FUE Donor Area Healing With ACell 3 Mo. Post-Op

[John P. Cole, MD]

I think we could swap spit (stories) all night as you seem to be full of them.

In the repair side of hair, there are over 30 years of bad, and when i say bad, I mean really bad work. I can recall listening to Martin Unger back in 1998 tell about how he offers chocolate or vanilla. Chocolate is a scalp reduction and vanilla is mini grafts or plugs. The patient asks what he recommends and he says a scalp reduction. Patients listen to what he recommends even though long term it offers the worts possible outcome. Patients always want what we recommend. When patients tell me to do what i think it is best, my first response is that they would never sit in the chair and tell the hair stylist to surprise them. People know what they want so start with what your goals are. What are your primary goals and let's proceed from there. Just last week I had a 26 year old tell me it was a 4 cm to 5 cm hairline. I sent him home. i was not going to build it. We gave him his money back and we failed to recognize his goals in advance. Had i built the 7 or 8 cm hairline he needed, he'd have been unhappy. Sometimes it is better to make them unhappy with what you can't do because long term it's a disaster waiting to happen.

Carlos is a dear sweet man. He would never intentionally do any wrong to anyone. Still he did primarily because he was not a forward thinker or a progressive thinker, or an evaluator. if one continues to do bad work and see it as good. eventually you harm enough people to carry that stigma the remainder of your life. How anyone could put plugs on a scalp or do scalp reductions for 30 years and not see the error of their ways, I have no idea. I became interested in hair restoration only because men wanted hair so bad that they would be willing to look like circus freaks to have it. How anyone could continue to offer such appalling work for years without ever thinking twice about it baffles me. I think it all goes back to the same old acceptance thinking that precludes advancement in the hair restoration industry as a whole. Think about it. For 30 years no one thought plugs and reductions were bad yet then suddenly things changed. Why? New docs simply said these results are unacceptable. Still, why did it take 30 years. I have no clue. I knew right away.

Yes, I have heard all these stories and much worse. I still hear how patients are told their strip scars will be pencil thin. That's fine unless you are the average which is not pencil thin or even if you are pencil thin but you marry two different hair growth angles and two different qualities of hair.

[John P. Cole, MD]

Ok, I'll look for words of wisdom tomorrow. I have to go to sleep now. I have 10 lab puppies that need to exercise their bladders at 3 am and then again at 6am. Training hunting dogs is a full time, part time job. Then I need to feed my ducks, quail, and pigeons. Goodnight. It's been fun.

[topcat]

Okay good enough. One last thought, would putting about 30 or so 4 mm plugs into this hairline be the work of a dear sweet man. I was 23 and thought I was adding a little hair to the temple regions. I now realize at the age of 50 I can tell someone in the twenties pretty much anything and they will believe me. Why someone would intentionally steer them in the wrong direction because of money is beyond me, maybe they are just wired differently.

Money does strange things to people and I see it on these forums daily as I see it in life. When I watch the many that come here and tell me how good of a person they are I think they are trying to convince themselves as they are constantly repeating it almost out of guilt.

I rarely bring up my own past as it really doesn’t matter but what does matter is what these guys that are in there 20’s are being told.

[topcat]

I worked in the night club/bar business for over 25 years and I can tell you 90+% of those employed were to varying degrees alcoholics. It sometimes made it difficult for me to work in that industry but I always stood by my principles. People would laugh at me when I would have trays of wheatgrass or 50lb sacks of carrots delivered but they accepted me over time.

The HT industry in my opinion is the same 90+% dishonest people to varying degrees and working in various capacities so most don’t get what I do especially when I derive nothing from this except the satisfaction of doing something good. Time to start the 10% club where having principles matter.

[John P. Cole, MD]

I think you made your point exceptionally clear and I agree. There are all sorts of nice people in any industry. How about the good old father Obrien down at the parish who gives you communion on Sunday and then gives your son something else on Monday. Nice does not insure someone is honest, decent, professional, or good. Nice men lie, confabulate, conspire, and ruin lives all in an effort to improve their personal situation. I could not agree more. Sometimes nice people ruin lives out of a degree of ignorance, however. Take the case of Thalomide which was sold over the counter by the nice pharmacist for morning sickness in the 50s only to discover soon there after that over 10,000 children developed birth defects. In the case of Thalomide, however, it did not take more than a couple of years to put two and two together and regulate the drug. Prior to this drugs were not thought to cross the placental barrier even though the effects of alcohol on the fetus were well known by then. The whole medical industry was ignorant.

In your instance, I have no compassion for the man who did this to you. You need to bring this up over and over again because it drives home a very significant point.

