Hair restoration is advancing at breakneck speed. Skill and artistry are supremely important to guarantee the best results. However, exciting new procedures and scientific innovations are also further improving results. Dr. Cole and Forhair take great pride in being at the forefront of such advancements.
This is a rather long post, but it is an important one. We detail three specific cases where a combination of Dr. Cole's skill and artistry combine with cellular therapies and scalp micro pigmentation, or SMP. The latter is an all-natural tattoo that replicates the appearance of growing follicles. The former, cellular therapies, are paving the future of hair restoration. As their name suggests, these procedures encourage hair count, growth, and thickness on a cellular level. An advanced platelet rich plasma that we call CRP (cytokine rich plasma) and follicular stem cell suspensions are two approaches Dr. Cole and Forhair are utilizing with ongoing success.
The first case, Patient BBV, showcases the potential of stem cell suspensions and CRP in an FUE repair. The second case, Patient CRC, details the superiority of CRP+ACell to PRP+ACell in application to FUE. The third case, Patient SSP, highlights FUT scar repair techniques using FUE and SMP. Keep reading for details regarding these exciting new developments that led to exceptional results.
Patient BBV: Hair Transplant Repair, CRP+ACell, and Stem Cell Infusion
Patient BBV had a procedure from a different clinic before coming to Forhair. This initial procedure from a different clinic involved 1500 grafts. After 18 months he knew the results were disappointing and below average. Unfortunately, such results are becoming all too common in the field of FUE hair restoration. More and more surgeons are offering FUE before building up the prerequisite experience and skillset. Other FUE surgeons willingly ignore best practices to cut costs -something that we at Forhair find abhorrent. On the bright side, though, more and more surgeons are becoming proficient at the method. FUE requires years and years of practice to perfect. The more surgeons proficient with FUE, the more patients who enjoy solid results.
Be it the surgeon's inexperience or whatever else, however, patients victim to disappointing results are right to be upset. Both unscrupulous and inexperienced surgeons detract from FUE's reputation as the foremost hair transplant method. For instance, the yield from Patient BBV's initial procedure is extremely low compared to our usual results. He came to us with a graft density of 0 to 30 per square centimeter and a hair density of 30 to 60 hairs per square centimeter. Talk about below par coverage!
Hair Transplant Repair: 2717 Grafts Using Different Punches
Using Hairmes, a unique program from France that determines hair coverage vs. scalp surface area, we mapped Patient CRC's donor potential. It calculated Patient BBV to have a hair loss of 78.99 hairs per square centimeter. Our solution was to add an additional 2717 grafts to both transplant and donor areas. He chose to undergo the fully shaven method of FUE.
We extracted his grafts using three different size punches. Those punch sizes are a 0.8 mm punch, a 0.9 mm punch, and a 1.0 mm punch. Most physicians use a single punch, but we often use a variety of punch sizes to harvest a variety of different sized grafts. This adds variance and improves results. We harvested two-hair grafts with the 0.8 mm punch, three-hair grafts with the 0.9 mm punch, and larger grafts with the 1.0 mm punch.
The hair transplant procedure was a success. We averaged 3.24 hairs per graft overall with a follicle transection rate of 4.9%. The total composition of his transplant was 8% of two-hair grafts, 64% of three-hair grafts, 34% of four-hair grafts, and 4% of five-hair grafts. This combination is a good balance between density and graft count.
We find that single hair grafts are quite uncommon in a repair unless the patient has a very sparse donor area. Strip surgeons and most FUE surgeons average 20% of single hair grafts because they accidentally split the follicle, increasing transection during the harvesting phase. This is a primary reason to avoid unskilled or unproven hair transplant surgeons. Such practitioners require far more grafts to create a similar degree of density as Patient BBV's hair transplant repair procedure from Forhair.
CRP + ACell and Stem Cell Infusions
After the repair, we treated his recipient area with CRP mixed with 60 mg of ACell. Forhair's minimally invasive technique is particularly suitable for CRP+ACell. Stem cell remnants from the donor areas have a good chance of rejuvenating after minimally invasive harvesting. In all, we typically see a 30% to 40% renewal rate. Put simply, this means 1300 to 1600 new strands of hair for every 1000 single follicle grafts.
Typically, we see 99% of grafts growing at 4.5 months when we treat the recipient area with CRP. We treated Patient BBV's donor area with 30mg of ACell mixed in hyaluronic acid and follicle stem cells that we created from 12 of his grafts. We also injected a stem cell infusion at the top of his head. ACell injections in the donor area particularly help promote follicle regeneration in 30 to 40% of the extraction sites. We anticipate that the addition of follicle stem cells to this mixture will further stimulate follicle regeneration. Each of these treatments -CRP, ACell, and follicular stem cell suspensions- are cutting edge cellular therapies for hair loss and hair transplantation.
