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

[topcat]

Thank you for the nice answer. I think my diet would be too long to go into, why I eat what I eat and when I eat it. I would say that I do consume much more cholesterol than most and I’m sure as a doctor with your training you would highly advise against this as that is part of your training and the information you are exposed to which would be understandable.

Personally I believe most of the medical training is controlled by those at a much higher level for the benefit of those that are in control much like many other things in the world and most doctors can’t think outside of that box and even if they tried that are quickly put back into line.

My only question is the suggestion of the 1 inch or 4 sq cm area having all the follicles removed and showing regeneration. This same question was posed to Gho well over 10 years ago and we still have not seen an attempt so of course it is very normal to ask the question.

I’m sure you can appreciate someone just getting to the point it does not mean one is being rude. We are all men here equal in my eyes. My main concerns here and why I continue to post is to see honesty and highly skilled work that doesn’t harm the patient.

[John P. Cole, MD]

Topcat, there are different ways to harvest follicles. One way is to take part of a follicular group. Another way is to take all of the follicular group. sometimes, this is easy. Sometimes, the donor area is not conducive to this. If you harvest part, the donor area will look more natural, but you will move fewer hairs because you leave more in the donor area. I do this often and this is what Dr. Gho has been doing in my opinion. He suggests that he is taking only part of the group down the middle of a group. There is not instrument capable of doing this. If the is able to do this, he should sell the tool because he could make a fortune.

Thanks for the diet information. Dr. Bisanga was one of my top surgery techs when he worked for me. He did not have a license in the USA so I started him as a surgery tech in hair transplant surgery in about 1998. We started him off in practice in Cyprus because he had alot of talent. You found a good one. Both he and I have always liked to eat so talking about nutrition is a good way to get both of us interested in the subject.

[topcat]

Okay well I feel the question has still not been answered. If Acell is promoting regeneration that show a 4 sq cm area with all the follicles removed by way of fue apply the mix and show the regrowth.

Of course I think Dr. Bisanga is highly skilled and has natural talent and I also like him as a person. He is very easy going and very easy to get along with which is something that is personally very important to me. Of course you are highly skilled that is well known and I have always told others the same and nothing different regardless of what others might think I am honest.

The highly skilled guys should all get together of which there are very few and start their own club. No need for me to mention who I believe belongs in that club but it would make it so much easier for other patients. The forums could be eliminated and we wouldn’t have all this nonsense that goes on and I say this only as an outside observer on something that has had a tremendous effect on the direction of my life but in reality most of it has been good for others not so much. I still see too many being misled by those that they believe are doing good as they keeping honing their image as being the good guys.

[John P. Cole, MD]

i don't think you could draw the line in the sand any more clearly regarding what you want with respect to Acell and regeneration, Topcat. Will do my best. Just recognize that while I have some computer talent, it is not where it needs to be on this one. I'm sort of in the hands of others in my office and some are not local. I have to catch them when I have time. In that I harvest all my grafts rather than use laymen like the robotics guys or Dr. Shapiro, I just don't have the face time I'd like to have with my computer geeks.

Yes, Dr. Bisanga is quite good. It is interesting that two on this forum came out of that class of assistants. One was Dr. Bisanga and the other was Dr. Mwamba. Both are now running very respectable practices in Belgium.

I get assistants all the time that worked somewhere else and they want top dollar. Most are not very good to be honest with you. It's pretty clear that their physician before me never bothered to monitor their quality of work. Most have to unlearn the bad habits and then learn how to do it right. Drs. Bisanga and Mwamba started with me, did a great job, and carried over their skill set and experience to their own practice. Both learned to the direction to make recipient sites by placing grafts in sites I made. Both learned what a graft should look like by knowing what I expected. Most physicians never cut many grafts so they don't have a clue what they should look like. Then most have never placed many grafts so they don't know that aspect either. Drs. Bisanga and Mwamba learned the basics first. It helped make them top tier physicians later on. The best physicians know how to cut their own grafts and how to place them. If they physician does not know this, how can you expect him to place levels of expectations on their staff? Honestly, they can't. It's like owning the airplane. If you have never flown it, you don't know when the pilot is doing a great job or when he is prone to kill you and all the passengers. Physicians have to get in the trenches first.