In 1958 Norman Orientriech published the first well known paper on hair transplantation when he described moving plugs of skin from the donor area to the bald recipient area. Orientriech gained notoriety out of this and he has been honored by hair restoration physicians many times over. He gave us the Orientriech punch or the tools of the trade. Now, the story I heard from a researcher that worked for Orientriech years ago was that Orientriech did not develop the either the technique or the punch. He learned the technique while in the Navy from another officer, took the method and the tools, and then put them all out there for the world to see under his name once his teacher died. According to this tale, he paid off the family of the true originator. Now I have idea if this story is true or false. What I do know is that if Orientriech, the inventor, did not develop the tools or the craft, then this is one reason the hair restoration industry stood stagnant for years with nothing more than plugs. True innovators do not sit pat with one technique. They are always looking for a better way. If you were never a true innovator, you were more than happy to keep the same old method around for decades with the tools in your name.

So, how long did plugs stick around? From 1958 until the mid-1990s this was the "gold standard". In 1988 Limmer first described total follicular transplantation. It was not until 1991 or 1992 that we saw our first 1000 graft strip surgery. Now, you know how resistant the medical industry is to change. First, they usually don't think there is a better way. Then, they don't think the better way is better. Then, only under market forces (patient demand) do they want to learn a new method. This transformation takes about 10 years. That's about how long it took for FUT to become main stream and about how long it took for FUE to become main stream.

My question to those who practiced hair transplant surgery from 1958 until 1990 is why on earth did you keep putting plugs on the heads of people when they looked so hideous? Why would you do this to a 23 year old when you have been treating patients for 20 years and watching what happens to 23 year olds who begin to loose their hair? One cannot forgive such a person. If you had been practicing hair transplant surgery since the 1970s as I'm told Carlos had, how could you have missed that 23 year olds with hair loss are the ones who get the most advanced degrees of hair loss. In 20 years, you had to recognize the limitations of the donor area. At the very best, a donor area would yield 350 to 500 (4 mm) plugs and that certainly is not enough hair to conceal the plugs or the bald scalp of a NW 5 or greater. Those who begin to loose in their 20s are more likely to become a NW 5 so prudence should have dictated that you don't do it.

Now if you are 50 now, that means you had your procedure in 1986. Plugs were the gold standard back then. By then, Carlos had been doing hair transplants for about 10 years. He should have known better, but he did not.

I often say that I did not choose hair transplant surgery for a field. It chose me. I had the opportunity to see a number of men who had gone through hair transplant surgery. I asked all of them a series of questions. Why did you have a hair transplant? What do you like about it? What do you dislike about it. The vast majority stated that they wished the result looked more natural, but they preferred having hair over the alternative of being bald. This started my journey in hair transplant surgery with a single goal - give men what they want and make it look natural.

When I began doing hair transplants in 1990, I began by reading what was available at the time. I skipped through what was old and went straight to the sections relating to new technology, follicular units, single hairs, and such. Then I asked to visit a man with 23 years of hair transplant experience and he allowed me to watch while he taught. I was taught many things. One was that hair loss stops at age 35. That is pure rubbish. Another was not to worry about donor area management for the ages. Again that is rubbish. Be aggressive in young men. Again this is dangerous rubbish. He taught me how to build a hairline that looked terrible and was angled improperly. He taught me how to do scalp reductions, which never benefited anyone other than the pocket of the doctor. When I tried to discuss new technology to him, he treated me like the young Dr. Arrowsmith and banished me to the prairie. There was no where to go back then to learn the new stuff. One had to develop it on their own back then. The same was true for FUE back in 2002 when I became infatuated with the technique. The same issues with donor area management, procedure, methods, goals, possibilities, etc. all had to be developed with FUE as they did with FUT in the early 90s.

Now it did not take me long to realize that the gold standard in hair transplants in 1990 was terrible. I never understood why it took those with 15 years of experience such as Carlos to recognize the same.

He was not an innovator. He has always followed market forces. In other words those who learn based on market pressure don't learn new technology until patients stop coming because you don't offer a procedure. Then you learn it. Once you have no choice other than to loose money or learn, you decide to learn. These sorts of followers are not the ones who look at the advantages of new technology. They stick to what they are taught and never budge until forced to budge. They never question how bad things look. To them, it's just hair. The same today is true with strip surgeons. They don't see their terrible strip scars. They don't even understand why you are so distraught about it. "What are you worried about, you have hair on the top of your head" is what they say.

