A FUE Question For All Top Doc's

Body hair transplantation is still only practiced by a handful of surgeons worldwide because it requires special instruments and techniques, is extremely time consuming, and the results and yield can be quite unpredictable. Though it would be wonderful, I don't foresee a point in the near future where doctors will offer donor recharging for free, or even at a minimal charge. In addition to the fact that many doctors don't have the experience or desire to perform BHT to begin with, even those who are comfortable working with it feel that there are many limitations to the medium, and find the extraction process extremely tedious and labor-intensive. For this reason, most BHT doctors discourage patients from using body hair unless it's a last resort, and when they do perform procedures with body hair, they charge a premium.

Hi CITGIRL

Well its a shame that only a few Dr's offer this technique because FUE alone in my opinion will not work on larger norwood scales...!

And yes I know Cole's motto of "LESS IS MORE"

I personally use a rule of thumb that states each norwood scale needs around 1250-1750 grafts depending on the hair shaft diameter and overall density in the donor area

So in a nut shell ....
A norwood 2 would need 1250-1750 grafts
A norwood 3 would need 2500-3500 grafts
A norwood 4 would need 3750-5250 grafts
A norwood 5 would need 5000-7000 grafts
Ext......

So without recharging with body hair or some other means then how can any FUE doc feel they could help a norwood 3 and beyond BY fue ALONE!

If that many grafts were to be taken out of anyone's donor area it will at some point start to become extremely thinned out and wispy regardless of the starting density

Also If there is an existing scar in the donor that's well hidden what do you personally think will happen at that point?........Yes it will stand out like a sore thumb

Listen all im trying to say is I'm not an advocate of strip ether especially in the wrong hands but FUE can be the better option if done correctly (proper sized tools) and donor recharging

If it comes down to a Dr not wanting to do what should be done for the esthetic result and for the patient due to BHT being a more tedious and tiring procedure then he should think again!.......And that goes for all Doc's

Telling a future norwood 6 who is at a norwood 3 that he is in good shape with a 2500-3000 graph donor area is in my opinion being lied to.

Don't get me wrong this has nothing to do with Dr Cole personally as a matter of fact I think Dr Cole is extremely artistic and does fantastic work but if i'm not mistaken he only does CIT now ......and does not like to do strip anymore ether.....

And that's ok but he needs to fill the larger needed numbers in some other way

This should also go to all other FUE practitioners in the business...BHT RECHARGING IS A MUST WITH THIS TECHNIQUE!.........PERIOD!!!

Its just simple math!!

FUE HAS POTENTIAL TO BE A MUCH BETTER TECHNIQUE BUT NOT AS IS....

I understand what you're saying but I still think there are just too many limitations and challenges to using body hair for donor recharging for it to become more commonplace.

Men who are at later stages on the Norwood Scale, and opt for hair restoration surgery, simply cannot (at this point in time) expect completely pristine donor areas- whether they opt for strip or FUE procedures. However, even without donor recharging, I believe the donor aesthetic post-FUE harvesting is superior to strip because you are not dealing with the linear scar and distorted hair grow angles along the closure. Dr. Cole's objective in performing FUE is to achieve an overall appearance whereby the density on top of the head is similar to the back- he does this by thinning out the back subtly and uniformly, while improving density on top and up front. Whereas, with a strip procedure, you’re clearing out a center section of scalp but leaving a dense section of hair above and below the scar- permanently limiting your hair length and styling options.

FUE with donor BHT recharging is fabulous in theory, and we have had great success using it on certain patients, but it is still too unpredictable of a procedure to be more widely adopted, or to be a standard part of FUE work. It is further complicated when we get patients who have already had strip procedures who want to hide these scars in addition to desiring further work in front or up top. We do a lot of scar grafting procedures but, again, grafts to not 'take' to scar tissue as well as they do to virgin scalp and it can therefore take more than one pass (and additional donor scalp or body hair) to achieve desired coverage.

