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  1. #11
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    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

  2. #12
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    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.

  3. #13
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    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?

  4. #14
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    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.

  5. #15
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    "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........

  6. #16
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    We’re certainly not throwing your case in the garbage but I (perhaps incorrectly) got the impression that you thought another strip procedure was the answer- something that Dr. Cole simply doesn’t feel comfortable doing for you. We actually had a scar grafting patient in just today who had a similarly extensive and trying experience with hair restoration surgery. He first underwent two strip procedures with a chain clinic. After doing further research on the industry and top physicians, he opted to receive a third strip surgery, this time with a highly recommended strip surgeon. Although he was very happy with the coverage he received, he was left with a scar worse than the one resulting from the prior surgeries at the chain clinic. To address this, he underwent a fourth procedure- this time, a scar revision. Unfortunately, the patient was still left with a scar about ½ centimeter wide, and wider in certain places. Although the latter two procedures involved trichophytic closures, the patient still came to us with a stretched scar, with distorted hair growth angles, and with very limited hair growing through the scar (in some sections, there is none at all). Unfortunately, even the most modern strip surgery techniques do not equal imperceptible scars. I’m attaching a picture of the patient’s scar; for reference, the distance between the vertical purple lines is 3.5 cm. In addition to the width, the scar is very pink, which does not blend well with the rest of the patient’s scalp. The hair growing through the scar is sparse and grows at an upward angle, whereas the hair above and below grows in an alternate direction. This picture also shows finer hair growing in and below the scar, compared to the hair above, which is clearly more course. These are all problems, possibly worse than what you are experiencing now, that could occur if you underwent another strip surgery (and this was in the hands of one of the most highly-recommended strip surgeons out there).



    I don’t want you to feel that we are trying to wash our hands of you. Dr. Cole has to talk people out of procedures every day. Often times, he is trying to keep people off the hair transplant train altogether because, as you know firsthand, it can be a very long journey, and difficult to find an exit. What you certainly don’t want to do is proceed with anything that could potentially create a bigger problem than what you have now. Every procedure comes with a certain degree of risk- whether it is a wide scar, white dotting, a poor yield, etc. No one can create a plan for you; you have to choose the one that carries the least risk for you personally. Dr. Cole is certainly willing to work with you on that. At the same time, however, if you perceive a significant problem with white dotting in your donor region after less than 1,000 extractions, we obviously have to encourage you to proceed very cautiously (if at all). Yes, BHT might be a great option for you, but it could also ultimately be disappointing as it can be a very unpredictable medium.

    Regarding the shaven patches, it is important to understand that, though we no longer consider this the ideal way to extract grafts, it is still a standard practice of care in the industry (much like strip surgery). The procedure Dr. Cole is doing today will not be the procedure he will be doing 10 years from now, or even a year from now. He is always looking for a better way and past patients must understand that there have been years of improvement between what he did then, and what he is doing now. At the same time, he has always done his best to pass modern improvements on to past patients for low or no charge. If he has created any sort of issue for you, he will absolutely look for a way to resolve it. This is the big challenge in being on the cutting-edge of hair restoration surgery and creating new technology: he is in uncharted territory and seldom has anyone to learn from, so he has to learn from experience. At any given point in time, Dr. Cole performs hair transplants in what he feels is the best way possible…only to find later on that there is an even better way. This is simply the nature of his position in the industry; however, he certainly takes care of his former patients and, if anything doesn’t meet his current standards, he is happy to rectify it.

  7. #17
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    I'm not sure what rout to go to CIT Girl at this point I'm so confused !!

    Cole is A good Doc and if i decide to do more CIT in the future he will be the one I turn to

    This also includes BHT .......... Strip may not be the answer, CIT may not be the answer unless i accept the hypo pigmentation issue or Acell works on the spots like in the article i posted.......

    I just hoping Cole and I could work on a step by step plan together sometime in the future....Especially if Acell works half as good as reported

    Please keep us posted on your Acell findings in the future CIT Girl

    Thanks
    Pvt

  8. #18
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    It is very tough decision because there are potential risks to any course of action. Basically, you have to select the one that carries the least risk for you personally- or else decide you can live with your current situation. We'll keep you updated on all ACell findings/developments- we're definitely crossing our fingers, as well.

  9. #19
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    FYI, Dr. Cole had another scar grafting patient yesterday. This patient was happy with his initial strip procedure with another clinic. However, he opted for a second procedure with a highly recommended physician in another state and he is now very unhappy with the strip scar he has been left with (again, no doctor is immune from such complications).



    This is another example of a trichophytic closure, yet it still stretched and, if you look carefully at the detailed photo above, you can see the distorted hair growth angles around the scar. This image shows where Dr. Cole has started to graft the scar in hopes of concealing it. You can get an idea of just how many incisions a scar like this requires for even a single-pass of coverage. This patient had approximately 500 grafts placed in his scar yesterday, and will likely require another procedure in the future to further conceal the strip scar.

    Here are a couple more images of the patient's strip scar:



    Last edited by CIT_Girl; 09-01-2010 at 02:41 PM. Reason: pictures too big

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