Dr. Jerry Cooley

PRP does not create new hairs, but thickens miniaturizing hairs. The degree of thickening will vary from person to person. In my opinion, the degree of improvement and duration of effect is better when the patient is on meds (e.g. finasteride, spironolactone, minoxidil, etc). If you have a significant proportion of miniaturized hair in the front of your scalp, you may benefit from PRP. Attached is an example of a young women started on spironolactone who had PRP/ACell treatment (result at 6 months).

A spectacular result! Must be a life changer for the patient. Congrats to the Farjo team!

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The duration of benefit from PRP depends on many factors: 1) how the procedure is performed 2) the patient's underlying genetic rate of balding and 3) what maintenance medications they are on. So a young guy balding fairly quickly who is not on meds may need PRP at least every year to maintain thickness. But someone is who has milder genetics and is taking finasteride may only need to do PRP every three years or so. Attached is an example of an older guy who was on finasteride for years, did one PRP/ACell, and then returned four years later. You can still see some of the benefit from a single treatment even after four years. I try to explain all this to people during a consultation. Clinics which promote PRP to everyone indiscriminately are doing people a disservice and many will feel like they did waste their money.

Spanker, this topic is actually very complex and I can't really do it justice with a short post. Dr. Greco taught me PRP eight years ago and I added ACell to it about 6 years ago. I've treated hundreds of patients over this time and consider it a useful option in our armamentarium. I don't consider it a miracle treatment by any means. Some people are good candidates while others are not. The best candidates are those with extensive miniaturization. I'll list some of the key points about PRP:

1. It is like a surgical procedure but with results that resemble medical treatments. If you take a hundred patients and treat them with finasteride or minoxidil and check them a year later, you'll see a range of results from mild improvement to great thickening, with most somewhere in between. The same with PRP. It's like a surgical procedure in that there are numerous variables which affect the outcome. Which centrifuge system is used, the platelet concentrate, whether ACell or other agents are mixed into it, how it is injected, whether it is 'activated' are just some of these variables. Know one knows for sure the best way to perform PRP and there are differing opinions.

2. To do a proper 'study', you need a large number of patients NOT on any other treatment (fin, min, etc), who are willing to come in every 3 months for measurements, and who would be willing to be a 'control' (ie have a placebo saline injection). Virtually none of us solo docs could actually carry out such a study in our clinics.

3. Just like a patient who has been on fin or min for a year may not appreciate any difference when in fact they have had significant improvement, a patient may respond to PRP but not be aware of it because it sneaks up on them over a course of a year. I've seen many examples of this. So if a patients reports on the forums that he didn't get any improvement from PRP, this may not be accurate.

4. Many of us who are doing PRP are in communication with other docs, sharing observations, and trying to determine the best way to perform it but there is naturally a lot of uncertainty at this time. I make it clear to my patients that it is an evolving treatment and there is much we don't know. I completely agree that some clinics out there are over marketing this and deceiving patients.

I'm including some PRP/ACell results (no transplant and no new fin/min treatment) which demonstrate the range of possible results from minimal to excellent improvement.

ACell does not create new hair follicles. It is placed below the skin surface as the edges are sutured together. It reduces thick scar tissue from forming between the two edges and promotes natural tissue regeneration between the two sides. It doesn't really change the 'look' of the scar but it does improve the 'feel' of the scar. Usually patients tell me they cannot feel any scar even if a 1mm line is visible.

Thank your for your response Dr. Cooley, I would be lying if I said I don't stay up at night picturing this happening to me, I wonder at what age did he realize he was destined for Norwood 7, I imagine he had his surgery in his 20's, but what age did the lateral humps begin to drop, I'll be 31 this year and Dr. Rassman said that the majority of men who are Norwood 7 can see a pattern by 30. Do you agrre or what's your thought on this?

I agree with Dr Rassman that most men who end up type VII will demonstrate some signs of this by age 30 (e.g. curly hairs around the ears, faint thinning low in the crown, etc). But obviously there are exceptions to the rule. Fortunately, type VII loss is uncommon.

This is a fascinating case, there is a guy at my work that looks just like his before, it looks terrible, question Dr. Cooley, how many grafts were used to the lateral humps?

 

If I ever become Norwood 7 I think I'll shave my head, but i think in this gentlemens case if he were to do another 2,000 grafts FUE he could strengthen the lateral humps and hairline and look even better.

I understand this case may frighten a lot of guys. But remember it is very unlikely that someone will progress to type VII loss as seen in this case. He did not take finasteride and we can see what happens as the underlying genetics manifests over time. A more likely 'worst case scenario' for most people is to imagine what one will look like as a type V/VI.

