08 Dec

ACell Clinical Implications in Hair Restoration Surgery

Hair Restoration Surgery and ACell Clinical Implications – current position

Acell

Acell And Strip Scars

Will ACell result in regrowth?

Clinical Implications of ACell in Hair Restoration Surgery

Review of current Literature

A much publicized recent report about the use of plucked hairs containing ACell seems to suggest that the plucking of hair can lead to follicle cloning. The author calls it “autocloning”. Presentations by Dr. Gary Hitzig and Dr. Jerry Cooley have been very enthusiastic about it, and many physicians seem to be convinced that it is a breakthrough in hair loss treatment. This response is meant to answer them, and the many patient phone calls that have recently begun requesting this type of treatment with tainted plucked hairs containing ACell based on these reports.

However, during a review of these presentations, no real evidence was found that ACell can result in better survival of the plucked follicles or for “autocloning”. ACell might improve the plucked follicles’ survival rate, but the authors have failed to show any conclusive evidence that this is the case. While they did show that the plucked hair follicles are perfectly capable of growth, they failed to present any conclusive proof that ACell has played an active role in the occurrence. They also failed to show that the follicles that are plucked can grow back in donor areas, which is necessary for the vaunted “autocloning” to take place. Furthermore, no evidence was presented that ACell can produce a robust, healthier growth as was the contention. Although some evidence was given that ACell can improve and soften a strip scar or that the transected follilces remain capable of regrowth, but evidence that ACell can improve the strip scar width was absent. Although some evidence showed that the ACell might offer better healing of the FUE extraction sites, there wasn’t enough evidence to properly evaluate whether follicle regrowth might be improved with ACell might in FUE extraction sites.

Given this state of the evidence, let us discuss some experiences with ACell, discussing the various findings of the above study by Dr. Cooley and examining the status of ACell today. My first look at ACell was in 2007, in the spring, and began research in it in June. The focus was on the treatment of horses with lacerations. Horses are, like mice, hirsute creatures, and while ACell has been seen to regrow hair in their wounds and lacerations, this fact may simply be a result of their natural predisposition to hairiness. It was wise therefore, to wait until ACell was approved by the FDA before it was considered for human use.

On application into the extraction sites from an FUE procedure, the challenge was to find the right mode of delivery for the product. It was originally available in either a thin sheet or as small particles, with a fine powder being available more recently. The true challenge was deciding on a way to get the particles into the extraction sites given that the particles had a bit of static electricity making them stick to the jeweler forceps being used to administer them. It seemed better to cut small pieces from the sheets to put into the extraction sites. The greatest of difficulties in the process was to remember the extraction sites that had been treated already. Every time the physician looked away in order to pick up a piece of the sheet, one lost track of the ones that had already received a piece, especially because the tiny pieces are difficult to see once they have been placed inside the sites of extraction.

As a result, it is quite likely that many of the sites remained untreated. To remedy the situation, the particles were mixed into a gel of hyaluronic acid. Small drops of this mixture were forced into the various extraction sites through a 1 cc syringe fitted with a needle of 18 or 19-gauge with its sharp tip ground off. Later, the newly available fine powder was mixed into this hyaluronic acid gel. The ideal mixture, it was found, was that of 60 mg of the powder with 2 cc of the gel. One cc of this gel mixture is enough to treat more than 800 of the extraction sites. Another option is to pre-treat these extraction sites using PRP, with the gel mixture being dropped into the sites afterwards.

Static electricity also makes it immensely difficult to treat non-shaven parts of the donor area with these ACell particles, making the gel mixture a better mode of delivery in these cases. The only question in the process is whether the ACell product will become or remain active after the gel has set or hardened. Assuming that the gel of hyaluronic acid will degrade, leaving the Acell active, the question remains whether it will degrade quickly enough.

In search of other delivery methods, the ACell was mixed into PRP, which just clumped up and became impossible to introduce in the extraction sites. Another option was to mix 30 mg of the smaller particles with 30 cc of saline and to inject this into recipient areas and donor scars. These areas are often treated with PRP or microneedling or both. The PRP is then activated by incisions to the scalp, or injections of bovine thrombin or the patient’s thrombin into recipient areas. The Acell ECM can be added to the areas that have been pretreated with PRP without any grafts, as done by Joe Greco, and an improvement is noticeable in as much as 70% of the people who have been treated with combination ECM and PRP protocols. Joe Greco has uses his own proprietary ECM obtained from patients, which he has not released to any other physicians.

