Killian

I am reluctant to go into this but I said look I'll post. I would not make any assumptions, especially as these are theoretical and I do not want people to get ahead of themselves and raise hopes. Please let us wait till month 5. I don't want to see projections written as to what's possible from this post. I don't mind chiming in with updates, but no projections based on what I post please 🙏

Some areas show improvement, other areas less so. There are a few hair coming in on the scar tissue regions, but these are just emerging and can be seen as short/stubby or some fine in calibre. Only time will tell. I stand by my original expectation of a mixed matrix with fibrous tissue/skin appendeges.

"Wasting cases" you think FUT patients are a waste of time? That these people are insignificant and secondary. This is just offensive and entitled on every level. These vials of verteporfin aren't a finite resource for certain people. And it's nobody else's business nor concern as to how they're used by the person who paid for them. You have no say unless you pay for the vial yourself, and only then do you have say in your case limited exclusively. Why do I even bother posting here I think when I read something like this. I am so disappointed and disheartened on every level by this comment.

No I am planning to do a final round into areas we did not reach via the punch-out technique. The punch-out technique was used on a strip scar, and one cannot punch the whole thing out. The punch-out technique may shrink the scar by up to 20-25%. I have no intentions to punch out FUE scars.

One should stop two weeks prior as it makes implanting more difficult - the grafts become slippery and increase in graft pop-out rate is seen. One shouldn't use topical right after transplant which is correct, but one may use oral Minoxidil right after transplant as it isn't applied to the scalp.

FYI, from a word document I keep: 22Jul2023 Verteporfin 50mg x2 in refrigeration, exp: Jul2024 Concerns prior to injection. 1) Effect of blocking YAP in area of severe tension (post-strip period in repeat strip cases which will last for weeks/months) as seen throughout stage one and two of the healing process AND and early remodelling. Injecting visudyne will theoretically prevent/augment the formation of fibrotic tissue/reorganisation of ECM. Fibroblastic phase lasts till week 5 post-op under normal healing circumstances and results in formation of scaffold and skin repair by contraction. Will inhibiting this in an area of tension increase propensity for stretching further down the line I wonder? no scaffold or contraction will occur when area is being pulled apart by forces of tension. Tension will be greater in repeat FUT cases and increased further depending on factors such as strip removal against collagen directionality (opposing poles of the strip especially) and strip height owing to a longer period of tension. I suspect stretching and great caution should be applied. 2) Effect on homeostasis vs proliferative. YAP activation enacts a reversible pro-proliferative transcriptional proma in keratinocytes and dermal cells that results in accelerated re-epithelialization of the wound bed. Verteporfin is a YAP inhibitor. Epithelialization occurs in proliferative phase allowing cells to migrate and repair the wound. Effect of blocking this?? 3) Remodelling begins once myofibroblasts begin contraction. Myofibroblasts increase expression of actin stress fibers and integrins, in order to produce the contraction needed to realign collagen. Reduce size of wound and secrete ECM proteins. Blockfing fibroblasts will prevent this, what will be the outcome in, again, an area of tension? 4) Any chemical interaction between tumescence and Visudyne. Unlikely - no 5) Hair length essential to cover/reduce light exposure - time taken to inject and scope of area to be treated considering light. 6) Effect of prolonged tension timeline to collagen basket weave structure formation period? No one fits all protocol may be possible, too many factors in FUT technique and case dependency to consider. Tension timeline will be variable. FUT leaves an atypical healing environment encompassed in tension. A more superficial scar removal later on in the remodelling phase may be safer when scalp laxity has returned and the approximated scalp has healed and is held together by the a deeper scar layer of collagen bundles closer to the galea – must wait till 8 months post op to be safe, ~80% tensile strength return by M6. Virgin FUT patients will have a quicker return to "normal" scalp laxity but repeat FUT patients will have increased tension over a much longer time period and this should be taken into consideration when blocking YAP in the early stages of wound repair. Leaving bridges of scar tissue present in repeat cases to "hold together" and reduce propensity for tension associated risks - shorter and thinner width FUTs may be safer in repeat cases. Should another full strip be possible bridges of scar tissue are essential, I suspect the risk outweighs the benefit to have a full strip in a repeat case without these bridges. 16Feb2024. No full strip performed. FUE ~260 in donor. The previous strip donor scar was treated with two techniques: punch-out technique and excision with epithelialisation. Verteporfin was then injected to the dermis. The verteporfin was injected to the upper and lower edges of the incision, then closed in two layers; subcutaneous with absorbable stitches 4-0 vicryl followed by upper layer with 5-0 prolene. Additionally, FUE was performed in the occipital donor area with 0.7mm punch and this was treated also with 50mg verteporfin. The treated area was carried out by injecting every 2cm, while at a 45 degree angle to the dermis. Note: off OM for two weeks to prevent graft pop-out rate from minoxidil API. Commenced 2.5mg this evening and 2.5mg 3X (half life ~4hrs) daily for two weeks going forward to increase growth factor influx from vasodilation, thus expedite the healing timeline and increase graft exposure to hemoglobin/ EGF, TGF-alpha, PDGF, TGF-beta, IGF-I, IGF-II. Grafts will connect to blood supply by 72 and fibrin secreted by day 13/14 for full anchorage – out of the Wds, back to normal as usual by then. Day 1 (17Feb2024): No post-operative redness around incision line – atypical. No inflammatory exudate from FUE extraction in normal tissue – highly atypical. Some form of augmentation in hemostasis has occurred I suspect. Day 2: Same observations, untouched look. No pain. Zero exudate on pillow even though slept on back for a full night. Day 3: untouched look. No pain Day 4: No formation of scabbing on the incision line. Interesting, usually along the incision line I can see the clotting/forming temporary scabbing. Change to epithelialisation? Slightly Itchy donor localised to the area treated. Day5 – day 14; Extremely itchy donor, untouched look, no redness. No effluvium of donor. Day21 – entering remodelling phase. Nothing of note. Day22-28: No effluvium of donor, should have happened by now. Signs of mixed matrix with erythema around incision – capillary dilation/inflammation induced by angiogenesis suggesting scar tissue will be laid down here. Other areas retain normal tissue colour and appear more akin to normal skin appendages – too early to conclude. I think there will be scarring warranting a second round later this year. Signs of less effect visible in areas of tension and visa-versa. It looks like as suspected tension is a risk factor and the verteporfin not effective here (or as effective). More time to conclude required, will know for sure by M5. Need to punch out areas we didn’t get and I think the right side will be able to be buzzed after. The left side will be problematic due to tension – may need to switch to punch out technique I suspect. Notable improvement of whole area with no.2 haircut and no visible signs at this length. Day25 - the left side I suspect has minor effluvium or stretching in the last week or combination of both. Pain noted here. I lean more to scar matrix than effluvium. Re-evaluate at M2.

