Why so many different survival rates for scar grafting?

[John P. Cole, MD]

There are studies that show the benefit of Acell on the growth of beard hair and chest hair in strip scars. This data has been presented at more than one scientific meeting and it has been published in the Hair Transplant Forum. There are numerous physicians who rarely attend scientific meetings. They often do not think there is anything to learn so they just don’t go. Mean while scientific data continues to build and be presented.

There is scientific data to support the capacity of Acell to promote follicular regeneration in the donor area. To date we have seen as much as 54% follicular regeneration in FUE extraction sites.

Acell is not going to improve the width of strip scars. Jerry Cooley feels that Acell will make strip scars feel more like normal skin.

Acell can help FUE hypopigmentation appear smaller in diameter when follicles do not grow back. All of this has been presented more than once to a scientific body of physicians.

Acell is not available in Belgium. Therefore, do not expect anyone there to recommend it or offer it.

I have heard that some physicians think that Acell makes the strip scar appear more red. This is possible because it stimulates angiogenesis. That means healing. Still red is not something you want in a strip scar if you can help it because it makes it more noticeable.

PRP alone has been shown to stimulate increased hair coverage in some, but not everyone seems to respond. The response is quite variable it seems. Adding Acell may help patients respond better. On top of that, it is possible to vary the hematocrit and PRP concentration so we may find that there is an optimal concentration that has a more positive influence. We do know that PRP will stimulate stem cells, improve healing, and might influence hair diameter.

There is no procedure (FUE, Strip, body hair) that has not had an occasional poor result. There is no physician who has not had a poor result. It fortunately happens rarely, but it may occur. No physician is immune from it. Therefore, it would be ridiculous to suggest that on occasion Acell might make a strip scar more red. Maybe you saw the first two and they were bad. Maybe the next 50 would have been good. I know my first chest hair transplant back in 2003 was fantastic. Then the bad ones came and it turned out that body hair growth in general works well in only 50% of the patients. Beard hair is different, though. It is between the scalp and the rest of the body in terms of growth. For me, I recommend head hair first, beard hair second, and then the rest of the body.

All right. Here is the skinny on strip scars. Head hair grows great in them. The blood supply is fantastic in strip scars. High densities tend to grow well in them. Still, I recommend that you have a lower density placed in your strip scar because sometimes the growth is not as good in normal skin when you have a higher density placed. I’ve never seen poor growth in a strip scar with head hair, but that means it will happen to me one day. Body hair is a different animal. About ½ the time it grows well and then it is visible in only ½ the patients. That means it tends to work out well in about one in four patients. Beard hair works well at all times. Expect a 60% growth from beard hair. As I stated, we can push the yield up with Acell and PRP based on initial studies.

I use PRP and Acell on a regular basis. I’ve never seen an adverse event from them. Of course, I practice only FUE and I’ve practiced nearly all FUE for the past 10 years. The reason I use PRP and Acell is because they can improve results in some patients. In a few, they can make results awesome. I also use liposomal ATP with my patients. I supply energy to the cells in the Petri dish and then directly on the grafts prior to implantation. Why? Because it may matter to one of my patients. It may not affect nine out of ten, but it might benefit the 10th. It’s sort of like the guy who walks along the beach tossing starfish back into the water that washed up on shore. When asked why he bothers because he can’t toss back the thousands of star fish that washed up on shore the night before, he replies, “well, it matters to this one”.
No one ever knows who is going to be the patient who benefits from cold storage, liposomal ATP, advanced holding solutions, PRP, and Acell, but if it makes a difference for you, I’m sure that you are going to be happy. Bad outcomes do occasionally occur so the more things we can do to help prevent them, the better for our patients.