Pictures are Worth a Thousand Words
Here, you can see Patient BBV's results at six months. It reflects a combination of cellular therapy and graft selection for the best outcome. Good graft selection enables better coverage with fewer grafts.
Of Special Note: Punch Quality Makes the Procedure
Punches are expensive. For this reason, many surgeons will use a single punch on up to four different patients. This is unacceptable. A punch will dull during use. A physician may harvest between 400 to 1000 grafts before a punch becomes unacceptably dull. At this point, follicle transection rates astronomically increase. Surgeons should always change punches during a case to maintain the sharpest cutting edge possible.
Forhair's dedication to the sharpest punches available is one reason we get better coverage from fewer grafts. We never sacrifice results to cut our costs -unlike most hair restoration surgeons. We believe that every procedure is a once in a lifetime opportunity for a patient to get the best possible result.
Top equipment along and proper technique ensures our patients enjoy the best possible outcome. Punches should be a single-use, disposable item. One cannot sharpen them like a knife. Hair transplant punches are simply too small. The diameter of the punch wall is only 0.1 mm, which is very thin. No one can restore their razor edge to the original degree of sharpness.
Dr. Cole's emphasis on quality instruments manifests itself in Cole Instruments. Through this organization, we offer some of the best utensils for hair restoration. This includes the serrated tip punch, the sharpest punch in the world and from the highest quality hardened steel. However, there is nothing sharper in the world currently available.
Patient CRC: 2,200 Grafts and CRP+ACell/PRP+ACell
Patient CRC was an interesting case. He granted permission for us to actually use different cellular treatments on each side of his head. The results are telling, to say the least. On the right side of Patient CRC's head, we injected CRP and 30 mg of ACell. On the left side, we injected standard PRP with calcium gluconate as the activator and 30 mg of ACell. We also used Regen PRP kits for both sides. We now know that Regen produces much lower concentrations of growth factors than other options. Forhair know uses other kits to generate PRP and CRP.
Hair Transplant Procedure
After injection, we transplanted 2200 grafts. We then used Hairmes to map Patient CRC's donor area. Patient CRC had a donor area containing 16,520 follicular units. He is one of the lucky ones. A donor bank of 16,520 is much higher than the average donor area of 15,200. Our procedure involved using five different punch sizes ranging from 0.8 mm to 1.0 mm. We use punches that increase in size every 0.5 mm, meaning we used 0.8, 0.85, 0.9, 0.95, and 1.0 mm. These grafts had more than a 95% success rate.
Patient CRC's case becomes interesting post-procedure. About 80% of the grafts were growing on the CRP side after three months. There was a much lower response on the PRP side. This observation led us to study the graft regrowth rate for CRP vs. PRP vs. placebo (saline). Our subsequent studies confirmed these findings and more.
On average, CRP initiates over 80% of grafts to grow at 3.5 months. 99% of grafts, meanwhile, grow at 4.5 months. This makes sense, as CRP has 6 to 8 times the concentration of growth factors as PRP, according to ELISA testing. Hair transplant surgeries without PRP or CRP typically lead to 10% of grafts growing each month post-procedure. We can conclude, therefore, that grafting with standard PRP only slightly improves this rate of graft growth. CRP exponentially increases results and may also improve the overall yield. However, we need to conduct more research to verify this hypothesis.
Patient CRC's results are great. However, and wisely, Patient CRC feels he needs a small procedure on the left, or PRP treated side, to improve his coverage. He is quite happy with his right side, the one treated with CRP.
Patient SSP: Scar Repair and SMP
Patient SSP showcases the general risks of Follicular Unit Transplantation, or FUT. The go-to method before FUE spread in the early 2000s, FUT has a few major detractions that FUE bypasses.
- A noticeable orbital scar
- Often, noticeable plugs that resemble doll hair
This was the case for Patient SSP's FUT procedure. This is surprising, as the surgeon who performed it is actually a famous doctor from Israel with wide repute for his success in challenging or dangerous procedures. Patient SSP, however, was rightfully disappointed with his results. The strip scar is bad, yes. The graft work was much worse. At least with long hair, Patient SSP was able to conceal the orbital scar. Nothing, however, hides bad graft work.
The Goal: A Normal Appearance
Patient SSP's hope was to look normal, even if that meant sporting some hair loss. His FUT scar, though, was so wide it was impossible to guarantee he could comfortably wear a buzz cut. What makes Patient SSP fortunate, however, is that he had a single strip harvest. Multiple harvests can warp hair growth angles. This sometimes makes it impossible to restore a patient to a normal appearance. To help Patient SSP we had to hatch a creative plan ahead of its time.
Scar Camouflage via FUE Grafts
Scar repair was the first stage of our project. Our objective was to make it look as normal as possible without compromising other donor areas. First, we harvested 447 grafts, in two procedures, from random locations all over the viable donor area. This irregular harvesting pattern makes extraction sites harder to see because there is no regular pattern. We call this design the "parking lot at the busiest mall in town the day before Christmas" pattern. The spots are there, but you really must look around to find them.