It is as I suspected looking more like a mixed matrix. Some areas have no scar tissue formation visible and appear as normal skin appendeges with more hair present - these are where the punch out technique/FUE was done, and possibly where some minor superficial excision was done but it is too early to tell In one area excised I see signs of scar tissue being laid down. There is erythema, which is seen in premature scars. There are signs of capillary dilation and inflammation induced angiogenesis which happens in early scar remodeling here. I note that in areas of greater tension the signs of scar tissue being laid down is prevalent. In areas of lesser tension, there are signs of normal skin appendeges. I would stand by my original speculation that it will be a matrix of scar tissue and normal skin appendeges, and ultimately not a silver bullet to yield a scarless hair transplant nor unlimited donor.

Honestly I'm not even going to think about these things now. I just want to see the present donor outcome first. I do also strongly suspect that we will see a mixed matrix of scar tissue and normal skin appendeges. Which would be amazing. I don't think this is a silver bullet though, I think it will possibly be a component/improvement of the process going forward.

I think it's playing with fire, what's the effect of injecting this around implanted grafts - unknown. A very small test would be needed first. I honestly wouldn't like to even speculate in fear of someone doing it. Even in my own donor, while it's healing great, god knows what will be the downstream effect. Only time will tell, it's all experimental and inconclusive atm.

Hahahah yeah to make videos I meant

Wow wow wow where is this coming from? This is not true.

Approaching 3 weeks on Friday. Little to no effluvium, reduced redness well into proliferative phase - I suspect hemostasis stage was successfully augmented. No scabbing nor exudate. Remodeling phase begins ~ 21 days post surgery (essentially I'm entering this period now). Typically, reorganisation, degradation, and resynthesis of ECM, granulation tissue matures to form scar tissue - this period will yield the real answer if augmented. Process will be visually discernable in a few months (~5)

Must be injected during approximation to inhibit YAP pathway in tissue hemostasis thus augmenting fibroblast activity/ECM deposition downstream.

I really wouldn't be looking at this as unlimited donor guys - you'll be disappointed. I never went into this with that ambition, purely to augment/improve the byproduct which is scarring. There may be some regeneration, as a product of normal skin appendeges. But these I suspect will be mixed in with the matrix.

I don't comment on other people, golden rule. I'm just an observer like everyone else. You would need to ask the person themselves for their primary perspective. On this forum I will only subject my own case forward for discussion with respect to trialing 50mg Verteporfin.