Personally, I like Carlos. That does not mean that I am tolerant of what he did to patients for many years. I have had my share of repair cases from his handy work over the years. Many did not have the money to pay me. Carlos will tell you that his worst advertising is his old patients. He has to live with that the rest of his life. I consider it fair punishment for what he did to young men in the prime of their youth, however. He needs to wake up every day and think of all the harm he did and then remind himself every time he looks in the mirror.

I'll leave this discussion with this comment. In 2005 I applied for an ISHRS fellowship training program. At the time, Carlos was the head of that program. In the program, you had to list an outline of your training in detail with regard to every aspect of hair restoration surgery. One had to deal with donor harvesting, recipient area, etc. Two topics were scalp reductions and flaps. Carlos was always a big fan of scalp reductions. My education on these was very succinct. "They don't work". Carlos denied my fellowship application because I would not give formal training on scalp reductions and flaps. I wasted a 1000.00 application fee along with hundreds of hours of work to put this program together. Still, I was not going to teach procedures that are most prone to damage lives. Carlos and I are still friends, but then again, he did not put 4mm plugs on my forehead. If he had, I might feel a whole lot different about him.

Never stop telling your story. If you don't tell it, people will never know that the vast majority of physicians doing hair transplant surgery have absolutely no idea what a good aesthetic result is. They just do what ever it was that they were taught. There are very few who say, "that looks like crap, let's look for a better way". Then there are also few who say, "I learned a good method, but I'm going to try to do a better job than what I was taught". My job is to teach as many as possible how to do the job right now, because there are not many who will try to take what they learn to the next step. If they learn it wrong, chances are good that they will always do it wrong.

[John P. Cole, MD]

Topcat, I never looked at your photos before, but I can tell that Brandy got ahold of you too. You went to the cutting edge at the time. I can see why you are suspect of the cutting edge. This lift business was never a good idea. I paid to attend one of Brandy's workshops in 1993. I walked away knowing I never wanted to offer that procedure. I can also see that you've had quite a bit of good work including body hair. Recognize that in 2002 non of this sort of surgery existed in the USA. By the time that Dr. Bisanga went out on his own in 2005, I had already developed all of it and personally trained all of his surgery staff that worked for him in Cyprus. A good hair transplant is a team effort. One does not do this procedure alone and it takes at least one year to train a team. You need a team. You are a huge fan of Dr. Bisanga, and I am too, but I'm curious what aspect of your amazing transformation that he pioneered. There are only two guys that I know of who pulled this rabbit out of the hat. One was Ray Woods for thinking of it. The other was myself for actually doing it. You are a carbon copy of a case I began in May 2003 and that is long before Chris saw FUE. When I began that transformation in 2003 none of this stuff existed anywhere in the world. I had to invent the technique and the tools. We did not show this sort of thing to Chris until the summer of 2003 and at that point all he knew was strip surgery. Did he do something new that I don't know about? If so, I'd love to advance my knowledge.

The Brandy lift elevates hair onto the top of the head at the expense of hair in the nape of the neck, back of the head, and above the ears. You've been stripped out. When you said that Dr. Bisanga had gone into the lateral humps of your scalp many times with no depletion, the first thought in my mind was the Brandy lift which essentially elevates the donor area onto the sides and top of the scalp. In short, the donor area moves superiorly. It was just a bad idea. It also appears that you had the slot correction he was so proud of that put that semicircle scar down the back of your head. Then someone over harvested yoru donor area and left a wide pink scar. Your nape hair is elevated on the back of you head. This is prone to loss over time too. One way I've tackled this sort of thing is to use abdomen hair to create a new nape of the neck.

I'm glad Chris was able to do this for you. I know from experience just how hard a case like this is and how much time it takes. It is good to know someone else can pull off a restoration like this as there are not many who can accomplish a repair like this. You are also fortunate that your body hair grew. It does not always grow. In my experience only 25% of body hair patients get good results. In the rest, you may get some growth, but you can't see it. Beard hair is the exception. It grows to an average yield of 60% and I've seen over 90% with Acell in combination. Of course this was a limited study without statistical significance. Still beard grows well, long, fast and curly. It's the coarse and curly nature that some don't like. So, you have to test beard first to see if patients like it. Your result looks great. I'm sure it's a bit thin because no one has enough hair to do the whole head, but totally awesome. I'm so happy with your result.

Well, I guess my case is a bit different. He had minigrafts on the hairline in addition to the brandy lift. I had to remove all the mini grafts first, but I redistributed them. It was an amazing transformation.

