Dr. Jerry Cooley

This young man was wearing a hairpiece (which is why the hair is shaved in the before photos. A surgery consisting of 2,853 grafts (4938 hairs) was performed. The immediate post op picture is followed by one taken at suture removal. We ask hairpiece users to keep it off for one week after surgery, then to only wear it loosely during the day thereafter until the hair grows in.

Thanks for the feedback. Her procedures were a year apart.

Correction: 3,000 grafts, over 5,800 hairs

This woman had severe fronto-temporal recession, similar to what is seen in men. This is uncommon but has a very negative impact because it is so hard to hide and makes the woman look masculine. She underwent two surgeries with a total of 3,000 follicular units (over 5,800 hairs) to create a more feminine hairline.

This man in his 30's was bothered by his uneven hairline. While he had minimal hairloss, there was significantly more recession on his right side. This is what we see in the majority of our patients and it can magnify the hairline recession. Also, he had a notable cowlick on the right which made the asymetry even more apparent. He underwent 1,396 grafts (2,854 hairs) to the entire hairline with emphasis on the right side. The results show a subtle balancing of the hairline with a more aesthetic appearance.

This man of Indian descent had plug transplants a decade prior. A session of 2800 grafts (5190 hairs) plus decoring most of the plugs in the front was performed. These plugs were 'recycled' and the follicles within each plug were cut into 1-3 hair grafts. After 3 months, some of the plugs regrew hair and these were treated with electolysis. Although faint light scars show where the plugs were, the overall result is very satisfactory to the patient.

Thanks for the feedback. Unfortunately I don't have immediate post op pics of either procedure. He is about a year and half out from his second. We did not shave his head prior to doing the second.

This is a man in his forties with type IV baldness. He had fine hair but good density and a higher than average hair/graft count. He underwent two surgeries (#1: 3036 grafts, 6269 hairs; #2: 3299 grafts, 7054 hairs) for a total of 6335 grafts and 13,323 hairs. A smaller third session is planned to add density to the crown.

Dr. Konior's post is so good, it deserves to be read and reread. Regarding his comments about variability in results: "There is no question that every surgeon on this planet has his or her patients who are not 100% satisfied. To deny that would imply arrogance, inexperience or blindness on behalf of the boasting party." One of the best parts of our annual ISHRS conference is the "live patient viewing" in which surgeons bring their patients to be viewed and inspected by their colleagues. I have yet to see any doctor present perfect results or perfect growth (and these were presumably their best cases). Although I try my best in every case, I know that I don't get 100% growth 100% of the time. "I have always viewed patients and their scalps like fingerprints or snowflakes ??“ no two are alike. The gamut that exists in the real world includes: 1) old patients versus young patients; 2) thin scalps versus thick scalps; 3) dry scalps versus oozing scalps; 4) miniaturized hair versus non-miniaturized hair; 5) thick caliber hair versus thin caliber hair; 6) high follicular-unit density versus low follicular-unit density; 7) high contrast hair versus low contrast hair; 8) high patient expectations versus low patient expectation; 9) responders to medical management versus non-responders; and 10) uneventful healers versus eventful healers. The intrinsic variables associated with this procedure contribute to the wide range of results that we all see on a day to day basis. Those of us who are really committed to this procedure do all we can to produce the best results possible, but these many variables confound the overall process and lead to results that vary from patient to patient. There are variables associated with all surgical disciplines that can affect outcomes in a variety of ways." In addition to the variable hair & scalp parameters that different patients have, the variability in "healing" factors deserves more discussion. Any doctor doing surgery on a regular basis notes that the exact same technique yields different results. Usually this falls along a bell curve: most get the expected results, while a few get either better or worse than expected results. I think that oxygenation/circulation issues are one of the main factors here. I did a study on over 80 transplant patients using a high tech oxygen meter on loan to me. The surprising finding was that baseline oxygen levels vary markedly among different patients. Oxygen content is a key factor in graft survival, especially in the first few days post op when the grafts have yet to develop their own capillary network. This may be one explanation for varying results in graft growth, in addition to the factors Dr. Konior mentioned. Perhaps I missed it, but UHT, were you on finasteride in the past? Please go and talk with Dr. Feller. He's a great surgeon that has his patient's best interest at heart. Good luck. Dr. Cooley

I have used both needles and blades for over ten years. Sometimes I prefer one over the other. In many cases, I use both and when the patient returns in a year for followup, there is no difference in the appearance of the hair growing from one site versus the other. If I'm working on slick bald skin, I tend to use custom cut blades. If I'm working in existing hair, I prefer needles. Most of my patients don't want to shave their head and I find that needles allow me to more easily make sites in between existing hair. The quality of results has to do with graft preparation and handling, careful creation of sites in the natural direction and angle of natural hair growth, and gentle graft placement. It has nothing to do with needles versus blades.