Regarding quality, I agree with you that we have set higher standards, but my personal belief is that the only true way to get a top notch quality control system is to have a physician who knows what should be going on making the judgement about who is good and who is not so good. The current system is like having a blind person judge a beauty contest. The judge can put their hands on you all they want, but you need one with vision, perspective, and insight to judge true quality. When I do repair work on patients who had surgery by physicians who are on various recommended lists, one recognizes the limitations of the current system. We are certainly much better off than we were in previous years, but we have a long way to go.

This is especially true with FUE. This is the hot topic buzz word today, but there are plenty of guys offering FUE today who have no formal training in FUE. They have few results. Many use laymen to harvest the grafts. Donor areas are not something to play around with. You can't go out and buy more hair after a surgery tech chews through it with a mechanical punch. FUE is similar to cutting grafts in that respect. If the physician does not know what he should be getting out of a donor area, then the surgery tech will produce what ever he wants and the physician will be happy. The only problem is that 30% of the hair might be destroyed and no one knows any better. This sort of thing is going on all over the world right now. Medical boards seem to be turning a blind eye to the whole matter based simply on the fact that no one is raising any alarms to this. Most likely, it will take some sort of class action lawsuit against practices that allow laymen to harvest grafts with a surgical punch to put an end to all this.

I'm all for great results. If a physician knows what is in a donor area and he knows what should be coming out of the donor area and he monitors follicle injury, then I'm tolerant of using techs to harvest grafts. I'm not a fan of it, but I'm tolerant of it. If the physician does not know what is in a donor area, if he does not know what should be coming out of the donor area, and if the does not monitor the follicle injury, I'm completely intolerant of this practice. The same goes for robotic surgery as this is predominantly done by physicians who have no experience doing FUE yet they turn the practice over to layman monitoring. Recognize that in one recent study with the robot that over 50% of the grafts had at least one transected follicle and almost 16% of the grafts were completely transected. Because the grafts simply disappeared the robotics folks just disregarded them and their response was that no one looks at grafts that closely. One can't calculate transection rates when grafts disappear, but one can estimate that about 30% of the hair was transected in that case. Patients can't look that closely, but physicians should even though it appears they are not. I think that if patients knew that follicle transection rates were so high, they would not allow a robot to do their surgery. Then again, people often seem to surprise me. Perhaps they are tolerant of such sub-optimal work.

Now I make my own equipment based on my own personal very high standards and expectations with regard to FUE. My standards are based on over 10 years of experience in FUE and over 5000 cases of FUE. I made several prototypes prior to using a single mechanical extractor on many patients. The reason i delayed using one was that the mechanical extractors could not match my manual methods. Only when i made one that could match my manual methods, did I begin to use it. I offer instruments for sale, but this is not to say that anyone can use them. Those with no talent can't make a paint brush create a masterpiece. A robot is designed to make someone with no surgical talent create a masterpiece. The problem is that a head moves every time a person breathes. A robot can't keep up with that. We are not screwing on nuts on a stationary object. We are trying to hit a perfect spot on a moving object. what is more, the objects are all different. Some have 3 hairs. Some have 6 hairs. Some have 2 hairs. the exit angle is always changing. Robots can't keep up with this.

The bottom line is that if you want good hair transplant surgery, find a good surgeon. Don't expect a robot to make up for a lack of skill in hair transplant surgery.

When I was in the 3rd grade, I wanted to play the trumpet. Those in the music department told my mother that I had no ear for music, but I really wanted to play the trumpet. My mother bought me a used trumpet and I tried for 2 years. I tried really hard. I practiced all the time. I was so bad that i was sent to the back yard to practice. In two years I learned to play one song and not well. That song was Mary had a little lamb. After two years, I recognized that my music teachers were right. I had no talent for music. I moved on. Now my daughter can play the violin very well, but I now know that I could never do that. Some physicians have no talent for hair transplant surgery. Robots certainly don't. When you don't have the talent, you just need to move on. Otherwise, all you will do is butcher your project just as I did with mary had a little lamb. Butchering a song is one thing. Butchering a patient is simply unacceptable. If your talent is so bad that you need to rely on a robot, just don't offer the surgery. Stick with strips if that is what you are good at. If you can't do FUE, my equipment is not going to make you successful at FUE either. My equipment is the best on the market for FUE. However, just as a Stradivarius violent is amazing, it can't make someone with no musical talent such as myself into a maestro. Remember, you can put all the lipstick on a pig that you want, but at the end of the day, it's still a pig.

