ACell, a Current Review of Applications in Hair Transplant Surgery

[HairRobinHood]

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?

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

http://www.iahrs.org/news/acell-matristem-hair-loss-dr-gary-hitzig-displays-preliminary-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".

[John P. Cole, MD]

Acell and body hair yields

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.

[Westonci]

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.

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.

[John P. Cole, MD]

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.

[Westonci]

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.

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?

[gmonasco]

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.

[John P. Cole, MD]

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.

[rapunzal]

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.

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.

[tbtadmin]

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[HairRobinHood]

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

The answer is - NO.

[John P. Cole, MD]

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.

[HairRobinHood]

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

In the 20 years I’ve been restoring hair

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

[John P. Cole, MD]

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.

[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.

[RichardDawkins]

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