It is notable that this gel mixture seems to eliminate the hypopigmented spotting occurring in FUE extraction sites. The extraction sites which remained hypopigmented were possibly the ones not treated with ACell, or simply did not respond to the treatment. Given the difficulty of administering the powder, the gel form is obviously easier to use and far easier to verify result, making sure that all extraction sites have been treated. The treatment has also shown the ability to encourage hair regrowth some FUW extraction sites. This unexpected regrowth with the PRP and ACell combination induces improvement in the native hair coverage in cases of androgenic alopecia. Some improved coverage is notable with ACell and PRP in native, or pre-existing hair. A Korea based study showed faster graft growth in the side treated with PRP; however this is not confirmed from personal anecdotal evaluations.

The findings can be summarized in the following way:

A mixed treatment of Acell and PRP is seen to induce improved coverage from the native hair, and ACell in donor extraction sites seems to improve the process of healing in these sites, it reduces hypopigmentation, it also induces follicle regeneration in the extraction sites. No real benefits have been seen yet from the treatment of grafts with ACell before implantation, although it is possible that it can improve the survival rate among some of the grafts. Further evaluation is necessary to confirm this fact. Despite these impressive initial findings, these are early days to be making firm decisions about ACell in FUE. A wider study is advisable, and a better delivery method must be sought.

In the case of one particular patient, who had undergone a large session of transplantation of body hair, there were significant findings. The patient had excellent beard growth, but the chest hair did not show a strong growth. In follow up procedures, his donor scars were treated with chest hair, but also injected with ACell/Saline mixture of 1mg/cc as well as PRP. This time the chest hairs showed improved and faster growth compared to areas treated only with PRP, with chest hair as well as his beard hair. Of course, no conclusions can be drawn from one case as the results might simply be anecdotal findings. More and extensive patient follow up is required, which can be difficult when patients mostly come from other states.

In September I spoke to Jerry Cooley discussing his results and my own experience, and I published some findings online. The understanding gathered from this conversation was that strip scars seemed to be less wide with an ACell treatment, although he hadn’t mentioned this in his Internet presentations, and he concluded that ACell improves a good closure. He also noticed that the scars – both punch and strip ones – were softer in consistency with this treatment. He related his personal experience in the matter, when he had a nurse make a punch into the scalp in two areas, one ACell treated, and one non-Acell. The punch was heard to crunch into non-ACell extraction sites but it slid softly in ACell scars without characteristic noises.

The ISHRS has a position paper on the matter, and Ed Epstein has agreed to let me issue a rebuttal. This position paper has clearly stated that, in the opinion of the ISHRS, scalp punching procedures or FUE should only be performed by licensed physicians. Given that Jerry is now president of the ISHRS, this provides some food for thought. On a review of Jerry’s Boston abstract, no results were found. A close review of his Internet publications, a study of his photographs on HTN as well as Bald Truth, and a consideration of his conclusions drawn from his presented results, has led to certain conclusions. Firstly, it does not seem that he has conclusively shown that plucked hairs grow faster or better with or without ACell. Neither has he demonstrated that plucked hairs showing growth in the patients’ recipient areas can also show regrowth in donor areas. The fact that the donor area heals softer to the touch is a subjective matter, and he does not show that these scars heal faster or better in any other ways after ACell treatment. Neither has he demonstrated that transected hairs left in a punch wound would always grow better after ACell treatment.

What he has shown is that plucked hairs produce some yield, a fact known since the 2004 Hitzig presentation. He has, indeed, shown that transplanted plucked hairs can often result in finer diameter hair even after Acell treatment. However there is no conclusive evidence that ACell tainted grafts do result in robust growth compared to others. There seems to be some evidence that healing after a punch biopsy is better with ACell. Overall, the excessive exuberance over ACell, at this time, seems to be irrational.

To conclusively show that ACell treated plucked hairs result in better or faster growth, Dr. Cooley should have used two separate boxes on a completely clean bald crown, treating one with plucked hairs treated with Acell, and the other with non-treated hairs. This wasn’t followed, instead treating plucked ACell treated hairs and implanting them into areas bearing hair. The overexposed “before” photographs made the areas appear balder than they really were, and the less exposed “after” photos made them appear more hirsute. Also, the fact that he chose to treat scalps with existing hair, styling became a factor as well, making it impossible to properly evaluate comparison photographs of plucked hair. Not disputing the fact that there was growth from these plucked hairs, it remains impossible to evaluate how much of it was from plucked hairs and not others. Given the absence of a comparison study, it becomes impossible to determine the effect of ACell on plucked hair growth.

Dr. Cooley states that the initial study on ACell and plucked hair gave him a 20% yield, and as he became more adept at plucking out hair, the yields also increased. One can surmise from this that he became quite adept at plucking out intact follicles, or nearly intact ones, which are known to flourish just as well in the absence of an ACell treatment. He has demonstrated that he can improve the survival rates of plucked follicles through these improved plucking techniques, but he has failed to show conclusively that this improved technique combined with Acell can result in better survival.