The bottom line is this. Most physicians do not add new technology to their practice until it has been around for 10 years. If it makes the 10 year mark, you might see more and more jump on board. Think about it. 10 years ago there were three physicians in North American including myself offering FUE. All the others said it was a bad procedure and that it would never work. Well it did and now it is here to stay. Acell, PRP, cold storage solutions such as hypothermosol, and liposomal ATP cost money. You are not going to find most physicians spending extra money until the patients begin to demand. That’s what happened with FUE. That is what is going to happen with advances in cell biology. Quite frankly, that is where the real jump is going to most likely happen in hair transplant surgery.

Yes, products like Acell and PRP need more research and objective data. The data is still in its infancy. Adding additional improvements such as liposomal ATP are simply one additional improvement because cells cannot manufacture ATP in sufficient quantities without oxygen and there is no oxygen supply to cells sitting in a Petri dish.

There is not such thing as an Acell disaster, quite honestly. There is plenty of cheap, however.

[ejj]

many times on this and other forums I have requested that Drs contribute to a repair fund , i believe that if 60 Drs threw in 1k per year to a repair fund then six patients could be helped out yearly , what matters is what help a patient receives when things go wrong ....

I am the victim of eight prior strip procedures , each time prior to a procedure papers are signed , I spoke to a person who informed me that a certain Dr in California is the most ` litigious` Dr he had ever come across , my view is that this ` may ` be standard practice across the industry and restricts information and ` may ` explain your comment re ` cheap talk ` as it ` may` appear that way due to restrictions on what can be said.

That said I applaud the fact that you only offer fue


ejj

[Folly]

Nice post Dr. Cole.

[ejj]

ps Acell isnt approved for use on humans in the european union .

Is it really to much to ask for just `one ` set of photographs showing a strip scar ,half treated with acell the other without , and say 20 fue extractions again half with acell the other half without , also photographs showing the donor regeneration , photographs showing the extraction area post op then six months later showing shaved down hair growing out of the extraction sites ?

would be good if any patients could chime in with there results either good or bad as acell has been being used since 2009 now .

ejj

[John P. Cole, MD]

ok, i'll put something up on Acell. What I did in the scar study was to take a patient with two scars. Donor scars are great for evaluating yields because they have no hair in them, usually. A trichophytic closure may leave some hair in the donor scar, but most of the hair that is supposed to be growing in the scar doesn't. One thing that has always baffled me is where does that hair go after chopping off the top of the follicles. i guess it just dies. Anyway, scars have not hair usually. When you do hair count studies on the balding scalp, you never know if the growing hair is preexisting hair that was in a resting phase or whether the growing hair is one of the grafts. With scars, you don't have that problem. They are a dessert without hair.

I put beard hair in one scar and added Acell and PRP. Scars have good circulation, but it is not as good as normal skin. PRP helps deliver more of the stuff needed for healing that will be in limited supply in areas where the circulation is not very good. This is why PRP on chronic wounds works so well. PRP brings the growth factors and proteins needed to repair injured skin. Scar tissue lacks some of this too, which i why i like PRP here.

Anyway, i expect a 60% yield with beard hair when i use it. I've done several hair yield studies with beard hair over the years and this is a pretty common yield in normal skin. I added PRP and ACell to one of the scars and planted 50 Beard hair. The yield was 92% in this scar. In the other scar I did not add PRP or Acell and the yield was ZERO. This was well below what i would expect. Then the patient came back. I added PRP and ACell again to this second scar and grafted it again with Chest hair. The yield this time was 100%. Chest hair is even less likely to have a high yield.

The one issue that concerned me with Acell from the beginning was how to deliver it. I think putting the powder directly in the extraction site is the best option, but it is impossible to remember which sites have been treated and which sites have not been treated. It is also impossible to deliver the Acell well because it has plenty of static charge and sticks to everything. When it is placed in a gel, it is much easier to deliver and make sure that every extraction site is treated.

I've not seen better than a 54% follicle regeneration rate yet. What i do is note the number of extractions I do from each of the 8 major donor regions and each of the 6 minor donor regions. Then I can go back and count the number of empty extraction sites with a pen that counts the number of times i touch the skin and place a mark on the empty sites.