Please see my post about factors effecting growth: http://hair-restoration-info.c...?r=52810352#52810352 As mentioned, trauma to the hair follicle during the transplant procedure (transection, crushing, dehydration) is the most important factor. Next is the oxygenation and revascularization of the graft. The newly transplanted graft must get enough oxygen in the first few days to survive, and new network of capillaries must form around it ("angiogenesis" or "revascularization") within a few days. Finally, there are factors that I refer to as 'biochemical' which refers to what happens while tissue is kept outside the body for a period of time ("storage injury") and when it is placed back in the body ("ischemia-reperfusion injury"). I believe all of these factors should be considered and addressed by the surgeon who wants to get conistently good growth. Jerry Cooley MD

Please see my full post on Platelet Rich Plasma: http://hair-restoration-info.c...?r=52810352#52810352. The potential benefits of PRP during hair transplantation are: 1. Speedier healing: less redness, crusting, etc. My experience has been that subjectively everything just looks better and patients generally agree. Whether this justifies the added time and expense of PRP is debatable. 2. Better results: this would presumably occur because of the growth factors released by the platelets (PDGF,VEGF, etc). These promote the formation of new blood vessels (angiogenesis) during the wound healing process. Since the PRP we use represents a 5-10 fold increase in platelet concentration over circulating blood, it is reasonable to think that angiogenesis around the grafts occurs quicker with PRP than without. It is important to remember that grafts initially are not hooked up to the circulation but must become revascularized within a few days if they are to survive. PRP may speed up this process. My impression is that wound healing and the overall results are generally improved with PRP, and especially so in those patients with significant scarring such as from multiple/older technique hair transplants. More research is of course needed. I definitely think that we will be hearing more about PRP in the hair transplant field in the coming years. Jerry Cooley, MD