Dr. Cooley has suggested that use of Acell improves the survival rates of the transected follicles. This is certainly possible, but transected follicles have been known to not just survive but also grow even in the total absence of any Acell. In short, he cannot prove, conclusively, that Acell use improves the survival rate of these transected hairs. What he has shown is the already known fact that transected hairs are perfectly capable of regeneration. Whether the actual ACell treatment had an affect on said regeneration, cannot be determined or adequately predicted, since the study was not undertaken to evaluate differences in the survival rate of transected hair on ACell treatment or without it.

Acell and Strip Scars – current position

Dr. Cooley has also suggested that treatment with ACell improves the appearance of the strip scars, yet he has failed to prove it. He states that the strip scars appear pink after ACell treatment because of angiogenesis. However, post surgical strip scars are pink in any case, even without treatment with ACell. In addition, strip scars have been known to stay pink, or even red, permanently even without Acell, hence his allusion to an association between pink scars and Acell is unclear. He also states that hypopigmentation lines persist following any strip surgery after treatment with ACell. The only real benefit to the treatment appears to be that the strip scars feel softer to the touch. Although there are ways to assess the comparative hardness of ACell treated scars, quantitatively, Dr. Cooley only offers a subjective, personal assessment. A force comparison analysis is missing, and although he suggests that treatment with Acell can improve a poor closure, he fails to present evidence in support of this conclusion.

Dr. Cooley has stated that treatment with ACell in sites of FUE improves healing, but does not encourage regeneration of the hair. My personal experience shows that ACell treatment can not only improve healing at the FUE extraction site but also reduce hypopigmentation. Dr. Cooley, however, has failed to examine and evaluate the FUE extraction sites within the presentation in question. He evaluates sites of 4 and 5 mm punch biopsies. In his presentation at the Hair Transplant Network, he takes a 4 mm punch biopsy of the scalp stating that healing would be better with ACell treatment, but regrowth would be absent. He states that this site is typical of FUE, which is not true. Few, if any, physicians perform FUE with 4 mm punches, and so the statement is misleading to an audience of lay public. FUE does not cause the kind of carnage resulting from a 4 mm punch biopsy. Given his attribution of extensive donor damage to the FUE process, Dr. Cooley’s healing assessment from the 4mm punch biopsy might seriously alarm the patients thinking of FUE.

This statement should be corrected. How does one know that this is indeed a 4 mm punch? One can assume, but in truth the punch size seems equally to roughly ½ the diameter of a black circle, which is a reticule of 0.5 sq cm fitting on a dermlite. The radius of this circle, 4 mm, and so the punch is roughly 4 mm in size. It is highly unlikely that Acell can help regrow hair within a punch biopsy with full thickness and all the stem cells being removed. Similarly it is much less likely that treatment with ACell will promote hair growth with a full thickness strip scar where excision has been performed for all stem cells. In cases of FUE, only the very upper portion of surrounding tissues is removed, and a full thickness extraction is not performed. The process eases out the inferior portions of follicles, leaving the stem cells behind, which probably accounts for the evidence of the regeneration of follicles in the donor area using ACell in FUE extraction sites.

Dr. Cooley, in his presentations, has also stated that these plucked hairs appear to be finer, meaning that they cannot adequately cover like transplanted hairs do. They are more likely to resemble the kind of coverage that body hair provides. In fact the only reason one might consider plucked hair would be to increase the yield from the potential donor areas. Has he, however, shown that these successfully plucked hairs which will grow in the recipient area, will grow back within their original places in the donor area? He hasn’t, and the only example of regrowth in donor area he cites was a female staff member who wanted transplant on the eyebrows. Not many hairs would be needed to be plucked for replenishing eyebrow hair. Nor were any grafts seen in the example. Although the growth quite good, in fact the best such example of transplanted plucked hair growth presented, there is no way to know if the growth in this example was better because of the improved use of plucking techniques or because of prior treatment with ACell.

In the given donor comparison shots, Dr. Cooley has shown an area behind, and at the top of, the patient’s right ear. The photograph has been over exposed so that the hair appears blonde, and the entire area appears void of hair. The needle holder appears in the center of this hairless circle obscuring any view one might have had of the plucked region. Upon first examination, one might assume that any patient would be quite upset to have a bald spot created by so much plucking of hair. A closer look will show that the area looks so fully plucked only because of the over exposure of the film, and is not attributable to over-plucking of the hair. On the other hand, the follow up shot shows her as having brown hair, due to the lack of over exposure. The donor region in this photo is just above the plucked area, an entirely different region within the donor area, asking us to believe that this is the same hair which was plucked and grew back.

