i hope you will go this way further with possible infinite Donor

Richard Dawkins, I am skeptical of autocloning. Nevertheless, it is one of those eye opening events that you have no choice but follow. i honestly think that Dr. Hitzig and Dr. Cooley need to inject the donor area with Acell, in addition to the plucked follicles. i'm really worried about what will grow in the donor area if they do not do this. I'm sure they will keep us posted on their results.

For me, i have no plans to test autocloning at this time. I learned something long ago. Patients come to me to get their hair back. i can assure this with FUE. i can't with autocloning. Still I'm totally in your camp with the concept of an infinite donor supply. We tried it with body hair. It worked well in some patients, but awfully in others. It was nearly impossible to predict the results. Today we are seeing a potential improvement by adding Acell to body hair transplants. Even if autocloning does not work and even if treating the donor area FUE extraction sites does not work, perhaps body hair and Acell will work. No matter which path anyone takes, they should proceed with caution. Do a little, see what works, and then do more. I'm so excited about what we are seeing in FUE donor area healing with Acell; however, that I just can't stop thinking about it. I certainly hope that is exactly where Dr. Cooley and Dr. Hitzig are with autocloning. My advice to anyone considering autocloning with plucked hairs remains that they should test the area with no more than 500 grafts. if it does not work for you, stop doing it. If it does work for you continue it.

Richard Dawkins, you bring up one more point. I cannot tell you how many patients I have seen in their 30s who started hair transplant surgery in their early 20s. There are so many of these individuals who wish they had never done a hair transplant. I worked on a repair case just this week with over 4 strip scars. His comment to me was that he started in the early 90s when long hair was cool. Then everyone started shaving their heads to conceal their hair loss. Now he wishes that he had not done anything. I wish he hadn't either. He got on the hair transplant freight train after watching an a TV commercial from an established clinic. He has not only multiple strip scars, but also pitted and pluggy grafts. His repair work will require at least 2 years of his time and my time. Waiting for an infinite donor supply for you is a good thing. My honest hope for you is that you will no longer want hair restoration by the time technology catches up to what you want. By the time many individuals hit their 30s, they no longer worry about their hair. They have other things to worry about like children, wives, and business. I hope you are able to put it behind you. I also hope your follicle loss does not put you in a place where you need an infinite supply of hair. Thus, my sincere hope for you is that you do not want hair transplants in the future and that your donor area is capable of restoring your hair loss should modern technology fail to produce the results you are in need of.

That leads me to one last comment. I don't read these forums on a regular basis. i have tunnel vision when i do. Did anyone see Jerry Brown's inauguration picture this month? I recall his inauguration in the 1970s. He was on the stage with Linda Ronstadt. Jerry had a hair loss problem at that time, but he looked like he had a full head of hair. Well, fast forward almost 40 years and it was all gone. The last thing you want is to start hair transplant surgery in your early years and wind up like Joe Biden with a huge bald spot in the rear. All of you guys take note. What you do today has an impact on what you will look like in the future. There is nothing wrong with waiting. Next year's model will be better than this year's model. We will have more time to work out the Acell, etc. kinks. For me, my first car was a Ford Galexy 500 that i had to bleed the breaks on every two days. I could not consider myself in that clunker today not simply because i'm too rotund to get under the car. We are simply not a match. Waiting will bring you nothing but the future. Hopefully the future will bring you peace with who you are in your absence of as much hair as you would like. Besides, perhaps modern technology will help you avoid surgery altogether.

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Originally Posted by drcole

For me, my first car was a Ford Galexy 500

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No Mercedes Benz with just 3 wheels?

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Did anyone see Jerry Brown's inauguration picture this month? I recall his inauguration in the 1970s. He was on the stage with Linda Ronstadt. Jerry had a hair loss problem at that time, but he looked like he had a full head of hair. Well, fast forward almost 40 years and it was all gone.

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How cosmetic doctors would redo Jerry Brown’s face

Cosmetic doctors say that Democratic gubernatorial candidate Jerry Brown, 72, has had little or no plastic surgery, but they have plenty to recommend to him.

http://inyourface.ocregister.com/201...ns-face/22686/

This is what i use to measure Acell. Note how little powder there is to equal 15.6 mg. This scale has glass all around to eliminate air flow and allow for a more precise measurement of the Acell. The scale is quite precise and carries a costly price tag. I like to be as precise as possible when mixing the Acell in my delivery vehicle such as hyaluronic acid or cellulose. This is the Acell powder, which i fell mixes much more homogenous than the Acell flakes.

