Why so many different survival rates for scar grafting?

[northeastguy]

Help!

I have recently been looking into repairing the donor scar I have from strip surgery. It has not been an easy decision..... I have first looked into micropigmentation but thats not the look i'm looking for, and honestly you can still see the scar. I saw some impressive results from a couple MD's but wonder if that is the exception. I have spoken with 4 very well known MD's and I'm getting a huge success range:

Dr A ..... 30-50%
Dr B ..... 85-90% with RPR and Acell
Dr C ..... 70%
Dr D ..... 30%

Obviously it is hard to decide what to do with stats like that!

I'd love to hair (sorry about the lame pun) from a few experts and even patients who have done this.

Thanks!

[534623]

i would choose none of them. reason – low yield aside, when they try to repair an old scar, they just create losts of new scars therefore. they just spread the old problem, even when the procedure is successful

[ejj]

I ve had 1032 beard grafts , grafted into my strip scars, I have no marks or visible scars on my face ,from the extractions . The grafts are growing and so far at ten months post op the growth is as expected . As with all hair restoration procedures it depends on who is doing the procedure , My Dr is Dr Bisanga at BHR Brussells feel free to have a look at my thread

Dont believe the hype on acell and prp , unproven ,untested and no results

hope this helps

ejj

[Spex]

Are you refering to yield of grafts placed into scar?

I agree with Ejj - Acell has no proven results and on the contrary i've seen a few scars with "acell" and not impressed in my honest opinion. The guinea pigs found that out the hard way

[northeastguy]

Ejj...... I just checked out your link. I have to say, those results look quite good. I'd say you got quite a great success rate. Sort of proves the 30% docs wrong....at least I'm hoping so anyway. I have to asume going in for another round would result in an even better outcome do to better vascular support? I'm hearing the number one problem with scar grafting is the lack of bloodflow or vascular support. If that is the case wouldn't you have a 0% success rate?
Spex..... can you explain why Acell is a waist of money? How did users find out the hard way? Does it do damage?

[Spex]

PM ej above and get his personal opinion.

[ejj]

acell = .. run for the hills ....

[northeastguy]

acell = .. run for the hills ....

.... Please enlighten me! i wonder why some MD's swear by it and others don't.

[ejj]

probably because there is an economic downturn and they need to sell there procedure harder

[northeastguy]

Does anyone have links to photos or examples of "Acell disasters"?

[John P. Cole, MD]

There are studies that show the benefit of Acell on the growth of beard hair and chest hair in strip scars. This data has been presented at more than one scientific meeting and it has been published in the Hair Transplant Forum. There are numerous physicians who rarely attend scientific meetings. They often do not think there is anything to learn so they just don’t go. Mean while scientific data continues to build and be presented.

There is scientific data to support the capacity of Acell to promote follicular regeneration in the donor area. To date we have seen as much as 54% follicular regeneration in FUE extraction sites.

Acell is not going to improve the width of strip scars. Jerry Cooley feels that Acell will make strip scars feel more like normal skin.

Acell can help FUE hypopigmentation appear smaller in diameter when follicles do not grow back. All of this has been presented more than once to a scientific body of physicians.

Acell is not available in Belgium. Therefore, do not expect anyone there to recommend it or offer it.

I have heard that some physicians think that Acell makes the strip scar appear more red. This is possible because it stimulates angiogenesis. That means healing. Still red is not something you want in a strip scar if you can help it because it makes it more noticeable.

PRP alone has been shown to stimulate increased hair coverage in some, but not everyone seems to respond. The response is quite variable it seems. Adding Acell may help patients respond better. On top of that, it is possible to vary the hematocrit and PRP concentration so we may find that there is an optimal concentration that has a more positive influence. We do know that PRP will stimulate stem cells, improve healing, and might influence hair diameter.

There is no procedure (FUE, Strip, body hair) that has not had an occasional poor result. There is no physician who has not had a poor result. It fortunately happens rarely, but it may occur. No physician is immune from it. Therefore, it would be ridiculous to suggest that on occasion Acell might make a strip scar more red. Maybe you saw the first two and they were bad. Maybe the next 50 would have been good. I know my first chest hair transplant back in 2003 was fantastic. Then the bad ones came and it turned out that body hair growth in general works well in only 50% of the patients. Beard hair is different, though. It is between the scalp and the rest of the body in terms of growth. For me, I recommend head hair first, beard hair second, and then the rest of the body.

