ACell, a Current Review of Applications in Hair Transplant Surgery

[John P. Cole, MD]

As you know, I am still waiting to see confirmation that Acell and plucked hairs produce a viable alternative. Until then, I will stick with FUE plus Acell on the grafts, as well as, treat my donor area with Acell.

Here is an example of a repair case that wanted fuller coverage and to look more natural. He had multiple prior pluggy transplants that left him unnatural and with multiple scars in his donor area. The prior grafting left him with few scalp hairs to graft.

When I do a repair case, I ask the patient if they want more hair and to be more natural or do they simply want to appear more natural. If they want more hair, I try to leave as much hair as possible from the original grafts because you can never get 100% of the hair to re-grow with you attempt to redistribute it. Then after adding hair, I reduce the larger grafts that are still visible. If they want to look more natural, but don’t want more hair, then I reduce the grafts using my method of FUE, which I call CIT. If they simply want to be bald, I try to remove all but single hair follicular units and then try grafting the removed follicular units into the donor scar.
Given that the donor scarring in this situation was so severe, it would have been difficult to make the donor area of this individual appear entirely normal. Therefore, simple removal of the grafts might have required the patient to keep the back and sides long rather than giving him the option to shave his head.

Based on his limited donor supply, I had no choice other than body hair. Body hair does not work in all individuals, but it worked well in this case. His beard hair grew well, but his chest hair did not. Adding Acell to the chest hair grafts in the follow up procedure resulted in a better chest hair result 10 months later.

The photos here show that grafting body hair can produce a nice result. When body hair works, it is a proven entity. I feel Acell may improve the results of body hair grafting, but we will need time to see. Body hair is not for every patient. You should have a test procedure done prior to a large procedure. You should do the same with plucked hairs and Acell in my opinion.

We grafted a small number of head hairs to the top, but most of the coverage is from beard hair and chest hair. We treated the scars with beard hair and chest hair. We also treated the extraction sites with Acell in the follow up visit. We treated only the scar area with Acell in the first visit. We also treated the area with PRP in both procedures. In the follow up procedure, we put Acell powder on the grafts and injected it into the recipient site.

In the follow more recent procedure I de-bulked some of the frontal hairline plugs. The latest photos were from the most recent procedure. The goal here was to add more density to the perimeter of the crown where you see the purple marks. The idea is to attempt to match the density in the center of the crown at the perimeter. If grafting will not accomplish this, we might consider de-bulking the central crown plugs.

As you can see, it is possible to treat a class 7 with grafting alone even when the donor area is markedly scared and when it is a repair case. My concern with plucked hairs as follows: When someone plucks hair to groom themselves, they are not plucking almost the entire follicular structure. These hairs will likely grow back. When you are plucking to get growth from Acell, you are plucking almost the entire intact follicular structure. I’m still looking for evidence that you can get two from one from this method. I’m also looking for a case that makes a measureable difference in appearance and yet leaves an almost intact donor area.

I would start by measuring a pre-operative hair mass index in one tattooed area of the donor area along with as accurate a hair count as possible. I would then pluck hair from the tattooed area and place the plucked hairs in two different boxes in a bald scalp. I would treat one box with Acell and the other box without Acell. I would then calculate the yield at 6 months and one year in each box. I would also measure the hair mass index and hair count in the donor area tattooed area 6 months and 1 year later. If everything looks good, you have a positive sign that Acell benefits plucked hair growth and that the donor area grows back.

Keep up the research. it's interesting.

[wolvie1985]

"My concern with plucked hairs as follows: When someone plucks hair to groom themselves, they are not plucking almost the entire follicular structure. These hairs will likely grow back. When you are plucking to get growth from Acell, you are plucking almost the entire intact follicular structure."


Please enlighten us doctor on how the act of a 'grooming' pluck differs from an HT pluck. As has been brought up here before in response to your previous anti-plucking manifesto, if the world's female population had figured out a way to pluck an eyebrow in a certain way so that the hair doesn't grow back, we probably would have seen it by now.