That so entertaining, gmonasco. I would not know where to look for such links as you point out. There is so much to take home from this presentation, however. Jerry Brown was quite the "looker" in the 70s. He had medium length hair just over his ears. He looked professional yet "hip". Fast forward almost 40 years and his has a shaven head with a Norwood Class 6 pattern. Would he shave his head if he had a strip scar? It is almost appalling to see plastic surgeons recommend a variety of procedures for him. One thing i noted was that no one recommended a hair transplant. I can only imagine what they might say about his strip scar....."he needs to get that reduced....he needs to put some hair in that scar....he's obviously had a hair transplant....he needs balloon expansion of his scalp to reduce the scar".

Here are the points. Even in your 30s you might have a full crop of hair or you may be a NW class 2. By the time you hit 70, you might be a class 6. Jerry Brown did it. Why can't you? Why in God's name would you want a strip scar put on the back of your head for any reason regardless of your hair loss pattern in your 20s, 30s, or 40s? I don't get it. you can avoid it altogether today. What are you going to do in your 60 and 70s when your hair loss has out weighed your donor area? Are you going to shave your head like Jerry Brown or grin and bear it like Joe Biden? The points are simple. Hair loss is a life long process. The consequences of anything you do today are going to catch up with you later on in life. If you have a strip procedure today, shaving your head is out of the question from then on. It is better to do nothing in my opinion than get on that ballon. If you have something like FUE, you will not have a strip scar. At the worst you can relocate the grafts back to your donor area without worry about hair growth angle distortion. Still the best solution of all is to do nothing as did Jerry Brown. Many recommended a brow lift, liposuction, facelift or eyelid surgery, but no one recommended a hair transplant. Still more important, no one recommended a scar revision for his inadequate hair transplant procedure.

if you are going to have hair restoration surgery, it is my firm belief that you should do it in a way such that you minimize the consequences of the procedure. It is better to do FUE than a strip procedure. It is better yet to add Acell and PRP in the donor area when you do FUE. It may or may not be better yet to do hair plucking plus Acell in the recipient area than FUE. Time will tell. What i can say unequivocally is that strip surgery is only for those with minimal hair loss. If your hair loss is greater than a class 2 in your 40s, you should probably avoid it because ultimately your hair loss will catch up with you just as it did With Jerry Brown. You will hear it time and time again from strip surgeons that you should have FUE only if you have minimal hair loss. Well my friends, it is the other way around. The only way you do a good job of hiding that hideous scar is to have minimal hair loss. What would Jerry Brown do with his strip scar today? Would he have been re-elected? I don't know, but one thing for sure is that he would not have his hair cropped short and plastic surgeons would be commenting about more than his eyelids, face, and adipose.

I had a patient in his late 30s ask me about a strip procedure just this week. I told him I would not do it and referred him to several well known colleagues. Obviously strip surgery is still something that many want, but long term will they still want it? i don't know, but i do know that I will not be practicing medicine in 40 years when the complications show up. I will not be around to clean up my scars any longer. Personally I want nothing to do any longer with strip hair restoration procedures.

Dr. Cole, I have an idea as a way to compromise between your skepcticsm on plucked hair as well as still being able to put the experimental use of plucked hairs to use.

In a regular FUE you take follicular units from the permanent donor region in the back of the head and place them in the balding area. The downside however is that the donor region is depleted as is the case for all hair transplants to date.

My idea is that you would carry out the normal FUE procedure (Extract Follicular units from the back of scalp and place them in the bald area) but you would add an additional step of plucking hairs from the donor region that are left over from the FUE procedure and soaking them in Acell and them inserting them into the Donor holes left over from the extraction sites.

Worse case scenario would be a normal FUE procedure, however the plucked hairs with acell placed in the donor holes do not regenerate. However this is not really a negative since you would end up with the same loss factor as normal FUE hairtransplant.

Best Case scenario, the implanted plucked with acell regenerate a new hair follicles in the donor holes. So you get the results of an FUE with the added benefit of regenerated donor hair.

Since there are donor holes left over from the FUE procedure you may as well put them to good use.

What do you think of my idea?

I think it is worth a shot. And i know Dr Cole you are sceptical about plucking but i think sometimes risks have to be taken.

Because with your showings about those non existing spots after a FUE procedure, i think you were on the right track.

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Originally Posted by Westonci

What do you think of my idea?

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I guess he likes you idea, because Dr. Cole likes everything what makes things more complicated than necessary.