All right. Here is the skinny on strip scars. Head hair grows great in them. The blood supply is fantastic in strip scars. High densities tend to grow well in them. Still, I recommend that you have a lower density placed in your strip scar because sometimes the growth is not as good in normal skin when you have a higher density placed. I’ve never seen poor growth in a strip scar with head hair, but that means it will happen to me one day. Body hair is a different animal. About ½ the time it grows well and then it is visible in only ½ the patients. That means it tends to work out well in about one in four patients. Beard hair works well at all times. Expect a 60% growth from beard hair. As I stated, we can push the yield up with Acell and PRP based on initial studies.

I use PRP and Acell on a regular basis. I’ve never seen an adverse event from them. Of course, I practice only FUE and I’ve practiced nearly all FUE for the past 10 years. The reason I use PRP and Acell is because they can improve results in some patients. In a few, they can make results awesome. I also use liposomal ATP with my patients. I supply energy to the cells in the Petri dish and then directly on the grafts prior to implantation. Why? Because it may matter to one of my patients. It may not affect nine out of ten, but it might benefit the 10th. It’s sort of like the guy who walks along the beach tossing starfish back into the water that washed up on shore. When asked why he bothers because he can’t toss back the thousands of star fish that washed up on shore the night before, he replies, “well, it matters to this one”.
No one ever knows who is going to be the patient who benefits from cold storage, liposomal ATP, advanced holding solutions, PRP, and Acell, but if it makes a difference for you, I’m sure that you are going to be happy. Bad outcomes do occasionally occur so the more things we can do to help prevent them, the better for our patients.

The bottom line is this. Most physicians do not add new technology to their practice until it has been around for 10 years. If it makes the 10 year mark, you might see more and more jump on board. Think about it. 10 years ago there were three physicians in North American including myself offering FUE. All the others said it was a bad procedure and that it would never work. Well it did and now it is here to stay. Acell, PRP, cold storage solutions such as hypothermosol, and liposomal ATP cost money. You are not going to find most physicians spending extra money until the patients begin to demand. That’s what happened with FUE. That is what is going to happen with advances in cell biology. Quite frankly, that is where the real jump is going to most likely happen in hair transplant surgery.

Yes, products like Acell and PRP need more research and objective data. The data is still in its infancy. Adding additional improvements such as liposomal ATP are simply one additional improvement because cells cannot manufacture ATP in sufficient quantities without oxygen and there is no oxygen supply to cells sitting in a Petri dish.

There is not such thing as an Acell disaster, quite honestly. There is plenty of cheap, however.

[ejj]

many times on this and other forums I have requested that Drs contribute to a repair fund , i believe that if 60 Drs threw in 1k per year to a repair fund then six patients could be helped out yearly , what matters is what help a patient receives when things go wrong ....

I am the victim of eight prior strip procedures , each time prior to a procedure papers are signed , I spoke to a person who informed me that a certain Dr in California is the most ` litigious` Dr he had ever come across , my view is that this ` may ` be standard practice across the industry and restricts information and ` may ` explain your comment re ` cheap talk ` as it ` may` appear that way due to restrictions on what can be said.

That said I applaud the fact that you only offer fue


ejj

[Folly]

Nice post Dr. Cole.

[ejj]

ps Acell isnt approved for use on humans in the european union .

Is it really to much to ask for just `one ` set of photographs showing a strip scar ,half treated with acell the other without , and say 20 fue extractions again half with acell the other half without , also photographs showing the donor regeneration , photographs showing the extraction area post op then six months later showing shaved down hair growing out of the extraction sites ?

would be good if any patients could chime in with there results either good or bad as acell has been being used since 2009 now .

ejj

[John P. Cole, MD]

ok, i'll put something up on Acell. What I did in the scar study was to take a patient with two scars. Donor scars are great for evaluating yields because they have no hair in them, usually. A trichophytic closure may leave some hair in the donor scar, but most of the hair that is supposed to be growing in the scar doesn't. One thing that has always baffled me is where does that hair go after chopping off the top of the follicles. i guess it just dies. Anyway, scars have not hair usually. When you do hair count studies on the balding scalp, you never know if the growing hair is preexisting hair that was in a resting phase or whether the growing hair is one of the grafts. With scars, you don't have that problem. They are a dessert without hair.