Having plucked some 200 hairs from a donor area in order to make a transplant in the eyebrow area, is it possible to pinpoint and identify the same 200 hairs that you plucked, after a year has passed, to verify whether they have grown back? Dr. Cooley, it seems, has not adequately demonstrated that the successful plucking of hairs that will grow finer within the patient’s recipient area will also have the original capacity for regrowth in the area it was plucked from. So, given no real benefit demonstrated plucking of hair for transplant might only end up depleting the donor area without succeeding in the effort of growing finer hairs in recipient areas.

As for beard hair the photographs Dr. Cooley presents show only a single hair that actually looks like the typical hair graft for beards. The others are fine, straight, and atypical of beard hairs. The hair in a normal human beard grows wavy, and is much coarser and thicker than scalp hair. Putting a beard hair graft and a scalp hair graft side by side shows clearly that beard hair is as much as twice the diameter. Also, beard hair has a wave or a curl which is quite different from the finer straight hair of the scalp, and the difference is visible even with wet hair. On comparing the beard hair portion of these photographs with the scalp hair portion, no great difference is visible in the gross quality of the hair, which suggests three possibilities. First, that the transplanted beard hair lacks the normal scalp hair characteristics, which seems unlikely given his presentation of several examples lacking the typical beard hair appearance. The second possibility is that the plucking has resulted in modification of the beard hair causing it to become finer and eliminating the characteristic beard hair curl or wave, in which case there would not be as much coverage as a typical graft of beard hair provides. And the last possibility would be if the transplanted plucked beard hair had no growth at all. Whatever the case, it becomes clear from these images that these plucked beard hairs do not offer as much coverage as the traditional transplanted beard hair. In addition, there seems to be no evidence to suggest that the plucked beard hair will grow back. One would suggest to Dr. Cooley that these non-growing hairs will become foreign bodies, and might ultimately lead to problems like cyst formation, affecting the yield from the transplant. They are essentially dead hairs, and must be removed.

Dr. Cooley ultimately suggests that when grafts are treated with ACell, the results are more robust hair growth. The two examples he presents, are problematic. While one appears to have zero hair loss, and the AFTER photograph a year later presented simply a different style with roots needing bleaching, the second example showed a gentleman whose result was consistent with the total number of transplanted grafts. The pre transplant photos showed the patient with wet hair, while the post transplant photos were taken with dry hair. The hair in the before photos were styled back to conceal the balding crown, while it exposed the hair loss towards the front. The after photos showed the hair which had been combed forward, exposing the balding crown making the front look much thicker. The actual overall result seems to be consistent with any other degree of hair loss, the patient having entered the procedure with the retained frontal hairline as well as a retained frontal tuft, and the follow up comparison showing no major change to suggest superior and robust graft growth.

In short,

1. There is some evidence that treatment with Acell improves healing in FUE.

2. There is also evidence that treatment with Acell can help regenerate hair in the extraction sites for FUE, but much further work is required to prove that these are not isolated anecdotal events.

3. No evidence has been suggested to prove that Acell aids plucked hair growth.

4. No evidence has been given to prove that Acell makes transplanted hair growth more Robust.

5. There is no evidence that Acell improves strip scar appearance

6. There is some qualitative evidence to show that treatment with Acell improves the physical feel of some strip scars.

7. No evidence has been given to show that Acell treatment induces regrowth in transected hairs.

8. No evidence has been given to show that the plucked hairs will regrow back in the donor area.

9. Some evidence suggests that plucked hairs tend to grow finer resulting in poorer coverage than extracted transplants.

 

Instead of succumbing to the current irrational exuberance about Acell, some hard scientific data is needed to support any possible benefits. Until such data becomes available, patients must exercise caution in terms of plucking hair for transplant or use of these Acell treatments. Misuse may result in lack of improved coverage, and may actually harm or reduce the potential coverage possible from reducing the hair shaft diameters, and may even reduce the potential regrowth of plucked follicles in donor areas. No comprehensive study has yet documented the yield to be expected from plucking hair for the recipient area, or whether the procedure is safe to the plucked hairs from donor areas. Caution is advisable until Dr Hitzig and Dr Cooley can produce hard scientific evidence and conclusive real data about these facts.

Many of the photos he has provided to HTN, and also in his Bald Truth video presentation on the Bald Truth. The first photo (photo number 1) depicts a punch site seemingly larger than 1 mm in diameter (the listing says 1- 3 mm) with transected follicle.  We can assume that this photo was taken with a ½ square cm reticule and a dermlite, considering the number of follicular present in the photograph. A 0.5 sq cm circle has a radius of 4 mm, and the punch in the photograph is roughly 1/3rd the diameter. The wound margins touch multiple other follicular units, not possible with a 1 mm punch, unless the hair density is really high. The “after” photo shows possible ACell induced hair growth which does not match the “before” follicular units, indicating that the photographs may even be of two separate locations, especially with the slight pinkish tinge visible in the very center of the cluster of hair.