Remember that Acell may not eliminate hypopigmentation. It will make hypopigmentation smaller though. Often times I still see hypopigmentation in extraction sites when regenerated follicles are growing through them. Acell seems to make them smaller, but not eliminate them entirely.

One interesting thing about hypopigmented sites is that they are larger than the punch that is used. They are usually about 1.79 mm in diameter regardless of punch size. With Acell they are much smaller.

I will put up some photos when i get some time.

I've heard a variety of reasons why Acell is not available in Europe. One reason is that the company does not have enough product to supply the world at this time. Maybe I'll call the company to find out what is going on with Acell abroad. I suspect it will not benefit every patient, but again, if you are the patient that it benefits, you are going to be happy. With FUE, I've used it on over 1000 cases and I've never seen a single patient have an adverse reaction to it.

With PRP my only concern is that it can increase frontal swelling. There are different concentrations of PRP and there are different cell components in PRP. I have a new machine where i can specify the exact concentration of the various whole blood components and mix different types of PRP. In other words, I can make a 1 to 1 concentration of PRP with a low hematocrit to treat my wounds (recipient sites and donor area extraction sites) and a higher concentration of Platelets to treat the grafted area and native hair. Before, i could mix a high concentration of Platelets, but it also had a high concentration of granulocytes. Granulocytes are fine for fighting infection, but they also induce inflammation. Patients don't want or necessarily need this and it is not going to necessarily help hair grow. Therefore, I love the new equipment where I can dial the hematocrit way back and eliminate the cells I don't need for cell growth. This is one of the things i'm talking about with regard to the advances in cell biology.

There are several phases of a transplant where things can go poorly. One is the harvesting phase. If you harvest poorly, you damage hair coming out. It is much easier to remove follicles in a strip procedure than with FUE. We are seeing more and more physicians offer FUE, but sadly, they are often not getting good training and performing poorly. My suggestion is to find a physician who specializes in FUE if you want FUE and if a physician specializes in strip harvesting, go with him for the strip. If the physician offers both, he is more than likely not a master of one of them. The next phase we are concerned about is graft production ,which is required in strip surgery, but unnecessary in FUE. Unfortunately, lay individuals do the graft production with strip surgery so physicians don't control this aspect of the procedure. Then there is graft storage where we want to minimize injury due to a lack of oxygen, cold storage, warm storage, and time out of body. Next is the re-implantation phase. This is where i think most of the damage occurs to cells, when it occurs. Replacing cells into the recipient area exposes them to oxygen and this leads to the production of free radicals including hydrogen peroxide, super oxide, and the hydroxyl radical, the most lethal of them all. Some damage may occur from dense packing and some due to problems with revascularization. We don't know all the pathways to destruction yet. What i do know is that strip grafts have adipose on them and this may protect them from the damaging affects of re-implantation to some degree. With FUE grafts there is generally no adipose so the follicles are more exposed to the dangers of repercussion. I think this is one reason to limit temperature, use free radical scavengers, and add energy sources to FUE grafts.

[John P. Cole, MD]

on the subject of repair work, there is a thing called operation restore. This is a fund that helps patients get repair work. It is an off shoot of the ISHRS and they are quite proud of themselves for setting it up.

I donated 4500.00 to it last year. A number of physicians also contribute up to 2000.00 to this fund. There are physicians who do the repair work for patients in operation restore. I think the fund pays for your hotel and travel, while many of the doctors donate their time in exchange for the right to market your photos. i'm personally not involved because I do the work for free many times and did it for free before there was an operation restore. Also, i have no desire to use patient misfortune to promote operation restore, the ISHRS, or myself. This is how the fund got off the ground. One doctor treated a child that was a burn victim and then posted the child's photos all over the place. I was happy to see the youngster get a more normal look, but hated to see the child become the poster boy for hair restoration surgery even if done under the banner of a non-profit organization.

What bothers me about repair work and patient cost is that the repair work is much more costly than doing it right the first time. If someone needs repair work and they are worried about cost, it is best to find a physician who will work with them inside their budget. That is what i've always tried to do.