Ultimately, and unfortunately, removal was Patient SSP's only solution for the frontal FUT grafts. These were large, prominent, and had visible pits. In less severe cases we can redistribute FUT grafts to create a more natural and elegant looking hairline. Patient SSP's FUT plugs, however, were too tight to repair. Redistributing them would risk frontal scars without much overall improvement.
SMP, SMP, SMP, and More SMP
Stage two of Patient SSP's repair was scalp micro pigmentation (SMP). This is an all natural tattoo that specialists apply to look like real hair follicles. It has wide use, from adding the appearance of thickness to bald or thinning spots to, in Patient SSP's case, creating the appearance of a buzz cut. Stage three? SMP. Stage four? Once again, SMP.
Applying these SMP treatments was not the usual procedure. Covering an FUT scar with SMP requires applying it to the scar and the area around the scar. Common practice in a FUT procedure is to pull neighboring skin over the one or two cm wide FUT extraction. Think of the resultant density as putting dots onto a deflated balloon and then inflating it. The result is that dots are wider apart. This is because of the stretch factor. Put simply, FUT scars stretch the skin and thereby reduce the hair density around it.
Patient SSP's wide scar was a particular challenge. We had to mimic the density of other areas in the donor area. A lot of planning and creativity went into formulating the right SMP blend. The result speaks for itself, however. We are very proud to successfully produce a convincing appearance of uniform hair density in and around the scar.
Results: A Normal Appearance, Even with a Buzz Cut
Our results photos show the 447 grafts and three of the four sessions of SMP. Patient SSP can now buzz his hair. FUT patients would have found this impossible before we developed our combination technique of SMP plus FUE. Each pass of SMP or grafting improves an FUT scar's appearance even more.
All that mentioned, avoiding FUT altogether is any patient's best option. FUT has not been the gold standard for over a decade. Practicing the method in today's age of advanced FUE is a disgrace. Surgeons still performing FUT are ignoring proven scientific progress. They are putting their own interests above that of their patients. These unscrupulous surgeons are a hindrance to the whole of hair restoration surgery. They give all of us a bad reputation.
Never be Misled: FUT is the Past for Good Reason
It is quite surprising that so many people still advocate for FUT. Such persons include FUT surgeons, of course, as well consumer advocates, patient advocates, hair transplant mentors, and websites. Why do most of these individuals and organizations advocate for an outdated method? A finder's fee!! In fact, FUT has no advantage over FUE. Far from it, in fact. Our studies prove that strip surgery kills hair due to traction alopecia.
Worse yet, no one can predict the width of the FUT scar. Surgeons trying to sell the procedure will typically do their best to convince the prospective patient that the scar will be pencil thin. Such thin scars do happen on occasion. Many FUT procedures that go perfectly, though, can very well lead to a wide scar.
Anyone who does not do their research may opt for FUT. At Forhair we find young men are the most susceptible to shady sales tactics or recommendations. Understandably, panic attacks can ensue when hair loss becomes obvious. These young men often resort to cheap procedures with bad doctors. They usually trust that anyone with an MD can successfully transplant hair. Even FUT, though, requires years of training. FUE takes even more time and training to perfect. Patients opting for the wrong surgeon risk disappointment and embarrassment worse than hair loss.
In this case, we had a newlywed man with a newborn. All he wanted to do was to look normal, even if it meant an ordinary person with hair loss. Unfortunately, his strip scar was so vast that we could not guarantee that he could wear his hair to a buzz cut. Fortunately, though, we managed to successfully camouflage the Patient SSP's scar. Multiple strip harvests can distort hair growth angles so significantly that it is impossible to put the patient back to a normal appearance. One of Forhair's goals is to correct such horrendous results, protecting all people from such ruthless indiscretions by exploitive doctors.
Conclusion: Innovation and Creativity Hasten and Improve Results
Skill and artistry are integral to a successful FUE procedure. However, as we showcase, new innovations and techniques are dramatically improving results. Dr. Cole and Forhair's rigorous application of these new advances are improving results for patients.
Cellular treatments, right now, are proving the next great step in hair restoration. From fostering faster and thicker growth to encouraging follicular regeneration in donor areas, CRP and ACell are proving incredibly beneficial. Follicular stem cell suspensions are showing even more promise. A recent study in Italy, partly influenced by Dr. Cole, shows that such suspensions can invigorate follicles to again start growing terminal hair. The importance of this study is major. Scientists theorize that such treatments, with further research, may even be able to generate follicles where there were previously none.
SMP, meanwhile, is proving of major benefit for FUT scar repairs. Patients who once had to obfuscate scars through longer hair can now happily wear a buzz cut. Each case is unique. Dr. Cole's expertise, though, and ability to combine SMP and FUE is noteworthy. Forhair will continue enabling more and more FUT recipients a shot at wearing their hair how they want, when they want.