So, essentially, there is not yet an 'ideal' solution which allows hair to be transplanted to the recipient area while still maintaining a 100% pristine donor area in the back (and if this is someone's goal, we'd advise them never to get started with hair restoration surgery). However, we have come a long way already and we continue to study how we can make further improvements with the use of new technologies, such as ACell.

What type of results can more or less be expected then?

Can you show some more before and after photo's from your clinic?
Im sure most on this site are interested in seeing more!

There are only 2 pictures of BHT on the site and only 1 of recharging....

My question is also if the idea is talked down to only a very very rare few why does the clinic recommend it the first place as a viable option on the site?

As this would be my procedure of choice at this point........Several smaller sessions of 350-500 scalp CIT with the same number BHT replenish .....So that's several sessions of 700-1000 grafts

The technique does work as Dr Umar is doing more and more BHT FUE and only started a few years ago....

Cole on the other hand has been progressing the technique for up to 7 years!

Unfortunately, In my case it would be the only way to go........ a 1 for 1.....

And I regret not using Cole as I think Cole does very good work on hairline reconstruction,,,....

As far as Acell Dr Cooley is doing some ground breaking research with actual follicle regeneration ....As of now its only single haired grafts but is starting to test larger numbers for scar coverage...

He's testing follicular plucking .....A hair would be plucked/tweezed then set in Acell then planted into a scar .........Acell has been shown to regenerate a complete follicle .....The end result looks like a FUE scar grafting session was done....Though its not 100% it seems like a great start.....

CIT Girl...

What type of results can more or less be expected then?

Can you show some more before and after photo's from your clinic?
Im sure most on this site are interested in seeing more!

There are only 2 pictures of BHT on the site and only 1 of recharging....

thanks

I cannot generalize about what results can be expected when it comes to body hair because, as I've mentioned, it tends to be unpredictable and success will vary from person to person. For this reason, Dr. Cole will not agree to perform large BHT procedures on anyone until they undergo a small test procedure with him to see what sort of yield they will achieve, and to ascertain whether they will be pleased with the results of a larger case.

We can only post photos of patients who have signed photo releases allowing us to post their photos. A lot of patients simply want to enjoy their new hair and move on with their lives after undergoing a procedure, and do not want their photos to be posted online (even if we only show them from their eyebrows up). We understand this and do not encourage anyone who doesn't feel comfortable to share. BHT patients, in particular, tend to be more private and, therefore, we do not have a lot of photos we are authorized to share. Those that are available are posted on our website.

Check this link out !

I just found it on the net regarding an FUE patient and Acell!!

Acells Matristem (powder +sheet) application in FIT

FIT (Follicular Isolation Technique ) is a procedure in Hair transplant surgery.
It consists of removing each follicle individually with a small punch .In donor area it creates multiple wound which heals faster .Collagen fibers( scar tissue) fill those empty spaces during the healing process.
Acells Matristem technology is a naturally occurring bioscaffold derived from porcine tissue .When Matristem is placed onto a wound ,it is resorbed and replaced with new native tissue where scar tissue would normally be expected.
With this characteristics ,the A cells Matristem should fill our donor wound and regenerates terminal hairs ;rending our donor resource infinite.

We applied the Acell powder and cover it with the Acell sheet as described in our study protocol.
We would like to present the first observations we made

This is very exciting. I read that Dr. Jerry Cooley and Dr. Cole are working with ACEll too. CIT girl do you know much about this?

Dr. Cole offers ACell at cost to all of our CIT patients. We haven’t done any official side-by-side studies so we can’t make any official claims about regrowth or healing in the donor area at this point in time. From what we know, ACell can regenerate skin tissue and promote faster and improved healing following a hair transplant procedure. Dr. Cole's primary goal in using ACell is to further improve the appearance of donor areas following follicular unit extraction by his CIT method. We’ve received feedback, from veteran patients, reporting that the healing process is much faster with the application of ACell.

Dr. Cole would like to further explore whether ACell might reduce the appearance of hypopigmentation that follicular unit extraction can sometimes leave in the donor region. He is also looking into whether ACell may be able to stimulate stem cells left behind when he performs follicular unit extraction. Stimulation of these cells could potentially induce the development of new hair growth. Again, however, we haven’t yet completed the studies needed to fully evaluate such possibilities.