Of course, repair work can be challenging. It is not always easy to do this. It often takes many procedures. Goals can sometimes not be achieved because one is often limited to sources that do not have high yields. This includes body hair. I once had a patient who needed quite a bit of work and he had 500 beard hair and 500 scalp hair grafts. He needed much more. He spent his budget getting the first bit of work and then he was demoralized because he was out of money. That is where the physician just needs to kick in and do more work on the house to help the patient get over the hump.

I gave about 80,000.00 to charity last year. Making money to give to charity is not always the easiest thing to do, but giving one's time is easy.

[ejj]

Dr Cole ,

Thank you for taking the time to reply, with such a detailed account , its very much appreciated .

I myself am undergoing repair using beard hair grafted into strip scars , so its of huge interest personally .

Am unsure re operation restore as i thought it was solely for accident victims , and not applicable to hair transplant failures/ repairs , please feel free to correct me if im mistaken .


Again thanks for the reply , all the very best

ejj

[John P. Cole, MD]

I'm not sure if operation restore is only for "accident victims". I'll do some snooping. I can't imagine why they would not consider repair work part of operation restore, but I would guess that perhaps the hierarchy at the ISHRS might consider bad ideas and bad work acceptable results. In other words, I've heard them say for years, what are you patients complaining about? It's just plugs, mini-grafts, pitted grafts, ridging and strip scars so why are you upset about them?

I had one yesterday. He was 19 when the largest TV advertiser got ahold of him. He had absolutely no hair loss what so ever and still doesn't. What he did have was grafts in his temple recessions like woman though. I took out about 300 grafts. Of course they told him they'd done 2400, but he did not have more than 300. I rotated them all to his strip scar. The chief medical officer of this group told me that he should not be blamed for what happened in his group prior to his arrival in 2001. Of course, this one happened under his watch so next time I see him, i'll let him know that it does not appear that much has changed with the group. At least they are working on hair multiplication. Maybe that will make up for their prior sins.

Dr. Bisanga started in the hair transplant field in my office, and I set him up in his first clinic. He is capable. You should be in good hands ejj. He eats a little too much, but he is a good hair transplant surgeon. You'll be fine.

[gillenator]

FUE seems to be the way to go for adding hair grafts to an existing suture line scar instead of cutting out the old scar only to have a "wait and see" hopeful attitude. The nice thing about FUE to the scar area, you can always add more later if you want. Survival rate will vary on the quality of the grafts and the amount of scar tissue in the area.

From what I have observed, that really depends on the individual patient. If the wider strip scar was more attributed to incompetence, and the patient has the scalp elasticity to "reclose" then removing some of the scar tissue and then utilizing Acell, PRP, etc, can make a dramatic improvement. Not on all, but some..

The problem with scar revisions is yes sometimes the wider scar is due to a healing issue and not incompetence. Cutting again can potentially make the new scar worse than the first one. And also, the blood flow is compromised everytime more cuts into the tissue are done. The less blood flow, the more scarring is left which any way you look at it will compromise yield.

Hopefully scar revisions are being done with closer scrutiny verses a wait and see what happens approach.

[topcat]

Since I am a patient of Dr. Bisanga I would describe him as more than capable. In my opinion he stands out as the best but of course I am a patient so many others will debate this statement. What I can tell you about him through my own experience is that he is a very soft spoken, down to earth, and a kind hearted person. This is also evident in everyone that works at BHR. He seems to employ those that are similar to himself and those same traits in those that work there are what make it a complete clinic as one person alone does not make a clinic.

Actually I was a little shocked at how down to earth he happened to be. I have worked for years in customer service and hospitality. When someone ever asked me what occupational group represented the worst in customers without a doubt it was always doctors. They were the most arrogant, the cheapest and always treated the service staff like shit.

As far as Acell is concerned the debate will end when substantial photographic evidence is presented. At this point is simply does not exist.