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

[John P. Cole, MD]

I certainly appreciate all the feedback I can get regarding any procedure. Years ago, I could learn from all my patients regarding what works well and what does not work so well. Then patients began to come from all over and it became more difficult to evaluate each response to treatment.

PRP is supposed to deliver growth factors that promote improvement in the quality of existing hair. If you have received one of these treatments within the past year, we will be contacting you next week to evaluate how you responded in areas that we did not graft or in short term responses in areas that we did graft. We expect you to do better in areas that we grafted long term in areas that had existing hair even if PRP has no benefit.

If you have pre-existing hair, we expect these areas to improve about 8 to 12 months after a procedure without PRP. If you improve sooner, it suggests a PRP benefit. If you improve in areas that we did not graft, then that suggests a PRP benefit. Then there is the possibility that you improved due to PRP and grafts over a span of time.

Combining PRP and Acell should result in a greater probability of improvement without grafts, but they do not guarantee such improvement. What we need to know is how many respond favorably. This is why we will be contacting you beginning next week.

Then again, you might heal faster with PRP. This is common especially with a 1X PRP concentration. Then we also feel you will get more growth factors with a 5X concentration of PRP and this might help improvement in yields and in the quality of existing hair. A high cell count improves the probability of swelling. Swelling is not necessary to induce hair growth. What we want is a low cell count and a high platelet count. Only the Angel system allows this sort of differentiation.

Now getting back to your question. Does Acell reduce redness? Does PRP improve healing? Might my last procedure not heal as fast as the more recent procedure?

We feel that Acell improves healing long term. We also believe that Acell can prolong redness, but Acell may not. We believe that PRP speeds healing in many, yet some may not heal as fast with PRP. PRP should improve healing in most, however.

In general, I have heard that my technique heals faster than most. Small incision sites heal faster than larger ones. Still we never expect anyone to grow hair before the 3rd month and at 3 months only 30% will grow. If you have pre-existing hair, don’t expect an improvement for 8 to 12 months and then plan on 12 before your hair looks fuller. Only those that were totally slick bald will see results at 3 months. Those that started with hair in an area that is grafted will not see new growth. What they will see is an improvement in coverage after 8 to 12 months. Your hair will suddenly appear fuller. It is similar to planting seed in a mature field of crop such as corn. You will not see the new corn stalks, but after they reach maturity, the whole field looks fuller. Alternatively, if you plant crops in a fresh area of dirt, you can see the new growth immediately. Once that crop grows, however, you can’t see new seedlings emerge because they are hidden. Such is the case with crops planted in mature fields. What you see is a thicker filed of crop only after the new seedlings grow to a height even with existing mature crops. Such is the case with hair. Only after new grafts grow to a style-able length will you see them.

Then there is this particular case. I studied this result last week. Then I studied the overlay we did beginning this week.

Here is my response. At 4 weeks I saw 5 grafted sites growing hair. Each site was still a little bit apparent most likely because Acell stimulates vascularity. I could see hair in pink extraction sites. Thus, we know 5 of 12 sites were growing hair at one month. Then, 3 months later I evaluated the area. My belief was that 3 sites had no growth and one site might have a single or a two hair re-growing. Then I looked at the overlay.

With the overlay, I feel there are 6 sites growing, 3 sites with no growth, and 3 perhaps. When I look at the overlay, I feel it is off slightly so there may be 7 or 8 sights growing and 4 or 5 sites not growing. The good news is that there area sights growing. The bad news it is hard to be exact at this point.

Yes, Acell can prolong redness, but in the long run, Acell can improve the overall donor area and perhaps also the recipient area. Still, we need to study this all further.

[topcat]

My own case is very well documented with what I would say is the quickest healing I have seen in watching the forums for years and viewing many cases. Some of my photos clearly show hairs growing as early as 8 weeks in the recipient area. I am 50 but my body can perform the same or better than the majority of 20 year olds mostly better. I have found this to be all diet related and as the old saying goes “let medicine be thy food and food be thy medicine”

Nutrition is truly the key.

[topcat]

As far as regeneration goes. Dr. Bisanga has gone into my lateral hump area 3 times to harvest what is left of my scalp donor and to be quite honest the area is as thick as ever……….hmmmm…..regeneration from superior nutrition…………..I don’t have documentation so you see where we get into some hairy issues if I were to start making that claim.

It has been stated on these forums for years. Extract every follicle from an area 1 square inch then let’s see if one has regeneration without attributing it to some normal hair cycling. Surely you can find one volunteer for the sake of science.

[Artista]

Dr Cole, Thank you for being so active here! Also-
Thank you so much for your hard work and ongoing dedication to the use of Acell.
I have been a huge Acell advocate way before it was even considered as a possible treatment for hair loss.
The 4x4 sample photo on this thread is an eye opener !!

[John P. Cole, MD]

Topcat, I agree that nutrition is very important. it's probably the one area that we've over looked in hair restoration surgery. I think a well balanced diet obviates most issues, but an improved diet is probably very important. Glad to hear that you have not lost density from harvesting. I measure cross sectional trichometry on all patients with hair that is long enough to measure. This is a measure of 4 square centimeters of hair surface area. basically, it's like taking a box of spaghetti noodles and measuring the surface area of the bunch. a box with more noodles will have a larger surface area. A box with larger noodles will have a larger surface area. I measure the surface area after FUE and i also have alot of data on those who have undergone strip surgery. in a nut shell, surface area of 4 sq. cm of hair decreases alot more after strip surgery than with FUE.

One of the things that happens with FUE is you tend to get white dots on the scalp. these are very easy to see and I most likely could find them on you Topcat. One thing that makes this case so difficult to evaluate is that they white dots are absent. That's probably part of the Acell affect.

Many hair restoration patients are very concerned about diet and health. I've not seen diet alone regenerate hair. Still, I think it is worthwhile for you to describe your diet.

Thanks, Artista. Many times it is the forum members that alert us to new ideas to be quite frank with you. We had 5 sites growing hair when they were still pink and easy to find. We will work on circling this week when we get time. I do think this is important. It's just not as easy as it seems

[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.