I believe I’ve read that Dr. Cooley has some further findings that he will be presenting at the ISHRS Meeting in Boston in October- so that should be very interesting.

Hi CIT Girl

Is Cole in the process of doing any research on the subject of Acell?

Or is he just using it as an add-on to his general practice without really researching into its capabilities?

Also many FUE doc's claim that FUE punch tools smaller then 1mm should almost always be used as it produces much smaller hypo pigmentation spots and less of the "white dot appearance"

I know in the past Cole has used larger tools but has he since started using smaller then 1mm punch in his 2010 CIT technique?

I Feel Cole is extreamly artistic is his hairline work but feel there are many people complaining about his extensive white dot scaring compared to say Dr Feller or Umar .....

I however like Cole

The punch size debate, as it relates to white dotting, or hypopigmentation, is one that comes up frequently and, for one reason or another, there seem to be posters on other boards who like to claim Dr. Cole’s punches somehow produce more hypopigmented extraction sites, or white spotting, than other physicians. For many years clinics employing Dr. Cole’s former staff members have made such erroneous claims. These clinics, that learned how to perform FUE either from Dr. Cole or through his former staff members, are hungry for customers and resort to such scare tactics in an effort to get patients. Part of their accusation is that Dr. Cole uses punches that are so much larger that “white spotting” is more likely with his procedure. However, these claims are misleading because, in reality, Dr. Cole uses over 30 different instruments and customizes his usage of the various tools to each patient’s needs and hair characteristics. No two patients are exactly alike so no two patients can be treated the exact same way. The variety that Dr. Cole has are the reason that he has the most consistent FUE results in the world. On a case-by-case basis, he uses the smallest instruments possible to remove each follicular unit intact.

The average hair follicle is about .42 mm in diameter, so it would stand to reason that you would need a punch size of at least .85 mm to remove a 2-hair follicular unit intact. If you use a smaller punch, you may not be able to consistently remove the full intact FU. An advantage of using the smaller punch is that you are more likely to get a repopulation of color in that extraction zone, and thus avoid hypopigmentation. However, by only using small punches, you will almost always only be able to transplant very small grafts, you will not achieve significant coverage for the number of grafts you are paying for, and you are more likely to have damaged or transected follicles. Of course in ideal situations, smaller punches work very well, but again, you have to be able to adapt to the individual patient. Dr. Cole’s adaptability is the crux behind why he has performed more FUE procedures, extracted more FUE grafts, and achieved more consistent FUE results than any other physician in the world. Increasing the transection rate along with extracting predominately one and two hair grafts goes against the very rationale of hair transplantation, which is to achieve density and coverage up top, and maximize the available donor supply. Dr. Cole’s mantra is to achieve the best result with the fewest grafts, and has made his results exceedingly popular with patients.

FUE has been in North America since 2002. Dr. Cole was one of the only doctors in North America performing FUE at this time (along with Dr. Feller and Dr. Robert Jones). Dr. Cole has since performed more FUE cases than any other physician in the world and (directly or indirectly) trained many of the physicians performing FUE today. Suffice to say, he knows what he is doing and how to achieve the best aesthetic results. It’s important to understand that no FUE doctor is immune to the possibility of patients developing hypogpigmentation. If the follicular unit is removed intact, there is a risk that the patient will see hypopigmentation- some patients will develop it, and others will not. Lighter skin tones have a lower probability of developing hypopigmentation, while darker skin tones are more likely to see it. Interestingly enough, however, it is extremely rare to see hypopigmentation in African American patients.

Another interesting issue relating to hypopigmentation is where it tends to develop. When it comes to body hair, we have seen it develop on patients’ chests and abdomens, but only rarely seen it on thighs, legs, backs or beard-extraction areas. We’re not sure why the pigmentation repopulates in some areas, or in some patients, but not in others. Furthermore, the size of the punch has very little effect on the pigmentation changes with body hair in Dr. Cole’s hands. In other words, the skin controls the pigmentation rather than the instrument.