[SilverSurfer]

Measuring regrowth of the plucked area

Dr Cole,
I find the method you are proposing to be accurate. I just have one question, if the hairs come from the beard, who would want a tatto in that area? Or in any other area of the head. Isn't there a better way to keep track of the area without the tatto? Are you referring to a permanent tatoo or some temporary kind of ink that will fade away easier?(I don't know if it exists but it would be useful in this case)

[SilverSurfer]

The repair looks very good by the way. The patient must be very happy. Congratulations.

[SilverSurfer]

What would you think on using beard hairs taken from the neck area, either below or in the area of the adam's apple(looking for the lowest point). Plucking in a straight 1 cm line horizontally. Measuring the density of the area before the plucking and 3 months or 6 months after.

I would go with an area located at the lowest point of where beard hair grows to use as reference and then measuring 1 cm up and across. This way you would have as reference the lowest point of the beard and the measurement would just have to be taken from that point and above.

To measure the growth in the recipient area I think the best way is to get a totally bald spot and try in a few hundred hairs like Dr Hitzig and Dr Cooley did and then measure what percentage 'took' in. Measure the caliber and the cycles (which appears to be the most difficult).

[RichardDawkins]

Right now iam really happy with the turn the things go. Thats what i think was missing the last decade before. The interaction between hairloss sufferers and surgeons and the will to go new ways, even if they may sound "unbelievable" at first.

[uselessgomez]

Wow, NICE repair work, Dr. Cole!

I am very impressed.

[KeepHoping]

Dr. Hitzig,

What is happening with the the patients who have gotten hair transplants with PRP/Acell? What is the growth like? How many more hairs are you getting than anticipated? Is it like 3 to 4 times than what's expected? I want to get an idea of how much coverage can obtained with a lower amount of grafts when implementing Acell/PRP into the mix. I'm trying to plan the next move at this stage and want to get an idea of the results coming in and when we will be able to see them?

A big thank you to all the doctors working with Acell and experimenting to find a solution.

[RichardDawkins]

Dr Cole

does this mean that you are also trying and experimenting with Acell and plucked hairs or are you suggesting your idea of doing it to others?

WOuld be nice to hear that you are also go for the plucking with Acell.

[John P. Cole, MD]

Plucked hairs

These are plucked hairs that are derived from grooming. Both males and females produce this sort of plucked hair when grooming their eyebrow, ears, beard, nose hairs, or any other unwanted hair. You can put Acell on these plucked hairs all day long and I have very little faith in the potential for hair regrowth. If one could get these hairs to regrow, you would indeed have an inexhaustible supply of hair or "autoclonning".

[John P. Cole, MD]

Plucked hairs

These are both follicles obtained from the donor area. The one on top is a fully intact follicle. The one on the bottom is an example of the hairs that both Dr. Cooley and Dr. Hitzig are calling plucked hairs. What is the difference? The difference is a minuscule amount of tissue at the base of the follicle. In other words, the plucked follicle is almost fully intact. Naturally, if you transplant this almost fully intact follicle, you would not be surprised to see a high percentage of them grow. If you add Acell to them, you might see a higher percentage of the follicles grow. What you are not likely to see is a high percentage of growth from the minuscule amount of tissue that remains in the donor area. In other words, you are better off to have fully intact follicles transplanted to the top, which have a much higher probability of growth than these almost fully intact plucked follicles in my opinion.

[John P. Cole, MD]

Plucked follicle

This is a stained version of the plucked almost fully intact vs the fully intact follicle. The one on top looks like Bart Simpson. This is the almost fully intact plucked follicle. All it lacks is the round part at the base of the follicle. Now who really thinks that if you leave only this tiny round part in the donor area and remove the rest of the intact follicle that you will get 100% regrowth in the donor area?

In other words, Bart Simpson is missing the top round part of his head. So is the plucked nearly fully intact plucked follicle. So are people who really think that this round part of the head could regrow a fully intact Bart Simpson.

[RichardDawkins]

This may seem right BUT as you can see there is a demand in the balding community for this. And i think this plucking in combination with Acell is definitely worth trying.

But i can understand that this may sound unbelievable to most people but, if we dont try it then we wont know for sure.

If i would be a US resident i would glady be your "Guinea Pig" for this procedure or Hitzig/Cooley.