Disscussion: given enough experience, a physician knows that in transected follicles where the entire follicle has not been removed, some or even all of the hair show regrowth. In short, if follicles are transected, the follicular units often show regrowth even without any ACell. Personal experience does suggest that Acell can induce some hair growth, but the data is not vast enough or conclusive. This particular example suggests nothing to conclude that treatment with ACell was the primary reason for hair growth seen in the punch site. One cannot even be certain that the two photos are of the same scalp location, although the slight pinkish tinge might suggest that the site is same and the skin is showing healing. On the other hand, some pinkish hue is visible in the perimeter of the “before” photo, with a blanched center area, possibly as a result of epinephrine in anesthesia. There can be three possible sources for the pink hue. It can be caused either by the circulation of blood to follicles, by capillaries in or under the skin, or as a side effect of healing from some surgical trauma. In this case the pink tinge is probably from follicle growth. In the first photograph, the follicular density can be estimated as approximately 84 follicles /sq cm while in the second it seems to be closer to 60 follicles /sq cm, suggesting that they might be of different sites on the patient’s scalp. Trimming the hair for the follow up shot might have been better.

The second photograph shows a punch site seemingly greater than 1 mm, without transaction, which he treated with ACell. The dermlite circle has a 0.5 sq cm size reticule, which Jerry stated was 5mm. however, this seems to be impossible as the circle is not ½ the diameter of the 0.5 sq cm reticule, whereas the radius of any circle of this size must be 0.4 mm. The after photo for this set shows a punched area without hair, where the pigment of the skin appears pink and is lighter than the surrounding area which has hair. However it does not seem to be the frank hypopigmented kid of white spotting that one sees so often in FUE, even though it is much lighter than the hair bearing areas around it.

Discussion: The presence of the slightly pink tinge in this photograph might be attributable to continued healing, given that the central region does not have any hair to suggest tinting from circulation to hair follicles. Might this tinge be from an improved circulation caused by ACell? Or is it a healing wound? Pink hues from surgical trauma may take more than 3 months to fade. If one revisited later, is it possible that one might see new hair growth that was induced by ACell? However, the dark skin tone present in hair bearing skin which is caused by melanocytes present in the skin and hair follicles seems to be absent here. Although it is not the hypopigemented “white spot”, there is a distinct difference in skin tone with surrounding areas. Although FUE does not always lead to hypopigmented “white spotting”, it is common enough with larger punch grafts like this one. Therefore, the skin tone in the pictures is due to either a not-completely-matured wound or an ACell related improvement in the healing process.

In the third example a punch biopsy of greater than 1 mm diameter is visible, probably a site for a 4-mm punch biopsy, where no ACell has been applied. The caption claims that this is a typical scar of an FUE punch, but the image is of one larger than the 1 mm typical FUE punch. The diameter of a typical punch biopsy is roughly 1/2 the diameter of a 0.5 sq cm circle, which is about 0.8 mm. So the punch site should be about 4mm. FUE punches generally do not measure 4mm, and the caption is therefore a blatant misrepresentation of punch wounds related to FUE. Assuming that the mistake was honest and unintentional, the inaccuracy should be corrected by the author, immediately. A retraction is also in order, given that this photo is sure to frighten some of the patients considering having FUE. The fact is that FUE procedures do not cause so much carnage in the donor area. The second photograph also reveals a pink central area that seems to indicate that the wound is in the process of healing.

Discussion: Given that the wound is in the process of healing, one cannot begin to assume that the absent hairs will not regrow. However, experience with grafts above as well as below 1 mm diameter, shows far lower chances of hair regrowth without ACell.

Will ACell result in regrowth? – Current position

Jerry has concluded unequivocally that with transected follicles, ACell treatment results in regrowth. Although this seems to be the case, transected follicles also regrow without ACell treatment. Jerry also notes that ACell helps punch biopsies to heal better. The probability is high, and similar results are seen by many practitioners, but his conclusion has not been adequately proved by the presentation. Given that the third set is of an area without ACell but still maturing, the only method of determining the softness of the skin is sticking a needle into it. A force comparison test, in Newtons, can be used to determine how much force is required for a needle to penetrate the tissue in either treated or non treated skin wounds.