We do know that pigmentation in the skin is comes from three things. One is the melanocytes in the skin. Another is the circulation to the follicles. The thirds is from the follicles in the follicular unit. If you extract an intact follicular unit, you will eliminate circulation to the follicles, which is no longer necessary. You will eliminate the radiating hue from the follicles because they are no longer there. Finally, you have only one source of melanin or pigment left.....the skin itself must repopulate the extraction site with pigment. Sometimes it does and sometimes it does not. Ask yourself, how is it more likely that a very tiny extraction site will produce more pigment than a slightly larger one? Assuming that the intact follicular unit is removed, there is no more likely tendency for the smaller extraction to produce pigment than the very slightly larger one. However, if you have only removed part of the follicular unit, then you are more likely to get pigment from remaining hair and remaining circulation to the follicle. Sounds interesting until you recognize the consequences of such a flawed procedure. The consequence is that you will transplant fewer hairs to the bald area and that you will necessarily kill some of the follicles you leave behind because not all transected follicles survive amputation. Thus, you must decide what your objective is. Do you want more hair to cover your balding area or do you want the most ideal outcome in your donor area. If the later is the case, perhaps hair restoration surgery is not the optimal solution for you in the first place. Perhaps a combination of very little hair and a more pristine donor area are desirable for you. This is why Dr. Cole not only customizes each procedure to the individual donor area, he also customizes each procedure to the individual patient’s expectations. While other physicians seem to paint patients into a corner with few options and possible outcomes, Dr. Cole leaves all the options open and available to his patients.

It is important to know that Dr. Cole makes all his own instruments. He does not buy from manufacturers. He employs a full time engineer and multiple part time engineers to help him create new instrumentation. He makes all his instruments from his own designs. Most other physicians purchase stock equipment off the shelf from a variety of second party vendors. These vendors buy from a variety of manufacturers. Each manufacturer puts a specific label on the punch they sell to the vendor. Each vendor in turn places their own label on the punch they sell to the physician. At that point, the physician may place his own label on the punch. Depending on the manufacturer and vendor, Dr. Cole has found that a punch labeled as 1 mm might actually measure 1.15 mm and a punch labeled a 0.6 mm might actually be 0.9 mm. There is no standardization with regard to punches on the market. Since Dr. Cole manufactures his own instruments from his own engineering drawings, he knows precisely the size of each of his instruments.

Now ask yourself another question: why don’t all these proponents of their personal approaches to FUE using their superior methods to that of Dr. Cole post their donor area results showing how much better their work is? The answer is quite simple: there is no difference in the donor area appearance when you extract intact follicular units using instruments that are within the range that Dr. Cole and other physicians use. In fact, Dr. Cole is the only physician who has actively studied this and found no difference in healing. If these other physicians and their salesmen are so proud of their technique and feel it is superior to that of Dr. Cole, why not shave the heads of their patients and show off their results? The fact is that Dr. Cole has worked on patients that have had FUE performed by almost every physician in the world. Regardless of the physician, the donor area results are the same when intact follicular units are extracted. The recipient area may be different in appearance from Dr. Cole’s results, but properly performed extractions all look the same.

The other topic you mentioned was ACell. ACell was something that Dr. Cole has watched carefully since 2007, but did not consider until it received FDA-clearance for use in humans. Even then, Dr. Cole waited until two other physicians began using ACell in their patients. These two physicians will be presenting their results on Acell in Boston at the annual ISHRS meeting.

