Clinical Implications in Hair Restoration Surgery and a Review of the Literature

Clinical Implications in Hair Restoration Surgery and a Review of the Literature

A recent report on the use of ACell with plucked hairs suggests that plucking hair can result in follicle cloning. This is called "autocloning" by the author. I'm issuing this response because I am beginning to get phone calls requesting treatment with plucked hairs that are tainted with ACell based on presentations by Dr. Jerry Cooley and Dr. Gary Hitzig along with irrational exuberance on the part of some physicians who incorrectly feel these presentations represent some sort of clinical breakthrough in the treatment of hair loss. In review of their presentations, I found no evidence that ACell results in improved survival of plucked follicles or that "autocloning" exists. While ACell may improve the survival of plucked follicles, the authors failed to show any evidence that it does. They were able to show that plucked follicles are capable of growth, but they did not present any evidence that ACell played a role in this occurrence. Furthermore, they did not show that follicles that were plucked grew back in the donor area, which would be a necessary requirement of "autocloning" to occur. There was no evidence that ACell produces a more robust growth as the authors contend. There was some evidence that ACell improves the feeling of a strip scar and makes it softer. They did present evidence that transected follilces are capable of regrowth. They did not show any evidence that ACell improves the width of a strip scar. There was some evidence that the healing of FUE extraction sites might heal better with ACell. They did not evaluate whether ACell might induce follicle regrowth in FUE extraction sites. With this in mind, I wish to discuss my experience with ACell and then discuss the findings of Dr. Cooley along with a discussion of where we stand with ACell today.

I first looked at ACell in the spring of 2007. In June of 2007, I began to research it in terms of treating horses for their lacerations since I own several horses. Horses are somewhat hirsute critters sort of like mice. Mice seem to grow hair when you apply butter. While ACell can regrow hair in horse wounds, it may simply be their predisposition to hair growth in general that is a work. I waited until ACell becameFDAapproved prior to considering it for use in humans.I really did not expect much. I started to apply it into extraction sites from FUE. The greatest challenge was how to deliver the product. The product originally came in two versions. One was a thin sheet and the other was small particles. More recently they offered a fine powder. The real challenge was how to get the small particles into extraction sites because the particles have a good bit of static electricity on them. This makes them somewhat sticky to the jewler forceps I was using to adminster the product. Subsequently, I began cutting the thin sheets into small pieces and putting a small piece in as many extraction sites as possible. The greatest difficulty was recalling which extraction sites had already been treated because you have to constantly look away to pick up another piece and it is often difficult to see the small pieces once you have placed them in the extraction sites. I'm quite sure that many sites were not treated. Then I began mixing the small particles in a hyaluronic acid gel and forcing a small drop of the gel mixture into the extraction sites from a 1 cc syringe and an 18 or 19 gauge needle that I ground the sharp tip off of. When the fine powder became available, I switched to using this in the hyaluronic acid gel. I found the ideal mixture was 60 mg of powder in 2 cc of the hyaluronic acid gel. One cc will usually treat well over 800 extraction sites. I often pre-treat the extraction sites with PRP and then drop the gel into the extraction sites. Treating a non-shaven donor area with ACell particles is very difficult due to static electricity. The gel mixture facilitates the delivery of ACell to these individuals. One question that remains is whether ACell will become active once the gel sets up and "hardens". The premise is that the hyaluronic acid will be degraded and leave the Acell to do its job. Will the hyaluronic acid degrade fast enough for the ACell to be affective? I tried mixing the ACell in PRP, but it just clumped and was impossible to administer to my extraction sites.

I also began mixing 30 mg of the small particles in 30 cc of normal saline and injecting this into the recipient areas to include donor scars. I often treat these areas with PRP and microneedling. I then activate the PRP by making incisions in the scalp or by injecting the patient's thrombin or bovine thrombin into the recipient areas. I have often added the Acell ECM to areas treated with PRP without grafts as Joe Greco has noted an improvement in up to 70% of individual treated with a combination of ECM and PRP. Joe has his own proprietary ECM that he obtains from the patient. Joe has not released this ECM to other physicians yet.What I've noted so far is that the gel mixture has the capacity to eliminate hypopigmented spotting in some FUE extraction sites. Those extraction sites that remained hypopigmented might not have responded or we might not have treated them with ACell. Again, it is impossible to know if all the sites are treated with Acell when you are using the powder. This is why I more recently began working with a gel because it is much easier to administer and it is far easier to verify that we have treated all the extraction sites. It also has the ability to induce hair regrowth in FUE some extraction sites. I did not expect this to occur, but we were able to achieve some regrowth. I have noted that the PRP and ACell combination can induce improvement in coverage of native hairs affected by androgenic alopecia. I have noted that ACell and PRP can induce improved coverage from native, pre-existing hair. A study in Korea showed that the PRP treated side resulted in faster graft growth than the untreated side. I have not seen confirmation of this study in my anecdotal evaluations, however.

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