By the way, your conditioning looks awesome. Many doctors can learn from this sort of transformation. Give us the steps involved. In mine, I took out the mini-grafts first and relocated them to the entire front. I also had to take out two and three hair grafts along the temples that had been placed in front of the brandy scars. Removal of grafts with FUE had no been described before I first did it. Then i moved leg hair to the temples, chest hair to the top, abdomen hair to the nape of the neck, leg hair to the scars, and then harvested hair from the lateral humps (top and sides) to the front. I moved leg hair to the area above the ears, white walls. It was a great result. I never moved beard, but beard can be a great source. He did not have much of one.

[topcat]

I am very familiar with Thalomide but I like your story about Father O’Brien much better. Why do they come back those that were victimized and sometimes do the same to others. I have seen repair patients or at least that is what they call themselves come back and profit from this industry any way the can and I know for a fact that they are dishonest because I have spoken to too many and have too many e-mails. But they continue to claim they are just paying it forward, chin up and all that crap. It’s hard for me to wrap my mind around it, it’s surreal.

Yes we all have different experiences and I will leave you with this last thought. Alex Jones the inventor of the Nautilus line of fitness equipment was both an innovator and inventor but in actuality he was more of a marketer. What he had claimed was an improvement in actuality was not, in fact one would have been better off lifting a rock as the hormonal effect on the body would have been 10 times that of what he claimed his machines were doing. Many in the industry felt pressured to buy his crap as the demand was coming from the public who didn’t know any better and there wasn’t anyone around to help educate them. So a lot of time and money was wasted and many are now coming along discovering the old way thinking it’s the new way which always makes me smile.

One day I will tell you the story about Leo Stefanos who owned a small candy shop about 6 blocks from where I grew up in the 70’s. The name was Dove Candies. It’s a good story as one could say the final outcome would be exactly where fue is heading if robotics spends enough on marketing. I knew that Dove bar Leo made very well, it was the absolute best in the world no one could touch it and Leo was a good honest man. Today that same bar tastes like sh*t.

[topcat]

Actually the real credit goes to Paul Paraskevopolus he is the one that really spread the word about Leo. None of us would have known as we thought what we were getting was the best. Every time we heard those Good Humor bells we would be running like lap dogs until Paul set us straight. Why did Paul do it, simply the excitement of an eleven year old and I would like to think that the eleven year old still exists in all of us. Paul didn’t care about money he just knew what he knew and he knew others needed to know.

Who would have thought I would be telling that story 40 years later and it would mean something. Makes me really believe we are all here to learn and regardless of our circumstances overcome them and help as many along the way as possible. We really do learn from so many people in our life.

Paul Paraskevopoulus………………thank you wherever you are.

[John P. Cole, MD]

This is the difference between the Artas extraction sites and a small sharp punch. The Artas uses a small sharp punch that is 1.0 mm and then follows with a "duller" punch that is supposed to be 1.2 mm. They claim this dull punch does not cut skin, it only dilates the 1.0 mm extraction site. You can clearly see from this photo that the extraction sites are much larger than 1.0 mm. Also, as you move to the side of the head, the hair growth angles begin to change from downward (negative) on a Y axis and zero on the X axis to downward on the Y axis and negative direction on the X axis. As this occurs, their dull punch is actually sliding across the skin, cutting a huge ellipse as it goes, and making an even larger wound. This sliding will occur because the punch enters the skin at the angle of hair growth and because it is not sharp, it begins to slide rather than cut. It's also one reason why over 15% of their grafts are completely transected.

If you go to the list of physicians who own an Artas, there is not a single one of them that really ever did much FUE at all. Sure, one guy did one or two smaller cases a month, but that's not really enough to become highly skilled at something. For most, their first introduction to FUE was the Artas. Another bought it only because he could not do FUE, but his assistant could do FUE. He was scared that if his assistant quit, he would loose all that FUE money he was making letting a layman with no formal medical training cut his grafts for him. Thus, he bought an Artas. There certainly is not a single owner of the Artas that I would consider a world leader in FUE. If I were a patient, there is not a single one that I would let do my FUE procedure. Most bought the Artas so they could offer FUE to their patients without so much as a reflection on how poorly the thing operates. They just don't know and the company representatives are not forthright about the true follicle injury rate. Those that do own this machine also use it for marketing purposes. One guy with clinics all over has it on the front of his website. He's the one that told me he was going to buy it for marketing purposes alone and did not care if it worked. He has no idea what a good FUE procedure is, but it's clear that his purpose is to make money. Another physician told me that the Artas was better at FUE than he was so he was going to buy one. My advice to all of them would simply be to let the company build a decent product and then buy one. Until then, they should not offer FUE. Clearly there needs to be a 10% FUE club as you mentioned. There is not a single one of these physicians or their Artas that would be in that club.