Dr. Cole’s main interest in ACell actually relates back to the hypopigmentation issue- he is interested to see whether it can regenerate melanin in the extraction sites, thereby eliminating the appearance of white dotting in those who would develop it. There is also a possibility that ACell could regenerate hair in the extraction sites, though Dr. Cole finds this possibility more remote. However, he feels that ACell’s potential for success is greater for use with FUE, than with strip, because the area we are looking to repopulate with normal tissue is so much smaller in the case of FUE. For example, to remove a significant strip of tissue and then expect ACell to regrow normal skin at the wound juncture and regrow hair where the chunk was removed is asking an awful lot. It is not likely that the 30,000 cubic milimeters you remove with a strip will regenerate. On the other hand, removing 1-3 cubic mm of skin and expecting it to repopulate with normal tissue is asking less than what we’ve already seen ACell is capable of. Acell may regrow the tip of your thumb, but it will not regrow an amputated arm. Furthermore, transected hairs in the donor area have the potential for regrowth. Thus, use of Acell in the donor area seems very logical with FUE. Dr. Greco has shown that a combination of PRP and an extra cellular membrane can induce improved coverage in up to 70% of patients. ACell is an extra cellular membrane. The combination might induce improved coverage from your existing hair. Might it also improve graft survival? We don’t know yet, but it is worth trying. ACell is hardly experimental. It is FDA approved for regenerating tissue. Thus, with FUE it is easily seen as a valuable adjunct. The problem is that it is difficult to deliver to the donor area and adds at least one hour to each procedure.

We have been monitoring our ACell patients for seven months now. One of the problems we have is that very few of our patients are locals and it is therefore very difficult for us to directly assess what ACell may have done for them. If we see a large trend of improvement among our patients who use ACell, we will certainly look into performing clinical trials. One of the limitations of ACell thus far is the delivery. If we proceed with a clinical study, we will need work with ACell to derive a better means of delivery the ACell to the extraction sites.

So, basically, we recognize that hypopigmentation is not an ideal outcome when it comes to FUE surgery. However, we are certainly working to find a solution and, in the meantime, recognize the development of white spotting, visible only upon shaving hair down to the scalp, as a ‘worst case scenario’. Not everyone will get it, though some will, and we very seldom receive any complaints from patients about it (the majority are just so grateful to have hair!). On the other hand, the BEST case scenario following a strip procedure is a thin, unstretched linear scar across the back of the head, a limited amount of hair growing through the scar, and distortion of hair growth angles. Hands down, even in the worst case scenario with FUE, it almost always results in a more pristine donor area than the best case strip result.

Like I said in the past "I LIKE COLE!"

As a matter of fact I would love to go for another session with him .....He did about 800 or so FUE's in my left side hairline with a sprinkle around the front and right side in 2005! I feel the left side looks totally natural and soft..

However the rest in the front and around the RIGHT side started to thin exposing some much older work I had done from Hitzig's older firm Long Island Med.....in 97

I had about 250 mini OVAL PLUGS and 100 singles ....I removed about 100 or so in my at the time too low hairline and dermabraded the area with good results

And was forced to wear a hat for almost 4 years due to the corrections and discomfort!!!

I also had 550 mini Micro's via slit from Eastwood Med Dr Loria that came out ok in 99, but they are not follicular units nor are they 100% angled correctly...

I also have slight hypo pigmentation in the dermabraded hairline side (RIGHT SIDE)

I spent about 2 years researching different Doc's in early 2003-2005 and decided on Cole to do my repair......

The trouble I have is I already have a scar (2 scars to be exact) and was one of the unlucky few that received hypo pigmentation from the FUE's

The area though still full looking and covering the scars will over time become thinned out if my hair loss progresses past a norwood 3 with progressive FUE's ....I presently need about 1200-1500 more in my front 1/3 (according to Cole).........

I also need some pit scars removed from my hairline (about 35-50) but cant afford the $6000 to book a half day with Cole.......as was the office request....That's just way too much for a max of 50 FUE sized pits...!

In a nut shell CIT GIRL I like Cole but no one is willing to give me a game plan or plan of action from your office!...so I'm trying all on my own to come up with the best approach to my situation...
and relay as i go

I know Cole is Busy !!

I may try a few BHT replenish over several smaller sessions then 1 large one due to not knowing the dot issue on my chest....(THE BEST BODY HAIR TO DONOR THICKNESS)

THATS WHY i AM SO INTERESTED IN THE ACELL IDEA......I do not want an extra 2000 hypo pigmented spots along with a thinned out donor revealing my scars......