Graft survival and the use of platelet-rich plasma in hair transplantation Jerry Cooley, M.D. Over the last year (2008), we have been testing the use of platelet- rich plasma (PRP) in hair transplantation. Our interest was stimulated by two previous hair transplant surgeons, Carlos Uebel from Brazil and Joseph Greco from Florida, who reported improved healing and graft survival with use of PRP. Before discussing PRP, it is useful to take a look at the hair transplantation process in general. Although we may sometimes take it for granted, it is quite amazing that hair follicles can be cut out of one area of the scalp and placed into an incision in another part of the scalp, and survive. Graft survival has been an interest of mine for many years, and I have written textbook chapters and given numerous lectures on this topic. We can divide these factors into three main categories: 1) follicle trauma 2) biochemical factors and 3) vascular factors(oxygenation/revascularization). Follicle trauma refers to the transection, dehydration, and crushing that follicles can be subjected to during the surgery. Use of microscopes and follicular unit techniques minimizes transection. Keeping grafts moist throughout the process, especially graft placement, helps eliminate dehydration. Careful graft placement by an experienced placer will reduce crushing and damage to the graft. Most surgeons agree that reducing follicle trauma is the most important factor in determining graft survival. Biochemical factors refer to the stress the hair follicles experience when they are kept out of the body for a period of time and then returned to the oxygenated graft bed. When tissue is outside the body, it undergoes 'storage injury' due to cut off of oxygenated blood, lack of nutrients, and temperature/pH shifts. When this tissue is then put back in the body, it is re-exposed to oxygen, which sets off a spark of free radical production that may effect graft survival ('ischemia-reperfusion injury'). In our clinic, we use tissue holding solutions which contain buffers, nutrients, and antioxidants which have been shown to reduce storage and ischemia-reperfusion injury. Most doctors use normal saline which lack these ingredients. Vascular factors include the immediate post-operative oxygenation and successful revascularization of each graft. Unlike organ transplants where the transplanted organ is hooked up to a new blood supply, hair transplants are 'free' grafts which are surgically implanted without re-attaching a new blood supply (because that would be impossible to do with hair follicles). Until this process is complete, the graft must survive by passively absorbing oxygen from the surrounding tissue. We have been using and testing a variety of techniques to 'prime the pump' so to speak: topical hyperbaric oxygen, vasodilators, and angiogenesis stimulators. This is where PRP comes in. PRP was developed in the 1970's but has only recently become popular in many fields of medicine. It is being widely used and studied in orthopedic surgery, dental/maxillofacial surgery, and regenerative medicine to name a few. Basically, platelets are isolated by first drawing the patient's blood and spinning it down using special centrifuging techniques. A small fraction of plasma enriched with platelets is drawn from this and then reintroduced at the surgical site. Because the entire process is carried out with sterile, disposable instruments and devices, there is no chance for contamination. How does applying PRP help transplanted hair? Remember that platelets are key players in the body's wound healing mechanism. Whenever there is a wound (e.g. an incision to place a hair graft during a hair transplant), the platelets are trapped in the clot and are activated to release various growth factors that stimulate the healing process. These naturally occurring growth factors include: -PDGF (Platelet derived growth factor) -TGF-a & b (Transforming growth factor alpha & beta) -EGF (Epidermal growth factor) -FGF (Fibroblast growth factor) -Insulin-like growth factor (IGF) -PDEGF (platelet derived epidermal growth factor) -PDAF (platelet derived angiogenesis factor) These factors stimulate new blood vessels to form (angiogenesis) and collagen to be produced. Cells are stimulated to divide and go into action surrounding the wound. In addition, white blood cells present in the area help eliminate bacteria in the area. PRP merely amplifies this naturally occurring wound healing process by providing increased numbers of platelets and white blood cells to the wound. It is important that the PRP be concentrated enough to have a therapeutic value and some techniques and devices in use by some physicians today may not accomplish this. Our system (Harvest SmartPrep) has been shown to produce at least 1.5 million platelets/1ml, well above the therapeutic threshold. This represents about a five-fold increase compared to the platelet count in circulating blood (for 10 cc of PRP). This is significantly greater than other commercially available devices Technology Platform 60 ml Process Volume 7 ml PRP 10 ml PRP Harvest SmartPRep 1,3 7.6x 4.6x Medtronic Magellan2,3 5.1x 3.6x COBE Angel4 4.3x 3.0x Fresenius CATS1,3 3.4x Biomet GPS 1 3.2x 2.3x PPAI Sequire1 2.0x 1.4x 1Kevy, et al, Comparison of Methods for Point of Care Preparation of Autologous Platelet Gel, JECT, 2004; 36:28-35. 2Kevy, et al, Center for Blood Research; Presented at AMSECT - Hemostatis in Blood Management Meeting; April 2004 3Stammers, A.H., Trowbridge, C.C., et al, Establishment of a Quality Control Program for Platelet Gel Preparation: A Comparison of Four Commercial Devices - Society of Cardiovascular Anesthesiology Meeting: 9th Annual Update on Cardiopulmonary Bypass, March 2004 4Cobe Cardiovascular, Angel Whole Blood Separation, 2004 306700000 Rev A 10/04 5x increase in 10% of whole blood volume processed 5x in (0.10 x 60 ml) = 5x in 6 ml PRP Both Uebel and Greco have found that coating the sites and grafts with PRP appears to speed up the healing process after a hair transplant. My experience over the last year has been the same. Redness and crusting are markedly less and everything just looks better quicker. Is the overall growth rate improved? Uebel and Greco have reported that this is the case. In general, I get excellent growth so it is hard to tell if there is a small benefit in terms of graft survival, but I think there is. So why aren't more surgeons doing PRP? There is a cost factor: the centrifuge costs many thousands of dollars and with each case, hundreds of dollars of disposable supplies are used. Because PRP is still relatively new, many surgeons are not that familiar with it and there is a natural tendency to resist change, especially when it involves more time and money. More research needs to be done to provide convincing evidence of the benefits of PRP. Based on the impressive healing with PRP, and armed with an understanding of the documented benefit of PRP in other areas of medicine, I intend to keep testing it to further define its role in hair transplantation.

Bill Every topical drug has a certain rate of penetration and a time required for absorption for it to have any effect. I don't know the specifics of ketoconazole but I'm sure much, much more gets down into the hair follicle with a leave-on foam compared to a shampoo. If minoxidil worked as a shampoo, it would be much more widely used. Ketoconazole (and zinc pyrithione) help dandruff by eliminating a yeast from the surface of the scalp and by being anti-inflammatory, so being in a shampoo form that stays on the skin a few minutes will have a positive effect. When it comes to penetrating the hair follicle and helping hair loss, I've always worried that ketoconazole in the shampoo form probably doesn't get left on long enough to have that much effect. I'm sure much more of the ketoconazole gets down into the follicle as a leave-on foam, where it can have a positive effect for hair loss. Extina foam has the same feel as Rogaine foam. Alot of guys don't want to use anything topically for hair loss because of the hassle factor, but if they do, I start with minoxidil. If they want to use something in adddition to that, ketoconazole (Extina) foam is the next logical choice. For guys who don't tolerate finasteride because of side effects, I push the minoxidil AND ketoconazole foam. Just my opinion. cheers, Jerry