I have trained a number of physicians in FUE. Some quite frankly should not be doing FUE because they have terrible hands so I tell them this. I offer hands on training outside the US. Do you think a single Artas physician ever asked me to show them how to do FUE? Nope. Not one. It was easier to just buy the machine without ever discovering what good FUE was prior to making that investment.

I believe that you need to first understand the principals of FUE. You begin by learning manual extraction. You need to know this so that you can understand how to use a mechanical extractor safely. Then you advance to mechanical extractors.

While there are many good engineers working on this project, they have not gotten this thing right yet. I hope they will, of course, because as you suggest, there is too much market pressure on physicians who either are unwilling to spend the time to learn FUE or they don't have the skill to do FUE. Patients are demanding FUE so expect more and more to buy an Artas simply for economic reasons.

[John P. Cole, MD]

Yes, Topcat, appropriate analogy of where FUE is heading, I fear. I pray I'm wrong.

[35YrsAfter]

He has no idea what a good FUE procedure is, but it's clear that his purpose is to make money. Another physician told me that the Artas was better at FUE than he was so he was going to buy one. My advice to all of them would simply be to let the company build a decent product and then buy one. Until then, they should not offer FUE. Clearly there needs to be a 10% FUE club as you mentioned. There is not a single one of these physicians or their Artas that would be in that club.

I have trained a number of physicians in FUE. Some quite frankly should not be doing FUE because they have terrible hands so I tell them this. I offer hands on training outside the US. Do you think a single Artas physician ever asked me to show them how to do FUE? Nope. Not one. It was easier to just buy the machine without ever discovering what good FUE was prior to making that investment.

Patients are demanding FUE so expect more and more to buy an Artas simply for economic reasons.

I spoke with a surgery technician who attended the recent hair restoration meeting in the Bahamas. She mentioned to me that while attending the meeting, two hair transplant doctors mentioned to her, they were considering purchasing the Robot strictly for marketing purposes.

35YrsAfter also posts as CITNews and works at Dr. Cole's office

[topcat]

Thank you for the detailed explanation. Having worked on heavy machinery including having done my share of machining I find it interesting. I found out the hard way as many when entering codes into the CNC one small error can result in a lot of damage. Not very pleasant when the tool slams into the turret head……..lol……….but I didn’t have to pay for those mistakes………..

Yes I have always worked more than I should have and 80 hour weeks were quite common. I found out digging holes can be quite expensive and the one I was digging was rather large…………lol……………never blamed Carlos and only blamed myself for not being smart enough. Nothing to do with intelligence but understanding not everyone was like me. I couldn’t intentionally harm someone so I never understood that for others it didn’t seem to be a problem. Never expected it from a doctor they left that lesson out of my classroom studies.

I was trained by Paul Ward Phd as a fitness trainer for The Health and Tennis Corp of America back in 78 which eventually became Bally’s. Paul didn’t want Arthur Jones’ equipment in the place because he knew it was crap. But Arthur was smarter and took his message directly to the public. Before long the public demanded it and as is often true the public knows very little. Same could happen with the ARTAS so the 10% should probably step up a bit more and educate the public as it is needed. I try but I have already been banned from 2 forums. One several years ago let me know that my promotion of FUE was very dangerous and that I should just move on and good luck to me………..lol………………they seem to be singing a different tune now as do some of the reps, funny how that works. He who pays the piper calls the tune.

I always thought of starting something where the 10% could get together but to be honest I can’t see myself making a dime from this business nor should I. My interests are in the field of health and fitness and I have a device I designed several years ago that targets the core. I have built 2 prototypes over the last 7 years and hope to bring it to market. I know I move slow but it works much better for me. But I continue to post because the building is burning and I don’t like to leave people behind. Trying to put a book together on how the forums work because I find it both bizarre and fascinating.

It’s seems to me as an outside observer that the 10% have painted themselves into a corner and need to do business a certain way which is so sad. I mean I look at one forum where the person advising others actually uploads his own homemade fetish internet porn and I think my god what are these doctors thinking. No one should be making any money in this business except the doctors and their teams. Surely that 10% are intelligent enough to figure it out as they must be a better way.

[Arashi]

Dr Cole, so you say that not only a complete new graft grew but it did produce hair long enough to Pierce the skin, all in just 4 weeks? That sounds quite impossible ?

[Boldy]

Good question Arashi. Talking from experience regarding previous ht's, everything you see in donor, in 3-8 weeks time line, are regrown transacted hairs, and maybe hairs in resting phase(telogen), that got a boost from acell/prp.

[FearTheLoss]

Dr. Cole, could we get an update on your regeneration studies? how are things coming along with Aminofix? Could see the pictures of your recent study?