As the matter stands, it is not possible to make any comparative judgments about the two examples of strip scar. However, the statement that this hairless gap is caused by tension on the closure does not ring true. On the contrary, tight closures are often seen to result in quite excellent scars whereas loose closures can give wide scars, which Jerry should also correct. It is great to know that treatment with ACell makes scars softer, and closer to normal skin, but it would have been better is the scar in the picture was not concealed by combing the hair from below to above the scar. It would have been better if hair was combed away on either side, making it more visible. Jerry states that ACell sometimes results in a prolonged redness lasting weeks or months, due to angiogenesis. Having followed strip scars from my procedures for years, I have seen that they always remain pink for up to 3 months, which might fade later or persist indefinitely. This doesn’t have anything to do with ACell, although whether Acell prevents any prolonged pinkness in a strip scar is worth examining.

However, it cannot prevent the disruption caused in the orientation of the hair growth by a strip, or improve the hypopigmenation of strip scars. Although Jerry has stated that the scars are less hard, it is often seen that scars do not look hard can still feel so to the touch. Whether or not it is an effect of ACell, a force comparison study is the only way to objectively and conclusively prove the fact. Scars start to widen at around 3 months after the procedure and continue doing so until 6 months, with the greatest effect being seen around month three. So, 4 months is probably not enough time to properly evaluate the scar. In addition, factors like multiple layer closures and trichophytic closures have not been discussed in the presentation. The overwhelming effect of the photos is to convince the lay public that Acell significantly improves strip scars, a fact he has failed to prove.

The two examples after this, in the presentation, claim that a mixture of Acell and saline, when applied to grafts, makes their growth more robust. In the first example, it is almost impossible to judge, because the hair is styled in a way where is not possible to judge any difference in the “before” and “after” photos. Even the parting is different, making it difficult to see any hair loss, making it seem like a different styled hair where the part is no longer visible and dark roots need bleaching. The hair seems to have much more body than can be expected from just 2000 grafts. It is usually not recommended to do more than 1000 grafts in women with some existing hair because there can be a high rate of shock loss. Whatever the case, these photographs do not prove that Acell actually resulted in the more Robust growth.

With the second example, there is a more visible result of robust growth. The only problems with these particular photos is that the pre procedure photos show wet and slicked back hair while the post procedure photos appear depict dry hair. Also, the angle of the camera is 90 degrees in the after pictures while the before pictures are taken at a lower angle making the hair loss much more apparent. At an angle of 90 degrees, the hair becomes blurred and much less distinct creating the illusion that there is more hair than really exist. In addition, given that the hairline seems largely intact in both photos, it becomes difficult to judge the quality of the final result. Also, with 2200 grafts, one can get excellent results even without ACell. In his Bald Truth presentation, the lower angle after photograph shows some slight thinning at the top and front and in the crown, which detracts from his argument of achieving robust growth. Although Jerry concluded that some new thinning might have appeared in the crown, it looks more as if the hair has been styled back to make front areas seem more bald in the before photographs, while after photos had hair styled forward improving apparent thickness of the front, and exposing the crown. There really is nothing in the 2200 grafts example, after 12 a month interval, to suggest robust growth with ACell.

Having seen these people in person, Jerry would of course have a much better idea about the result quality. However, those same conclusions cannot be drawn on the basis of the photos. Personal experience does show that ACell in conjunction with PRP does improve the native hair quality in some people, in the absence of hair grafts but that cannot be extrapolated to happen in any significant percentage of cases, let alone all such cases. It is eminently possible that ACell treatment did significantly improve the quality, as both examples had plenty of native hair. It does stand to reason, according to my personal experience, that ACell can help to improve the overall survival rate for grafts and transected hairs, but not conclusively proven.

There are a few comments to be made about the plucked hair examples as well. The basic requirement for healthy hair growth is the presence of an intact whole dermal sheath. In the examples of the beard hair and the scalp hair, both follicles have almost completely intact dermal sheaths. In scalp hair, the dermal sheath is 2/3rds intact.  Below this level there is only an internal portion of the hair sheath. The outer part of the hair sheath as well as the dermal papilla is absent. In beard hair, the dermal sheath is also almost intact. However, the presence of internal portions of sheath is not sure to be present below the level in beard hair. In essence, both examples are similar to follicles, transected at its lower 1/3rd. There have been multiple transection studies that have shown that transected hairs can grow new hair from both the upper and lower portion. One particular study that examined transected examples of single-hair follicles showed that some 41.3% of the upper portions grew new hair in the range of 33.3% to 53.3%, while some 53.3% of the transected lower portions grew hair in the range of 46.6% to 80%. In short, the hair may have regrown whether with ACell treatment or without it.