I think your ideas are good. I first did this by taking hair off the legs and putting it in donor area extraction sites. Guess what? The donor area looked better with less hypopigmentation. The problem was that the hairs from the legs were fine in nature. Their coverage value was minimal. Chest hair did better, however. Not only that, when i put PRP in the extraction sites the survival of body hair in the extraction sites was better.

Now here is my concern with plucking hair. If i pluck a hair, will the hair re-grow in the donor area or will it die? Suppose i pluck a hair and put it over in my extraction sites. Suppose the plucked hair re-grows, but the spot where the plucked hair does not re-grow. The end result is a one for one transfer. Now suppose a worse case scenario. The plucked hair re-grows, yet it is finer. Now we have a one for one transfer, but the end result is less hair volume owing to the finer hair. Now the worst case scenario is that i pluck the hair and nothing grows. Now i and a one for one loss.

I'm all for trying new things, but i don't want to do things that are not likely to yield results especially when they affect other people. I spend almost all of my non-family spare time fishing. I would never go where the fish are not likely to bite. The same is true for cosmetic surgery. You need to go where the results are. I'm already putting Acell in my extraction sites. Suppose i put a plucked hair in my extractions sites with Acell. Suppose something grows. Was it the plucked hair or the stimulated hair follicles from the FUE graft that i removed? Best for me to stick to my plan in the short interim. You have a good mind thought. Perhaps you should come visit me and stimulate me mentally. if my plan does not work and plucking does work, then we will all be plucking. If my plan does work and plucking does not, then we will all be doing FUE. I think we need different minds and differnt points of attack to see what works best. One thing is for sure. if i put Acell in a donor extraction and a plucked hair we will never know whether the plucked hair grew or whether it was stem cells from my minimal depth extraction procedure.

Now hypopigmentation is a local phenomenon. We don't see it on the beard or legs. We rarely see it on the back. It is common but not ubiquitous on the chest or abdomen. It is common on the scalp. What these variables tell us is that hypopigmentation is not a procedure result. It is a local result. With Acel we are overcoming the local results and at times re-growing hair.

My greatest challenge is not what i do. My problem is patient follow up. Most of my patients come from different states and different countries. I don't market and I don't advertise. What i have is a long standing reputation of good work which results in many patients. I'm happy to have this, but change is based on seeing your results. What i really miss is seeing my patients every 3 months. I feel this is what made me better over the years. I wish i had that today, but sadly my reputation has superseded my personal touch. What i need is more local patients so that I can follow them up more closely and make changes as necessary. I'm always looking for patients i can follow closely. I live in a rural community close to my horses. When you don't advertise, you simply don't get may local patients. I truly miss having my patients visit my home and i miss having dinner with them....with their families. More importantly, yet not more personally rewarding, i miss close patient follow up. We need this to ensure we are on the better path.

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You will hear it time and time again from strip surgeons that you should have FUE only if you have minimal hair loss. Well my friends, it is the other way around.

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Given today's state of FUE technique and its limitations, do you think it's currently advisable for anyone with more than minimal hair loss to undergo an FUE transplant?

Even i am not a doctor but with regards to some late findings i say today its more advisable then 5 to 7 years before.

There are those who would say that anything more than a minimal FUE procedure presents the same problem as FUT: if your hair loss continues, you won't have more available donor hair for future (FUE) procedures, and you won't be able to shave down due to the FUE scarring.

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Originally Posted by Gary Hitzig MD

So far no problem with direction--it is a great question though.
FUE transplants require extensive shaving of the donor area causing a long downtime to the patients. Strips offer the ability to transplant "coupled follicular units" allowing for better central density and a quicker more cost effective procedure. Downtime is minimal.
That being said, each patient and Physician needs to choose the procedure that they are most comfortable with after reviewing the options. ACell seems to even the field.

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If there has been no problem with direction, then would that not add further suggestion that you are actually 'waking up' the 'faulty' stem cells, in line with the recent research as you spoke about on the show recently?

This is amazing news if true, although I still have much doubt over the procedure.

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Originally Posted by gmonasco

There are those who would say that anything more than a minimal FUE procedure presents the same problem as FUT: if your hair loss continues, you won't have more available donor hair for future (FUE) procedures, and you won't be able to shave down due to the FUE scarring.

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FUE in combination with Acell wont go to the shotgun white dots. Thats only one of the Acell benefits. With adding Acell, it seems that there was no FUE extraction in the donor area and you have aldo a higher chance of follicles to regrow in your donor area.