[topcat]

Thank you for the reply and although I’m not a surgeon nor do I work in this business I don’t need to in order to agree or understand as for me this is just plain common sense that applies to many things in life but most don’t seem to get it.

I have posted many examples in my own way over the years to try and help others understand but I’m not always sure the message gets across. I have even taken a picture of a wooden gate my neighbor built and hung…………lol…………..I have watched him for years. He does not know how to use a level or a square the most basic tools of the carpenter so of course one can’t expect him to hang and build a gate that will look good and work well. I agree you either have the talent or really do everyone a favor and move on to another line of work. You either have that vision in your mind and can see it or hear it or you can’t.

I also agree with the bottom up approach of understanding and becoming good at anything and can use so many examples in my own life. One must always master the basics and that mastery can only come through repetition and what most don’t get is that it is almost endless repetition over and over again both physically and in your mind when others would least expect it that person is practicing in their mind, behind the wheel, at the dinner table, the waiting room, wherever. Does everyone have this ability or the desire to want to be that great, the answer of course if no.

Finding out who has the natural talent along with the vision and determination to be really great is the most difficult part of researching a hair transplant once again my own experience in life outside of what goes on in the ht industry is that most people are very lazy. It’s not enough to only have the talent or to be surrounded by people along the way that help you as we all have been helped by others in some way at some time in our life but one needs to have that inner drive to just want to be the best. Where does this come from, I’m not quite sure but for me personally I can use any situation negative or positive to become better, to use it as a driving force and not give up. From what I have observed most that have tried fue by hand have given up………too hard for them. So why in the world would someone choose a person that gave up so easily or did not have the skill because now they have a robot…………sorry but I agree, no thank you I’m looking for someone with determination.

I also believe although it might be hard for many you need to be a people person to be in this business. It’s important to the patient and it’s important when one wants to surround themselves with a high quality high caring staff. I remember reading the experience of a patient from that Cyprus clinic about 10 years ago. Dr. Bisanga did not perform a procedure on this patient while the patient was at the Cyprus clinic but what he did the gesture that he made really stood out in my mind. It can only be described of an act of a very kind, gentle man that cared and had a big heart. These too are important traits.

Sometime it’s almost like I have too much life experience in the area of working and dealing with people as my work has required it and I can give so many more examples of so much that matters when trying to figure out this industry and who is honest and who is not. It has gotten much easier over time.

I look forward to seeing updates and thank you for the reply.

[534623]

Please feel free to call or email me with any questions. Ask for Chuck

Is it allowed to ask a question ...


...concerning this ...hmmm... should I say "photo" or "photos" - if you understand what I mean with "photo vs. photos" ....

[topcat]

I think we can all thank many around us for some of the skills and good qualities that we have may possess. I always thank my dad for giving me such a strong work ethic and just general drive to want to excel at whatever I choose to do.

Someone I think that is not given enough credit is Dr. Woods. Regardless of whether he chose to share information or not as I believe had I been in this same business knowing how many of the vultures in it operate I might have done the same. What I do really respect about him is that he is not afraid to be politically incorrect and state exactly how the industry along with the forums and some of their operatives work. For that it seems that he has had to pay a very hefty price at least that is the way it appears to me but I can respect a man with a set of balls.

I think the biggest move forward in this industry will not be a new technique or process but when these handful of really talented doctors trying to do the right thing put any ego they have aside and decide they have had enough of what they see going on and form their own group. I would love to see this happen and have nothing to gain accept the satisfaction of seeing these wannabes but will neverbes out of business along with those that work in this industry and can only be described as snakes in the grass. I watch and hear what some of them do and it really turns my stomach because I was that young guy once. These young guys think they know but they really don't understand what is going on and it's not as easy as simply telling them.

Maybe one day it will happen.