The next photograph shows a plucked donor area which is “completely filled in with new hair” five months later. The first photo shows a needle driver within the plucked area, obscuring the view of the hair. The photo is also overexposed and makes the hair appear blonde, and making the entire area even the more hairy ones, seem quite thin because of the high exposure. This made it impossible to judge how many hairs were removed from region which seems to be located just behind the upper portion of the patient’s ear. The after photo on the other hand is underexposed and darker and the zoom is more diffused. The density of the exposed area above the ear seems to be not so great, and the two areas are probably not the same. In the Bald Truth video, scalp hair was plucked and introduced in the eyebrows, which means that the number of removed hair was quite low. With such few hairs being removed, it is not possible to be sure that the hairs in the donor area grew back. No conclusions can be drawn as to the rate of regrowth simply from these photos. On average, it is likely that about 53% of them would grow back.

The next picture shows a crown to which 100 plucked beard hairs have been transplanted, in the “before” and “after” format. The “after” photo is closer zoomed and less exposed, and the hair styled differently than the before picture. The level of exposure and, similarly, the degree of zoom affect the final appearance of hair bearing areas. Even taking all this into account, the after photo does appear to have more hair. However, the fact is that beard hair, when they grow a wire-like texture, whereas These hairs are straight and finer than any beard hair should seem. ACell has growth factors. They are not like PRP growth factors in that they are present in natural concentrations (according to the manufacturer), but they have them never the less. I’ve seen the combination of PRP and Acell induce native hair growth. Perhaps Acell alone induced improvement in the quality of the native hair. These certainly do not look like beard hair grafts. Furthermore the improvement appears global in the after photo. The overall improvement is much greater than I would expect from 100 beard hair grafted to this size of a recipient area. While there is improvement in terms of the photographs, I cannot attribute this to 100 beard hair graft plucked or otherwise obtained.

The next photograph shows two areas where 100 scalp plucked hairs were placed next to 100 plucked beard hair grafts. Based on experience 100 single hair scalp grafts will produce a better yield than 100 beard hair grafts, but the beard hair grafts will produce an obvious result and perhaps a better cosmetic result based on the diameter of a beard hair compared to a single scalp hair. The styling appears the same. I think the before is exposed more than the after. The coverage of the after is better even outside the demarcated lines depicted on the before photos. The scalp side has better growth and coverage. The beard side does not look like beard hair. Again, I cannot attribute the improvement strictly to the grafts, but there is improvement.

The next photos are from plucked moustache hair transplanted to the bald crown. The middle shot shows the bald crown. Was this shot take after grafting or before grafting. I certainly do not see evidence of graft growth in the bald crown. The next shot is a very close up showing some fine, lightly pigmented hairs. The cosmetic result is negligible. It reminds me of what I often see with body hair transplants. Often times you can get growth. If you magnify the area, you can see the growth. You can feel the growth. However, from a few feet away, the growth disappears. In other words, even if there were growing, plucked facial hairs, the cosmetic benefit is minimal. Furthermore, they do not look like typical beard hair grafts as they are fine, straight, and lack a wire-like nature. The biopsy shows a growing hair and sebaceous gland. I can’t comment on this.

The next photo shows a non-growing plucked beard hair. Notice how large the diameter is of this hair. Also notice that it is already bending over and taking on the appearance of a beard hair that is growing. I took out many of these that Dr. Hitzig placed in 2003. I’ve also seen them many times from non-growing beard hairs that were transplanted. They do not all grow when transplanted. Perhaps 60% grow at best. The other shot is 4 plucked beard hairs planted in the same incision site. These 4 plucked beard hairs are not as large in diameter as the one non-growing beard hair. The depicted beard hairs lack the characteristic wire-like nature. I do not think they are beard hair. The biopsy is supposed to be of the 4 beard hairs, but the biopsy contains 5 medulated hairs and one apparent non-medulated hair. The four closely related hairs have a similar diameter. The non-medulated hair has a smaller diameter. The 5th medulated hair is slightly smaller than the other four. I don’t see the 5th medulated hair or the non-medulated hair in the gross photograph. These inconsistencies are no scientific in my opinion.

On review of his publication, I do not feel he has decisively supported any of his conclusions. The only conclusion he has supported is that of a softer sound when cutting into an ACell extraction site based solely on his own personal experience of having an unlicensed assistant cut into his scalp with a punch. This is not to suggest that I am not fascinated or impressed with his efforts and research. I simply feel he has a long way to go in order to substantiate his conclusions.

I find the theory that plucking hair will result in autocloning possible, but I do not see results here that make me agree with his conclusions. Furthermore, I do not see any evidence that it works. The plucked beard hairs do not have the characteristics that are common with beard hair grafts. They appear finer and more straight. It might be possible to concede one example where beard hair resulted in straight finer hair, but three is hard to believe. With enough experience with beard hair transplants, it is difficult to accept that these results are possible with normal beard hair. One must then wonder whether ACell itself induces this increase in the native miniaturizing hair diameter, whether plucked beard hairs treated with ACell result in this type of finer straighter hair, or whether plucked beard hairs grow just as well without ACell as demonstrated by Dr. Hitzig. Based on personally observed results, it seems possible. It is commendable that Dr. Cooley is working to advance the techniques of efficient hair transplantation, and one can agree fully with his hypothesis, but the findings so far are not completely convincing.

