ACell, a Current Review of Applications in Hair Transplant Surgery

[John P. Cole, MD]

That so entertaining, gmonasco. I would not know where to look for such links as you point out. There is so much to take home from this presentation, however. Jerry Brown was quite the "looker" in the 70s. He had medium length hair just over his ears. He looked professional yet "hip". Fast forward almost 40 years and his has a shaven head with a Norwood Class 6 pattern. Would he shave his head if he had a strip scar? It is almost appalling to see plastic surgeons recommend a variety of procedures for him. One thing i noted was that no one recommended a hair transplant. I can only imagine what they might say about his strip scar....."he needs to get that reduced....he needs to put some hair in that scar....he's obviously had a hair transplant....he needs balloon expansion of his scalp to reduce the scar".

Here are the points. Even in your 30s you might have a full crop of hair or you may be a NW class 2. By the time you hit 70, you might be a class 6. Jerry Brown did it. Why can't you? Why in God's name would you want a strip scar put on the back of your head for any reason regardless of your hair loss pattern in your 20s, 30s, or 40s? I don't get it. you can avoid it altogether today. What are you going to do in your 60 and 70s when your hair loss has out weighed your donor area? Are you going to shave your head like Jerry Brown or grin and bear it like Joe Biden? The points are simple. Hair loss is a life long process. The consequences of anything you do today are going to catch up with you later on in life. If you have a strip procedure today, shaving your head is out of the question from then on. It is better to do nothing in my opinion than get on that ballon. If you have something like FUE, you will not have a strip scar. At the worst you can relocate the grafts back to your donor area without worry about hair growth angle distortion. Still the best solution of all is to do nothing as did Jerry Brown. Many recommended a brow lift, liposuction, facelift or eyelid surgery, but no one recommended a hair transplant. Still more important, no one recommended a scar revision for his inadequate hair transplant procedure.

if you are going to have hair restoration surgery, it is my firm belief that you should do it in a way such that you minimize the consequences of the procedure. It is better to do FUE than a strip procedure. It is better yet to add Acell and PRP in the donor area when you do FUE. It may or may not be better yet to do hair plucking plus Acell in the recipient area than FUE. Time will tell. What i can say unequivocally is that strip surgery is only for those with minimal hair loss. If your hair loss is greater than a class 2 in your 40s, you should probably avoid it because ultimately your hair loss will catch up with you just as it did With Jerry Brown. You will hear it time and time again from strip surgeons that you should have FUE only if you have minimal hair loss. Well my friends, it is the other way around. The only way you do a good job of hiding that hideous scar is to have minimal hair loss. What would Jerry Brown do with his strip scar today? Would he have been re-elected? I don't know, but one thing for sure is that he would not have his hair cropped short and plastic surgeons would be commenting about more than his eyelids, face, and adipose.

I had a patient in his late 30s ask me about a strip procedure just this week. I told him I would not do it and referred him to several well known colleagues. Obviously strip surgery is still something that many want, but long term will they still want it? i don't know, but i do know that I will not be practicing medicine in 40 years when the complications show up. I will not be around to clean up my scars any longer. Personally I want nothing to do any longer with strip hair restoration procedures.

[Westonci]

Dr. Cole, I have an idea as a way to compromise between your skepcticsm on plucked hair as well as still being able to put the experimental use of plucked hairs to use.

In a regular FUE you take follicular units from the permanent donor region in the back of the head and place them in the balding area. The downside however is that the donor region is depleted as is the case for all hair transplants to date.

My idea is that you would carry out the normal FUE procedure (Extract Follicular units from the back of scalp and place them in the bald area) but you would add an additional step of plucking hairs from the donor region that are left over from the FUE procedure and soaking them in Acell and them inserting them into the Donor holes left over from the extraction sites.

Worse case scenario would be a normal FUE procedure, however the plucked hairs with acell placed in the donor holes do not regenerate. However this is not really a negative since you would end up with the same loss factor as normal FUE hairtransplant.

Best Case scenario, the implanted plucked with acell regenerate a new hair follicles in the donor holes. So you get the results of an FUE with the added benefit of regenerated donor hair.

Since there are donor holes left over from the FUE procedure you may as well put them to good use.

What do you think of my idea?

[RichardDawkins]

I think it is worth a shot. And i know Dr Cole you are sceptical about plucking but i think sometimes risks have to be taken.

Because with your showings about those non existing spots after a FUE procedure, i think you were on the right track.

[HairRobinHood]

What do you think of my idea?

I guess he likes you idea, because Dr. Cole likes everything what makes things more complicated than necessary.