In this case, about 2,000 grafts were used to rebuild the lateral humps, with the remainder used to fill in the front and 'shrink' the crown. I agree he could use an FUE to further refine his appearance. But he is so happy that he doesn't feel the need at this point. The photos don't fully convey the transformation from someone who looked unnatural from across the room to someone who looks relatively normal after a single procedure. Some men just don't have the head shape to pull off a shaved head look, and he definitely prefers the way he looks now to that. I always recommend young guys try shaving their head before doing a transplant to see if they like (or could live with) that look. If the answer is 'no', that helps in the decision making.

Thanks for all the comments.

4400 grafts where you dont shave the recipient area seems like a heck of a lot of extra work. I doubt most of us would understand when you have to work around long hairs in your way for 10-12 hr surgery.

 

Great result.

Thanks for the comments.

It is extra work to transplant around long hair but this is the way I've always done it (>20 years) so we are use to it. In my opinion, shaving is nice but the patients who come to see me don't want to do it because they expect to be back at work in a week or so without it being obvious they've had a transplant. Also, in my opinion, shaving does not reduce the chance of shock loss but it does make the surgery go quicker. Every once in a while, a patient tells me they don't care if I shave, so I do. It doesn't change the final results.

This patient is in his mid-40’s and had hair transplant surgeries over 20 years ago. Fortunately, the original transplant was entirely competent mini-graft procedures that were well planned and state of the art for that time. The hairline fortunately had not been placed too low. His hair loss progressed over the years, leaving the transplanted hair as an isolated island. He was most likely a type IV or V when he had his original surgeries and he progressed to type VII. Despite the number of previous surgeries, I judged he had one good strip left. We performed one FUT of 3,582 grafts to fill in the side walls (‘lateral humps”) and to shrink the crown from the outside in. He is shown one year later with a much more normal appearance.

This is great! The patient has good teeth too:) What is the breakdown on the hair counts? I don't understand the part about your variation of PRP. I thought PRP is PRP.

Hair counts: 1-838, 2-1655, 3-634, 4-37

About PRP, that's a great question. Actually, there a lot of different ways to 'do' PRP. Adding ACell is just one variable. Some of these other variables are: the device used to centrifuge the blood, the concentration of platelets achieved, the total volume injected, the size of the syringe and needle used to do the injecting, the level in the scalp it is injected, whether the PRP is 'activated', the use of microneedling, etc. All of these can affect the result in my opinion.

This patient is in his late 40’s and has the “A” pattern of frontal loss. We started him on finasteride and performed FUT of 3,164 grafts. We also performed my variation on PRP/ACell therapy which I believe helps to induce early growth and a thicker overall result for many of my patients.

The patient is quite a character and when he asked me during the pre op photos whether he should smile, I told him that he was supposed to look sad in the before photos and happy in the after photos. He really had fun playing along with that!

If there are any questions about this result don't hesitate to ask.

That's really interesting Dr Parsley. If that result is only at 3 months, I would expect much more improvement over the next 6-9 months. I have had many patients tell me that they really saw it kick in at the 9 month point.

This patient is in his mid 30's, has a youthful appearance except his hair loss makes him look much older than his age. We started him on finasteride and performed FUT of 3,637 grafts ((1-768, 2-1,330, 3-972, 4-96). He is shown one year post op. He told me this had completely changed his life!

This patient is in his 30's and has the vertex pattern of hair loss. With this pattern, the hairline is relatively preserved, while the hairloss progresses from the top outwards. He did not want to take meds, despite my recommendation. The goal with the restoration was to create a conservative result that would frame his face, and continue to look natural with the passage of time. We performed FUE of 2,117 grafts (1-209, 2-898, 3-1110) along with PRP/ACell. The results are shown 17 months post op.

great result--is he on medication?

No, he is not on medication. He had tried it in the past. He did not have any problem with libido or other issues, but he did have a decrease in his sperm count, which was picked up because he and his wife were going through fertility treatments. The sperm count increased significantly after quitting the finasteride. This is very rare but it can happen.

Thanks for all the comments.

This patient is in his mid 30's and wanted restoration of his frontal hairline including temples. There was no thinning in the crown. We performed FUT 2,664 grafts (4,581 hairs). He is shown 13 months later.

This patient is in his late 40's and was interested in frontal restoration. During the consultation we go over the differences between FUE and FUT. Most of my patients cannot shave and expect to be back to work in a week so they opt for strip FUT. This guy was an ideal candidate for FUE. He did not mind shaving and always wears his hair quite short and therefore wanted to avoid even a minimal linear scar. Furthermore, he lifts weights and works out alot, and did not want to worry about stretching his incision during the healing phase. We performed FUE of 1,511 grafts (1-456, 2-667, 3-367, 4-21). We also performed PRP/ACell on the top, to provide some overall thickening, as well as to the FUE donor sites to enhance healing. He is shown pre op, immediate post op, one day post op, and 9 months post op. He told me he can go to a one guard with no visibility to the FUE sites.

Wow. Incredible results.