Cole is however the best at FUE and is not doing much strip these days and rather not do one on me......

Though I regret that I may not have an option to go back to Cole unless Acell and BHT replenish is the throughout solution for my case....I love his hairline work and this is coming first hand.......So as you can see I'm really at odds .....

You also may know I wish i never started down this road in the first place but I was young and stupid (27) I'm now 42............I'm just looking for some closure and peace of mind in 2010...........I don't think that's asking to much........... do you?

I didn't mean to imply that I thought you don't like Dr. Cole or his work!

I think the issue that it comes back to is that, you did not feel that FUE was an optimal procedure for you, and Dr. Cole does not think that another strip procedure is the way to go, and therefore doesn't feel comfortable performing one on you. One of the big concerns he has, in you opting for another strip procedure, is that you will have an increased likelihood of complications, such as significant stretching of your scars. However, if another strip procedure is ultimately the route you want to take, there are definitely a handful of very skilled strip surgeons out there who would probably be better suited to perform such a procedure on you. As you noted, Dr. Cole has really moved away from strip surgery in recent years and would prefer to refer those patients, interested in strip, along to doctors who perform such surgeries more regularly.

Dr. Cole, like many HT physicians, is reluctant to take on patients whose expectations he feels he cannot meet. I promise our feelings won't be hurt if you find another surgeon who is more on board with your 'game plan'- you might even want to shoot Dr. Cole an email and see who in particular he would recommend if you do opt for strip procedure. I wish you the best of luck in whatever you decide to do and really hope you can find that closure and peace-of-mind!!

On a somewhat separate note, Dr. Cole mentioned that a likely reason why you were one of the patients who experienced white spotting might be attributed to the fact that you had your procedure a number of years ago when Dr. Cole was doing something called 'FIT shaven patches'. Before he had mastered his C2G non-shaven technique, he performed this procedure as an alternative to shaven FUE (in your case, probably because you did not want to expose your strip scars by shaving your head). This involved shaving small 'patches' (that could still be camouflaged by existing hair) and removing follicular units from these shaven zones. Unfortunately, this resulted in relatively concentrated areas of extraction, overly thinning out certain areas. Dr. Cole uses the metaphor that it would be like wiping out a small area of trees in the middle of a forest; from a bird's eye view, this would be quite noticeable. However, Dr. Cole recognized the flaw in this method quickly and now extracts FUs over a much larger expanse of scalp. This is like removing the same number of trees, but throughout the entire forest...which would be barely detectable when viewing the region from above. The move away from shaven patches (which some doctors are unfortunately still doing) is an example of the constantly evolving nature of hair transplant surgery- top doctors want to continuously raise the bar in terms of quality and aesthetics.

"Dr. Cole, like many HT physicians, is reluctant to take on patients whose expectations he feels he cannot meet. I promise our feelings won't be hurt if you find another surgeon who is more on board with your 'game plan'- you might even want to shoot Dr. Cole an email and see who in particular he would recommend if you do opt for strip procedure. I wish you the best of luck in whatever you decide to do and really hope you can find that closure and peace-of-mind!!"

Well I'm not counting Doc Cole out yet and also hope you are not throwing my case in the garbage ........... I still feel he does some great hairline work..........its just the method of extractions we/i need to work on via CIT/ BHT

I also dont think my expectations are set that high , a natural looking hairline, some moderate density and some scar work.........all of which i think Cole is extreamly capable of

I'm also still thinking about the BHT replenish as mentioned Cole also stated the possible reason to for the hypo pigmentation and felt he would do his best to assist in my repair along other lines like the BHT idea....With Acell

As far as your office feelings not being hurt... WHAT ABOUT MINE!~

I spent many months looking over top docs to make my decision on cole

So you are more or less telling me that asking to work hand in hand in my personal case is reason enough to disregard a patient to another clinic?

Also at this point if you understand whare the mistake was made then i feel a rectification is in order........