[John P. Cole, MD]

Very interesting, Topcat. Yes, we both agree. You have to want to be good at something. You have to have the talent. Then you have to get the experience. When Dr. Bisanga worked with me in his last year, we worked 7 days a week three weeks out of each month for one year. He got the time to become very good and he wanted to be good. He was a very hard worker and he helped me out when I needed his help the most. So did Dr. Mwamba, but Dr. Mwamba was with me through 2005. He got a ton of exposure to FUE. Both did everything I ever asked them to do and they never complained. They always put the patient and the result first. I always demand that of my staff, however. If they are sloppy in their work, they don't last long. Those that we keep are very dedicated to their work. They work tirelessly to produce the best possible result. I would never have succeeded without my wonderful staff over the years. I demand alot of them, but they always come through. My belief is that each patient's hair loss and restoration or repair situation is the most important thing in their life at that moment so we have the duty to give each case our absolute best. If my staff is ever having a problem in life, I always ask them to leave those problems at the door of the office and deliver their best effort for every patient. If a problem in life prohibits them from doing their best effort on any given day, they know that they have my blessing to stay home because nothing can interfere with the quality of work each day. I never had that issue with either Dr. Bisanga or Mwamba. They were both wonderful assistants and they have both become outstanding hair restoration surgeons.

This is my best attempt to show the extraction sites. It is interesting that when i went back to the extraction site overlay, one of the sites i thought had nothing clearly had at least one hair. Often you can't see the difference between one hair and two hairs in a photo. I often prove this even under my 6X magnification by trying to extract a single hair unit only to find that almost all are at least two hairs. With a photo, you simply can't tell if it is one hair or two.

The overlay did not fit perfect, but it is close. Size of the images is a little different.

Also, one site I was certain had a hair probably does not.

Remember that we had 5 hairs growing in 5 extraction sites at about 5 weeks. At about 3 weeks I put in the tattoos because it was getting hard to find the extraction sites because they were healing so well. The tattoos were not placed exactly like the 1 sq cm area that I harvested from. I placed them only so i could find them.

The blue line represents the tattoo marks. All extractions were within these marks. The green circles represent definite regrowth sites. The purple represent the definite no regrowth sites. The red represent sites I'm not certain about. I am least certain about the red circle to the bottom left.

[topcat]

Well I have been observing this industry for a very long time. I have spoken to many people over many years, listened and have taken notes along with having almost a photographic memory. I can easily draw back into my collection of information and pull out all kinds of facts but I will leave that for another day.

I will say this from my own life experience. I have had many teachers along the way and I have developed many skills along the way. My practice of many of those skills can only be described as having passed those of many of my teachers . That is life sometimes and many of those teachers smile when they see me do my thing and that makes me feel good and I’m sure they feel the same.

Thank you for the update. I can’t say I’m convinced but I say that with no agenda and only honesty. I will keep watching.

[John P. Cole, MD]

Well stated. Every teacher wants their students to advance. While teachers advance after students move on, one always hopes to learn from the student. There are so many ways left to advance this discipline. No one person can do it all on their own. A student that stands still is not advancing the discipline. There simply are too few who step out of the box and come up with improvements.

When I first started in this field we had plugs and mini grafts. They looked terrible. A handful stepped out of the box in an effort to create a more natural result. The vast majority of physicians were much slower to adapt, but over time they adapt. One always wonders whether this adaption is based on aesthetics or patient demand for a more optimal outcome, however. The good ones keep advancing and always stay a step ahead of the vast majority. It is the little things that make the greatest difference.

[topcat]

Sure nothing wrong with advancement but patients who know very little need to be better informed and extremely cautious. If we were to believe in each and every advancement we would all be tattooing our heads, having robotic or endoscopic fue or who knows what else. The majority of the advancements over the years are gone because they were in fact crap and were only meant to advance the numbers forward in someone’s bank account. So of course one needs to always move forward with extreme caution when listening to many of the carnival barkers in this industry.

[John P. Cole, MD]

That's true. If you have been in the field long enough, you know when it sounds too good to be true. With anything new, you need to exercise a degree of caution. I know from experience with body hair that I didn't believe it would work. Then I tried it and the first few cases were great successes. Then I had some major failures. One needs repeated success to pass judgment.