 

Thank you for presenting a case with a very young patient and demonstrating that while there are general "rules" for the best age to get a transplant, nothing is set in stone and it really does vary from person to person. I'm sure many doctors wouldn't have even considered a hair transplant on a 16 year old, so it's great to see you step up to the plate with a conservative (and confident) approach. Adolescence is hard enough as it is without having to deal with going bald, so I'm sure you saved him an enormous amount of grief and heartache.

 

Out of curiosity, how many more grafts would you say he has on backup? How many procedures did/do you anticipate over the years? And how are those predictions/anticipations holding up in real time?

Pkipling

Thanks for the comments. Just to be clear, he came to see me for finasteride at 16 and we did his first transplant at 21, and his second at 26. We've used up almost 4000 FU's out of at least 8000 total available by strip (more after that with FUE). My donor assumptions at the beginning have played out as I would have expected but I did not expect his hair loss to progress the way it did from age 21 to 26 with him being on finasteride. By being conservative in this young man, we've kept enough grafts in the bank to address new areas of thinning and I'm hopeful the PRP/ACell will inhibit further thinning. He is exceptionally realistic and committed to the process.

Thanks to all for the positive feedback.

This is an interesting case. In some ways, it is a 'worst case' scenario for young men seeking hair restoration. He first came to me in 2004 at the age of 16. His hair loss had actually started at age 14 and he had a strong history of balding on both sides of his family. He started finasteride and minoxidil with stablization of his hair loss. He came back five years later, wanting a transplant. As with all young men, I talked to him about the commitment this involves and to confirm he didn't want to try shaving his head as an alternative to hair restoration. We performed FUT of 2000 grafts to the front half of his scalp, with a conservative hairline and moderate density. He was very pleased with the result. He returned again five years later noting progression of his hair loss. He said he had continued his finasteride and minoxidil so I have to conclude that his underlying balding had pushed past the medical treatment; it would of course be much worse if he were not on these medicines. In Dec 2014, we performed FUT of 1,738 grafts, filling in the front and light coverage to the crown, as well as performing PRP/ACell. He just returned at 8 months with good results. By not dense packing, we still have plenty of grafts for future use. He plans to return periodically for PRP/ACell as needed. While this case in not typical, it does show the need for good planning and the importance of acknowledging the progressive nature of hair loss.

This patient came to see me four years ago and is in his late 30's. He had been on finasteride for many years. We performed FUT of 1500 grafts (3031 hairs) to strengthen the hairline and address the corners. He is shown at one year post op. He recently came in to address some thinning of non-transplanted hair behind the transplant (last two photos). We performed a small fill in session to these areas. Given that he has been on finasteride almost 15 years, it is not surprising to see some gradual thinning. The medicine is still working and if he went off it, he would rather quickly catch up to where is genetics would have him be. The other interesting thing about this case is the prominent cowlick at the hairline on the left. I try to blend in to an existing cowlick with the grafts and soften it.

This patient is in his 30's and came to see me four years ago for some hairline work. We started finasteride and performed FUT of 1,819 grafts (3,817 hairs). He is shown at one year and just recently came in to see me for a finasteride refill. The final four photos are from this visit. The results have held up well over this time period.

This lady had a face lift and brow lift several years prior. The face lift resulted in loss of the side burns, which prevented styling with the hair pulled back. The 'coronal' brow lift resulted in a scar running from side to side, several inches behind the hairline. This also caused thinning of the hair in front of the scar. I see this commonly in women who have had a brow lift. In this case, we performed FUT with 2,929 grafts (6,258 hairs). She is shown 18 months after the procedure. She is thrilled with the results.

No there isn't, if anything the pre acell/prp pictures look thicker than after. I am not talking about the hair transplant pictures fyi.

Sparky

I think maybe it wasn't clear which were the before and afters in that string of photos. Let me try again. Three patients here, the before on the left, the after on the right. No effect of finasteride, minoxidil, etc. Do you still think the pre photos look thicker?

Dr Cooley

Dr C ,

 

Sorry but need to ask you as i just thought of

 

If this Pt had 2500 Grafts taken about 10 yrs ago what type of surgery would that of been? FUT, FUE or even them old style plugs they was still kicking around.

Also how do rate his last surgery on a scale 1/10? could todays Methods & new tools would have given him any better? or do you think from the Methods & tools they had back then, they did as good as they could of done back then?

 

i know this is how long is a piece of string sort of question but please try to answer best you can.

 

Thanks Dr C

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It was strip harvesting but I don't know if it was strict microscopic dissection. At that time, a lot of clinics took out strips and then cut the grafts with magnifiers not microscopes. Strictly speaking, this is minigrafting, not "Follicular Unit Transplantation". It was not terrible, but it wasn't that good either; pretty typical for chain clinics of that time period.

Ontop

Thanks for the comments. I think his donor looks good from the photos because he colors his hair. That always makes it look better than it really is.