[John P. Cole, MD]

I think your ideas are good. I first did this by taking hair off the legs and putting it in donor area extraction sites. Guess what? The donor area looked better with less hypopigmentation. The problem was that the hairs from the legs were fine in nature. Their coverage value was minimal. Chest hair did better, however. Not only that, when i put PRP in the extraction sites the survival of body hair in the extraction sites was better.

Now here is my concern with plucking hair. If i pluck a hair, will the hair re-grow in the donor area or will it die? Suppose i pluck a hair and put it over in my extraction sites. Suppose the plucked hair re-grows, but the spot where the plucked hair does not re-grow. The end result is a one for one transfer. Now suppose a worse case scenario. The plucked hair re-grows, yet it is finer. Now we have a one for one transfer, but the end result is less hair volume owing to the finer hair. Now the worst case scenario is that i pluck the hair and nothing grows. Now i and a one for one loss.

I'm all for trying new things, but i don't want to do things that are not likely to yield results especially when they affect other people. I spend almost all of my non-family spare time fishing. I would never go where the fish are not likely to bite. The same is true for cosmetic surgery. You need to go where the results are. I'm already putting Acell in my extraction sites. Suppose i put a plucked hair in my extractions sites with Acell. Suppose something grows. Was it the plucked hair or the stimulated hair follicles from the FUE graft that i removed? Best for me to stick to my plan in the short interim. You have a good mind thought. Perhaps you should come visit me and stimulate me mentally. if my plan does not work and plucking does work, then we will all be plucking. If my plan does work and plucking does not, then we will all be doing FUE. I think we need different minds and differnt points of attack to see what works best. One thing is for sure. if i put Acell in a donor extraction and a plucked hair we will never know whether the plucked hair grew or whether it was stem cells from my minimal depth extraction procedure.

Now hypopigmentation is a local phenomenon. We don't see it on the beard or legs. We rarely see it on the back. It is common but not ubiquitous on the chest or abdomen. It is common on the scalp. What these variables tell us is that hypopigmentation is not a procedure result. It is a local result. With Acel we are overcoming the local results and at times re-growing hair.

My greatest challenge is not what i do. My problem is patient follow up. Most of my patients come from different states and different countries. I don't market and I don't advertise. What i have is a long standing reputation of good work which results in many patients. I'm happy to have this, but change is based on seeing your results. What i really miss is seeing my patients every 3 months. I feel this is what made me better over the years. I wish i had that today, but sadly my reputation has superseded my personal touch. What i need is more local patients so that I can follow them up more closely and make changes as necessary. I'm always looking for patients i can follow closely. I live in a rural community close to my horses. When you don't advertise, you simply don't get may local patients. I truly miss having my patients visit my home and i miss having dinner with them....with their families. More importantly, yet not more personally rewarding, i miss close patient follow up. We need this to ensure we are on the better path.

[gmonasco]

You will hear it time and time again from strip surgeons that you should have FUE only if you have minimal hair loss. Well my friends, it is the other way around.

Given today's state of FUE technique and its limitations, do you think it's currently advisable for anyone with more than minimal hair loss to undergo an FUE transplant?

[RichardDawkins]

Even i am not a doctor but with regards to some late findings i say today its more advisable then 5 to 7 years before.

[gmonasco]

There are those who would say that anything more than a minimal FUE procedure presents the same problem as FUT: if your hair loss continues, you won't have more available donor hair for future (FUE) procedures, and you won't be able to shave down due to the FUE scarring.

[Bakez]

So far no problem with direction--it is a great question though.
FUE transplants require extensive shaving of the donor area causing a long downtime to the patients. Strips offer the ability to transplant "coupled follicular units" allowing for better central density and a quicker more cost effective procedure. Downtime is minimal.
That being said, each patient and Physician needs to choose the procedure that they are most comfortable with after reviewing the options. ACell seems to even the field.

If there has been no problem with direction, then would that not add further suggestion that you are actually 'waking up' the 'faulty' stem cells, in line with the recent research as you spoke about on the show recently?

This is amazing news if true, although I still have much doubt over the procedure.

[RichardDawkins]

There are those who would say that anything more than a minimal FUE procedure presents the same problem as FUT: if your hair loss continues, you won't have more available donor hair for future (FUE) procedures, and you won't be able to shave down due to the FUE scarring.

FUE in combination with Acell wont go to the shotgun white dots. Thats only one of the Acell benefits. With adding Acell, it seems that there was no FUE extraction in the donor area and you have aldo a higher chance of follicles to regrow in your donor area.