Many probably have some application such as the tattoo. Tattooing has limited use, but then again we really need to follow it a long time to make sure that it does indeed fade with the newer pigments. I can't imagine someone will be happy with blue dots once their hair turns white. Then there are those that rarely if ever have any benefit such as scalp reductions, plugs, minigrafts, flaps, and balloon expansion. Even body hair works well in about 25% of the patients. Beard hair works well, but it sometimes looks like beard hair and that can be an issue for many. Come to think of it, even hair transplants aren't the best idea for all patients. Strip scars can create long term problems for many. FUE does not work optimally for all. I thought of endoscopy a long time ago to replace strips, but who wants a bald zone in the donor area. I think it is worth seeing what happens long term with this method to replace FUE. I'm glad people are innovating. We all want a better aesthetic result. The one thing we can't do is replenish a donor supply. That's why I'm hoping for continued success with Acell and hopefully stem cell therapy later on. Stem cells have not worked out yet. With the Acell bandage we apply, there will be issues coating a larger area and it is costly to apply. It is a cost I will have to eat for now and in limited trials. One trial certainly does not suggest future positive results. Also, we might be replacing three hairs with one hair in some sites as only a handful of sites appear to have multiple hair growing.

Next we will have to do one box without Acell and one box with Acell to evaluate if there is any firm improvement with Acell as opposed to placebo. We will also try to do a better job with photographs going forward as we learned a great deal about their importance in this single patient trial.

[topcat]

Stem cells in my opinion are a long way off. I have watched Geron for about 20 years and the FDA has a way of crushing anyone regardless of the amount of data they provide or money spent if it is a threat to the status quo. It is only when the status quo benefits that it will come to market and as of now the money is being made in current treatments not cures. Although they were working with patients suffering spinal cord injuries it still poses a threat to the greater market. Sometimes we can see the same in hair transplantation when something that is actually better comes along it becomes a threat to the status quo, thankfully they don’t wield much power.

Acell experimentation is not even on the FDA’s radar as long as you are not trying to cure cancer you are safe. If no harm comes to the patient then it just becomes a matter of proving something of which I have not seen much.

Advancements come in many ways. I had an interaction recently and without going into great detail I was so impressed with this person I had to let them know. We conversed briefly and he passed on the title of a book he gave his daughter when she was 12 and it made a huge difference in who she became as a person. I in turn purchased that book and also passed on another book to this same person that I regularly keep several copies of as I believe it is one of those types of books of which there are many that can advance someone as a person so I tend to hand out a copy here in there for people I think are special in some way. We both advanced as people during that interaction which can sometimes be more important than advancing in the engineering of ideas.

I read a book by Daniel Golman it must have been almost 20 years ago. There was a short story in it that I always remember and it can relate to hair transplantation as it is a team effort and as a patient I want the whole team to not only be great at what they do but happy that they are doing it. So as I have written advancements come in many ways. I will cut and paste the story below from “Emotional Intelligence” as I’m sure many can learn from it.

In his book, Goleman relates the story of Melburn McBroom, who was a domineering leader, with a bad temper. The problem with this combination of emotional deficiencies was that he also happened to be an airline pilot. In 1978 as McBroom’s plane was approaching Portland, Oregon to land, he noticed a problem with the landing gear. He decided to maintain a holding pattern as he obsessed about the landing gear. His co-pilots watched as the fuel gauges approached empty, but they were so fearful of their leader’s wrath that they said nothing. The plane crashed, killing ten people. This story is told in training courses to enforce the need for teamwork, open communication, cooperation, listening, which leaders with high emotional intelligence foster.

Don’t want to get to far off topic so I look forward to further updates.

If you get a chance take a look at my posting in the "off topic rants" section. " Leadership in the HT industry. I thought it was worth posting but unfortunately I think most will miss it.