And this means much because iam not a fan of FUT or hasty reactions, but this time well its only a win/ win situation (and i was more then just sceptic at first) but some biology departments at the university did try plucked hairs with an ECM substance and it worked.

The key thing is the tissue left at the plucked hair. Sometimes even when hair falls out by natural cause you can see white dry and solid tissue stick to it, but its dry and dead.

As a self experiment i did to myself i plucked different hairs from different "zones" from my body

1) nose hair (there are three hairs in particular which drives my nuts)
2) eye brows ( there are around six or so which stick out)
3) temple area (there i used a mole as reference point to see if it grows back) actual scalp hair
4) beard hair (again i used a mole as reference point)

Timespan : Around 6 years or more

Observations : Every single plucked hair had at least three times a substances stick to it, the tissue. I could also exactly predict when it in fact had this tissue around.
- everytime when i felt a little sting in the plucked area i could say "White substance" and it was

Result :
1) nose hair : still growing (which sucks) and i witnessed NO difference in size or diameter.

2) eye brows : still growing but in longer time spans. No change in diameter or size

3) temple area : scalp hair is still growing, no decrease in density, size or diameter also no irretations there (scar tissue and or blemishes or redness)
Also no whitening when tanned.

4) Beard hair : dont get me started it grows like i dont know. No signs or redness, scar tissue or anything visible

Conclusion : All areas still grow there natural hairs, i plucked those areas approximately more then 10 times in six years and all of them had some tissue stick to them at some point.

I also did a small experiment with chest hair but after a while i left it because it was really painful to tweeze those hairs all the time, but what i saw was it still grows and even with replacing it with tissue stick to it.

Everyone can btw do this himself at home and observe the things. Maybe those who wanna try it could exactly write down the numbers and charts and stuff.

But believe me nose hair hurts like hell.

So my conclusion is, plucked hairs will regenerate themselves even when you pluck a terminal hair with tissue stick to it.

But i cant test the second part of it "Plucked hairs transplanted with Acell" because i lack the equipment like Acell

[John P. Cole, MD]

I hear you man. i want this concept to work as much as anyone. The issue is merely that what you are plucking contains a small amount of internal dermal sheath and a dead hair follicle. I would love to see Acell make this grow. On the other hand, what Dr. Hitzig and Dr. Cooley are doing is plucking the external root sheath, internal root sheath, and dead hair follicle. they missing only a tiny fraction of the follicle at the base around the bulb. If you pluck a nearly intact hair follicle a few may regrow, but most will not.

think of a follicle as your foot. The part that grows the hair is your sock. Your hair resides in your shoe. when you pluck a hair, you tend to pull out your foot and leave the sock in your shoe. You may have a few fibers on the foot from your sock, but mostly you have a bare foot. The sock that remains behind has the ability to grow a hair. The part that you pulled out of your shoe cannot grow a hair. Now, if you can remove almost the entire sock and leave only the outer part of the toe of your sock in your shoe, then what you remove can regrow an intact follicle. the part tiny amount of sock that remains in your shoe, will not grow a follicle.

when i say we should study the benefits of plucking on the recipient area and the donor area, i mean that we should tattoo a place on the back of the scalp rather than on the beard. While you can remove tattoos easily later on, no one really likes them in a visible place unless a tattoo artist is doing the work. For that matter, we could simply pluck all the beard and see what grows on top and what regrows.

Enthusiasm on your part will help drive these guys to study plucking and Acell. i'd need to visit Dr. Cooley to see what he is doing and how he is doing it if i were going to venture into this arena.

[RichardDawkins]

I appreciate your willingness to actually work with both doctors (thats something i miss from those other self proclaimed "experts").

I personally hope that you get together with both or one of them as soon as its possible because a lot of repair patients and hairloss sufferes in general would be very pleased.

As i said before it would also be nice if there is someone here who would do the "guinea pig" part and get the study done with your ideas and contributions, i would do it as i said if i were a US resident and without hesitation.

So my only advise or recommendation to you Dr Cole, as a hairloss sufferer, get in touch with them and do another step towards helping hairloss suffering people.

Maybe someone here is willing to do the guinea pig job i really hope so.

And i mean, "If donor regrow is possible even with FUE sometimes why not go the extra mile"