Ceasar I am copying my post elsewhere here, regarding the use of topical ketoconazole in men who can't tolerate finasteride. You might discuss this with your physician. Good luck. Posted September 28, 2008 07:54 PM Hide Post For men, we recommend finasteride as firstline therapy. If men can be committed to daily topical treatment, then 5% minoxidil can be effective, especially when combined with finasteride. There is growing evidence that ketoconazole is helpful too (go to PubMed and check out: Topical application of ketoconazole stimulates hair growth in C3H/HeN mice. J Dermatol. 2005 Apr;32(4):243-7. J Dermatol. 2002 Aug;29(8):489-98. Comparative efficacy of various treatment regimens for androgenetic alopecia in men. Med Hypotheses. 2004;62(1):112- Ketocazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. There is some weaker evidence that zinc pyrithione might be helpful too (see Br J Dermatol. 2003 Aug;149(2):354-62. The effects of minoxidil, 1% pyrithione zinc and a combination of both on hair density: a randomized controlled trial). For men who cannot tolerate oral finasteride because of side effects, we recommend topical 2% ketoconazole foam, which is available in the US as "Extina foam". I believe that any leave on product like Extina will work better than a shampoo that is washed off the scalp within minutes. Just my opinion. Hope this helps.

For men, we recommend finasteride as firstline therapy. If men can be committed to daily topical treatment, then 5% minoxidil can be effective, especially when combined with finasteride. There is growing evidence that ketoconazole is helpful too (go to PubMed and check out: Topical application of ketoconazole stimulates hair growth in C3H/HeN mice. J Dermatol. 2005 Apr;32(4):243-7. J Dermatol. 2002 Aug;29(8):489-98. Comparative efficacy of various treatment regimens for androgenetic alopecia in men. Med Hypotheses. 2004;62(1):112- Ketocazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. There is some weaker evidence that zinc pyrithione might be helpful too (see Br J Dermatol. 2003 Aug;149(2):354-62. The effects of minoxidil, 1% pyrithione zinc and a combination of both on hair density: a randomized controlled trial). For men who cannot tolerate oral finasteride because of side effects, we recommend topical 2% ketoconazole foam, which is available in the US as "Extina foam". I believe that any leave on product like Extina will work better than a shampoo that is washed off the scalp within minutes. Just my opinion. Hope this helps.

Sorry to hear about the side effects. We have had some patients who find that less frequent dosing still helps their hair but does not cause side effects. It seems that each person has a unique set point when it comes to side effects. Some do fine at 3 times a week, others at 2, while some of our older patients can only take it once a week. If our patients can't tolerate finasteride at all, we really push the topicals: minoxidil, ketoconazole, zinc pyrithione shampoo, etc. It can be a tough situation for some patients. Good luck.

Hi guys. I do have an opinion on this topic. Propecia is approved by the US FDA for once a day use. This does not mean it is the best dosage, only the one that was studied and approved. The average serum "half-life" of finasteride 1mg is about 5 hours in young men and 8 hours in older men. This does not mean that half of the medicine is out of your body in that time period though. The finasteride molecule is distributed throughout the body where it binds to the type II 5-alpha-reductase enzyme, thereby inhibiting conversion of testosterone to dihydrotesterone. Serum DHT is reduced about 65%, and less DHT means less balding. But several studies show that a single dose of finasteride suppresses serum DHT for 7 days or more (Eur J Drug Metab Pharmacokinet. 1991 Jan-Mar;16(1):15-21, J Clin Endocrinol Metab. 1990 Apr;70(4):1136-41, Prostate. 1989;14(1):45-53). So the finasteride is leaving the bloodstream, entering the tissue throughout the body, and binding to the typeII 5AR enzyme, resulting in long lasting DHT suppression. I do not "recommend" my patients take finasteride daily, every other day, twice weekly, etc. Rather I feel it is my duty as their doctor to advise them of the known facts about this medication. Most of my patients choose to take it on a Mon-Wed-Fri schedule, which is rational from my point of view. Many of my younger patients take it daily 'just to be sure' while my older patients are happy to take it two or three times a week. There are no clinical studies showing that less than daily dosing is as effective at treating hair loss as daily dosing and for obvious financial reasons, the pharmaceutical company making finasteride has no incentive to fund such a study. I hope this information is helpful. It is up to each patient to make an informed decision about which dosage is right for them.