I put beard hair in one scar and added Acell and PRP. Scars have good circulation, but it is not as good as normal skin. PRP helps deliver more of the stuff needed for healing that will be in limited supply in areas where the circulation is not very good. This is why PRP on chronic wounds works so well. PRP brings the growth factors and proteins needed to repair injured skin. Scar tissue lacks some of this too, which i why i like PRP here.

Anyway, i expect a 60% yield with beard hair when i use it. I've done several hair yield studies with beard hair over the years and this is a pretty common yield in normal skin. I added PRP and ACell to one of the scars and planted 50 Beard hair. The yield was 92% in this scar. In the other scar I did not add PRP or Acell and the yield was ZERO. This was well below what i would expect. Then the patient came back. I added PRP and ACell again to this second scar and grafted it again with Chest hair. The yield this time was 100%. Chest hair is even less likely to have a high yield.

The one issue that concerned me with Acell from the beginning was how to deliver it. I think putting the powder directly in the extraction site is the best option, but it is impossible to remember which sites have been treated and which sites have not been treated. It is also impossible to deliver the Acell well because it has plenty of static charge and sticks to everything. When it is placed in a gel, it is much easier to deliver and make sure that every extraction site is treated.

I've not seen better than a 54% follicle regeneration rate yet. What i do is note the number of extractions I do from each of the 8 major donor regions and each of the 6 minor donor regions. Then I can go back and count the number of empty extraction sites with a pen that counts the number of times i touch the skin and place a mark on the empty sites.

Remember that Acell may not eliminate hypopigmentation. It will make hypopigmentation smaller though. Often times I still see hypopigmentation in extraction sites when regenerated follicles are growing through them. Acell seems to make them smaller, but not eliminate them entirely.

One interesting thing about hypopigmented sites is that they are larger than the punch that is used. They are usually about 1.79 mm in diameter regardless of punch size. With Acell they are much smaller.

I will put up some photos when i get some time.

I've heard a variety of reasons why Acell is not available in Europe. One reason is that the company does not have enough product to supply the world at this time. Maybe I'll call the company to find out what is going on with Acell abroad. I suspect it will not benefit every patient, but again, if you are the patient that it benefits, you are going to be happy. With FUE, I've used it on over 1000 cases and I've never seen a single patient have an adverse reaction to it.

With PRP my only concern is that it can increase frontal swelling. There are different concentrations of PRP and there are different cell components in PRP. I have a new machine where i can specify the exact concentration of the various whole blood components and mix different types of PRP. In other words, I can make a 1 to 1 concentration of PRP with a low hematocrit to treat my wounds (recipient sites and donor area extraction sites) and a higher concentration of Platelets to treat the grafted area and native hair. Before, i could mix a high concentration of Platelets, but it also had a high concentration of granulocytes. Granulocytes are fine for fighting infection, but they also induce inflammation. Patients don't want or necessarily need this and it is not going to necessarily help hair grow. Therefore, I love the new equipment where I can dial the hematocrit way back and eliminate the cells I don't need for cell growth. This is one of the things i'm talking about with regard to the advances in cell biology.

There are several phases of a transplant where things can go poorly. One is the harvesting phase. If you harvest poorly, you damage hair coming out. It is much easier to remove follicles in a strip procedure than with FUE. We are seeing more and more physicians offer FUE, but sadly, they are often not getting good training and performing poorly. My suggestion is to find a physician who specializes in FUE if you want FUE and if a physician specializes in strip harvesting, go with him for the strip. If the physician offers both, he is more than likely not a master of one of them. The next phase we are concerned about is graft production ,which is required in strip surgery, but unnecessary in FUE. Unfortunately, lay individuals do the graft production with strip surgery so physicians don't control this aspect of the procedure. Then there is graft storage where we want to minimize injury due to a lack of oxygen, cold storage, warm storage, and time out of body. Next is the re-implantation phase. This is where i think most of the damage occurs to cells, when it occurs. Replacing cells into the recipient area exposes them to oxygen and this leads to the production of free radicals including hydrogen peroxide, super oxide, and the hydroxyl radical, the most lethal of them all. Some damage may occur from dense packing and some due to problems with revascularization. We don't know all the pathways to destruction yet. What i do know is that strip grafts have adipose on them and this may protect them from the damaging affects of re-implantation to some degree. With FUE grafts there is generally no adipose so the follicles are more exposed to the dangers of repercussion. I think this is one reason to limit temperature, use free radical scavengers, and add energy sources to FUE grafts.