[John P. Cole, MD]

That is a good story. One could also theorize that with a problematic landing gear in certain circumstances, it was more prudent to hold the course looking for a solution than to put the plane down especially in cross winds and down shears. Who lived to tell the whole truth? As you suggest, a team approach is of benefit unless the rest of the team has a sure death option. In which case, a more cautious approach might have been optimal provided that the fuel gauges were accurate, which they often are not. I owed a plane for many years and I know that small things make a huge difference between life and death. One time I was flying from Charlotte to Atlanta in the rear of an 8 seat plane. I looked out the left side and noted that the left side engine had stopped soon after take off. I made my way down the aisle to the ****pit and told the captain that the left engine had stopped. He was the most gracious person you could ever expect to know. He turned around and told me to sit down and shut up. He worked for me, but I could tell in his tone that he was aware of the situation, the situation was serious, and he needed to focus on landing a twin engine with one engine working. A twin with one engine wants to turn in circles. He did not need teamwork. He needed focus. He landed the plane and we all survived. Sometimes those on the team think they are of help, but they are not really. Do you honestly think that those about to die because there was no fuel simply shut their mouths so they could be the focus of someone’s book? I don’t. I think they noted it, they were scared to death, they froze, and somehow they must have lived to tell the tale. No one dies because they are afraid to say the fuel is empty when the alternative is to live and say there is no fuel.
Let me tell you another plane story. I was in the ****pit one night flying into weather. My pilot had us on course to land without visibility or Instrument Flight Rules (IFR). Suddenly, the ****pit came alive from the tower asking us to say position. My pilot stated his position and the tower came back to pull up immediately because we were 7 miles off course. Still we continued to descend. Finally, I turned to the pilot and said “they said to pull up because we are off course” He did. We came back on the IFR and landed safely. My pilot upon landing told me he was “shitting kittens”. Don’t suggest to me that someone about to die is not going to take corrective action because they are afraid of persecution over death.

People express concerns out of fear that the actions will result in serious negative consequences such as death. They do not express concern because they are not sure that their beliefs are potentially disastrous. One does not express concern when they are not certain. One does express concern when they are certain. One does express an opinion when one has an idea based on experience that an action will result in a negative consequence. If one does not have such experience, one is not likely to express a concern.
Then there is the gentleman approach where you do not say anything because you want to be pleasantly professional. This is an approach common in medicine where someone disagrees, but they don’t say anything out of professionalism. Actually, they do say something, but only under their breath, but never to the guilty party. This is pretty common in medicine.


In my clinic, I am tough. I expect miracles. My staff knows what I expect. They respond. When I make a slight mistake, they correct me. Does that sound funny? I’m that really tough airline pilot, yet should I make a single mistake, my staff knows and they let me know. That is what you are talking about. Teamwork. My staff knows that my expectations are so high that they will not allow me to make a mistake however so slight. We watch out for one another, but they are so compelled because I am so compelled. While I cannot imagine a team allowing a plane to crash as they watch the instrument gauge run to no fuel, I can imagine a compulsive team making certain that no one makes a single mistake. Humans do make mistakes. A well greased team prohibits even the slightest error even by their leader. My job is to make sure they know what is right and what is wrong. We watch each other’s back, but ultimately, the quality control is in my hands. They know I don’t tolerate mistakes and they have the same perception of my work.

Topcat, I think you are a work of art and a breath of fresh air. You are right. i need to look at your writings because I am certain they are full of wonderful insights and analogies. I think they could very well make us all better people. You have made me think and perhaps I need to think deeper. Deep thought is never a hinderance when your work holds the welfare and happiness of others in your oh so limited human hands. Thank you for your comments. My rebuttal is simply off the cuff and could change as i continue to contemplate your valuable lessons.

[topcat]

Well I laughed at your response as it was very good and very interesting. Some of it I would disagree with but we all base on views on different experiences.

I have spoken to countless repair patients as I’m sure you have. Something some of us have in common and is kind of unique is that same fear of authority that kept us from taking appropriate action to save ourselves before it was too late. One story in particular from a patient relating his experience during a flap procedure struck a nerve for me and was especially eerie.

When I sat in that chair 28 years ago and caught my first glimpse of Puig I knew with no doubt I was in extreme danger but I was frozen by the fear of what I perceived as authority so you see sometime this does happen as I remember it very well like it was yesterday. I guess there are always two sides to the coin and I am aware of that also through other personal experiences but I will spare you the stories.

Even today when I hear from the patients who got switched over to strip at the last minute because the doctor told them they were not a candidate for fue I understand what they must be feeling when it happens and I despise a doctor that would do this to a young man or a rep that would represent him.