After Dr Woods suggested that large scale body hair transplants work well, and when patients started demanding it, I reluctantly performed the first large body hair transplant of my experience. This first transplant yielded great results, but they all don’t work equally well. Many yield poor results or provide very little final cosmetic benefit. Similarly, some of the results with treatments with ACell are enough to pique interest, but so far it is not enough to be sure that a brand new modality for the treatment of hair loss has been found. It may be that we’ve only seen the lucky ones so far and that the poorer results are around the corner. It is wise to exercise caution and to proceed with much less haste and exuberance, after a great deal of further study has been undertaken.

The fact that we have seen some unexpected hair regeneration with ACell does not necessarily mean that it is going to be consistent. It is pleasing that there seems to be better healing using ACell, with far less hypopigmentation, making its use worthwhile for FUE procedures. Combination ACell and PRP may also induce improvement with miniaturization, as Joe Greco suggests. Or, as is also possible, this may be just a hit or miss kind of proposition and that could be the reason ACell may be the reason for the improvement in some of the patients. This is worth bearing in mind as more professionals embark on the ACell adventure.

When Jerry presented a case to this group of a patient with numerous grafts placed which subsequently shed hairs, and asked for the group’s opinion on whether their removal should be carried out immediately or after a wait, I advised him to wait until there was regrowth, based on my experience with removing grafts using FUE. I first reported, in 2003 the efficacy of the use of FUE techniques to remove the individual follicular units from larger grafts. This first published report about the use of FUE for the removal of plugs and minigrafts was put up on my website. I have since treated hundreds of patients with this method gaining considerable experience. This extensive experience reflects that without the extraction of the entire follicle, regrowth might be seen. Regrown hair can often be more squirrely compared to the original grafted hair, and it is advisable to get all the follicles out in the first round. The only problem with the extraction of grafts is that the grafted hair can often follow a much more circuitous path within the recipient area of the scalp than the native hair follicles.

It is a fact that many people who perform FUE have claimed that these hairs do not have a straight approach in the donor scalp, however this claim is not valid. Curly haired people can certainly have aberrant hairs exhibiting splay, however most patients do not, although patients of African descent can exhibit quite a significant movement. Patients with mixed African and Caucasian descent tend to exhibit more predictable type of follicular path, which grafted hairs can lack. As a result, far more care is required when extracting these grafted follicular units compared to the extraction of native donor units. Based on my extensive experience, my advice was based on what I consider to be far greater experience than anyone else in this group was that Jerry better wait for the hair to regrow because failing that his only option would be to make a wide excision, which might increase potential scar formation. Jerry however went with the recommendations of other group members and went with the extractions before regrowth occurred. The image he sent us of the post surgery extractions was so small that magnification to evaluate his work was not possible, and I asked him to send me a better quality image, as I like to study new procedures and learn what I can from new efforts. Jerry has not complied with the request, nor has he sent me the follow up photos I requested. I would encourage Jerry to allow me to learn from his efforts, by sending me those images. As of now, I suspect that either the patient showed a significant regrowth from the original grafts, or the excisions made to remove them were larger even than the original grafts and resulted in further scar formation. I am open to being proved wrong, if he can send me the results!

The extraction of grafted follicles using FUE does minimize the scar formation, but can often result in the transection of the follicles. The follicles must therefore later be excised using a range of means that help locate and remove the remainder. Unless they are fully removed, they tend to regrow. Unless you can see the follicles, it is not easy to locate or remove them completely, which is why it is wise to wait for regrowth to occur before attempting to remove these grafts.

It is possible I have ruffled a few feathers with this, and I apologize for that. However, before anyone overreacts, please consider that I know a considerable amount about this material, probably more than anyone else in the group. Please stop criticizing and begin thinking about the issues. Even if I remain un-reactive within the group, I would like to continue to be a part of it because I always learn new things from what the rest of the group has to say, and that helps me to improve on your procedures by all the information shared by you.

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Author:

John P. Cole, MD is one of the pioneering surgeons in the world who uses a Follicular Unit Extraction technique – CIT ® (Cole Isolation Technique) to perform hair transplant surgeries. In fact, he has invented a number of surgical instruments for this particular technique that help leave no visible scars behind. The STRIP harvesting procedure is also performed by him. He has also had tremendous success with body hair transplantations.

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