August 14 2007, 3:33 pm PT | Posted in: FUE + Hair Transplantation
I would like to know your opinion on this procedure: Hair Science Institute
The procedure is called “HairStemcell Transplantation” and promises near complete regrowth of the donor site. It seems way too good to be true but I want to have an expert opinion on it before I jump to any conclusions.
It seems what they are doing is Follicular Unit Extraction (FUE), but they try to differentiate from FUE with what they call a Hair Stem Cell Transplantation. It is especially confusing when they show both side by side, yet they look the same. From the photograph they provide, they are using a standard dental drill head piece.
In short, stem cells are not readily identifiable even under a microscope. So to claim stem cell transplantation is likely a misnomer or sensationalism at its best to exploit the buzz word of “stem cell”.
Finally there are no doctors mentioned on this website that is associated with “research”. I find that highly suspect.
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Actually, the Dr/researcher who founded HairStemcell Transplantation has published stem cell related studies in the most prestigious peer-reviewed dermatological journal in the world. See the following link:
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2133.2004.05862.x?cookieSet=1&journalCode=bjd
Interestingly, I found a unrelated group of researchers who performed a study and found when they left the lower third of the follicle in the skin, it resulted in 72% regrowth of the extracted donor hair. This is interesting, because the first stem cell technique offered by Dr. Gho was based on the earlier research of Dr. Kim’s studies where it was found that both upper and lower transected follicle parts have the ability to turn back into fully formed hair follicles when implanted into the skin.
The problem with Kim’s earlier research was that it resulted in very inconsistent regeration. However, Dr. Gho (and the other team I cited) found that when you leave the lower third in the skin, if you can transect it at just the right depth, it will regrow into a fully formed follicle. IOW, Kim’s studies removed the follicle, which of course leads to trauma and also disturbing the natural signaling environment. But I should note that it is not easy to judge how deep to cut the follicle, so this lead to inconsistency in Dr. Gho’s technique.
Now you might be wondering how Dr. Gho managed to get around the problem Dr. Kim identified of inconsistent regeneration of the upper 2/3 of the follicle. Keep in mind that most of the studies done (i.e. Swinehart etc.) have used saline solution to soak the grafts in prior to transplantation. Dr. Gho found that by using stem cell culture mediums as a soaking solution, the upper 2/3 follicle is stimulated to regenerate on a much more consistent basis.
I strongly encourage you to perform a small scale study of leaving the lower 1/3 of the follicle in the skin so that you can better understand the ramifications of this technique.
Interestingly, Dr. Gho claims to have gotten around the inconsistency problems associated with his lower 1/3 technique by performing longitudinal transections. However, I know very little of this technique, and unlike his earlier lower 1/3 technique, I have been unable to find independent research to back up these claims. Then again, it took several years after its introduction for his claims about his earlier technique to be independently proven.
If you look at the grafts in this photo (blow them up in photoshop), you can see that they differ a great deal from regular FUE grafts. Clearly, part of the follicle has been left in the skin. Pay close attention not only to the amount of tissue, but the fact that nothing is extracted below the actual hair bulb. That is interesting to say the least. You can also see photos of the regenerated donor hair. But like I say, you should do a few very small scale experiments with leaving in the lower 1/3 of the follicle in the skin to observe the hairs regenerate. It definitely works if you get the transection at the right depth. But if you want to fully mimic Dr. Gho’s older technique, you will have to be somewhat familiar with stem cell science. If I were to attempt this personally, I would start with a standardized keratinocyte medium intended to culture DP cells and fine tune the mixture over time based upon results.
Sorry, I forgot to include the link with the photo of the grafts.
http://hsi.mxt.nl/en/haarstamcel-transplantatie-hst–3.html
I am including the study I was referring to about the donor regrowth. It was featured at http://www.med-haarverpflanzung.de but the link has since gone dead. Note that the figures cannot be shown in the text format of this post. Also, this study was performed by an FUE clinic that concluded that the donor regrowth technique should not be used in FUE procedures. However, IMO, it is not that black and white because there are several key differences between this study and Dr. Gho’s old FM technique.
It states in this study that the regrown donor follicles cannot be extracted a second time because the surrounding tissue is too soft. However, this is not true. The follicles can be repeatedly harvested, but they must be allowed to fully reform first. Thus the second extraction of the follicle should not be performed for a minimum of 10 months following the first extraction. Keep in mind that the amputated follicle has to have time to fully regrow the upper 2/3rds. So it should not be messed with before this has occurred. I say to wait 10 months, but, if I’m not mistaken, Dr. Kim’s study showed that it can actually take up to a year for this to occur. However, Dr. Gho seems to indicate that 10 months is a sufficient amount of time to wait.
Also the study states that the upper 2/3rd extractions should not be implanted into the recipient area. This is also not true. But it is imperative to first soak the grafts in a solution of growth factors that is similar to a culturing medium. This helps to enrich the signaling environment and causes a very high percentage of the grafts to regenerate new end bulbs and grow in a similar manner to a regular HT. However, in some cases, it can take up to a year before the full cosmetic result can be seen.
As you can see, when performed properly, obtaining donor regrowth is not a problem as it happens quite naturally. The trick to performing this procedure is in recipient site placement of the upper 2/3 of the follicle. As far as I can tell, Dr. Gho has figured out how to get ~95% of the recipient hairs to regenerate with HT quality. The main question with his technique at this time is how well he can place the hairs. There are those in the community that believe he is a better scientist than he is a HT surgeon. I personally do not know one way or the other, but photos of his placement techniques I have seen in the past seem to indicate that the technique has certain limitations compared to some of the better FUE work I have seen. The key when contemplating getting any HT is to do your own research.
Here is the study:
INTRODUCTION
The limitations of the donor area reserve is the most important problem to be solved by all physicians dealing with hair restoration surgery. The studies for increasing the potential donor supply such as hair cell implantation and in vitro hair follicle regeneration are still under investigation due to their poor results. The only recent advance is the follicular unit extraction technique also known as FUE. This technique allows the surgeon to obtain an increased number of follicular groups from the scalp and other body areas. However, as the level of baldness advances the number of grafts needed is not sufficient for a satisfactory result.
Several authors have proved that follicular epithelial stem cells should be located in the bulbar region as well as the bulge area. In 1995 Kim et al1 and in 1999 Reynolds et al2 reported that the outer root sheath cells cultured from different parts of a hair follicle could regenerate into a differentiated hair follicles. Based on Dr. Kım and Dr. Reynold’s studies, we hypothesize that transecting the hair follicle from different levels should allow doctors to obtain several viable donor grafts from one donor hair. Therefore, the number of donor hairs available in a patient’s donor area would increase in comparison to the techniques used today. This manipulation will result not only in hair growth in the recipient site, but will also allow for hair regrowth from the remaining part of each follicle in the actual donor site.
In this clinical study, we transplanted different parts of transversly trisected hair follicles, harvested by the FUE technique, from the donor site. We then tested the hypothesis by duplicating the available donor hair grafts in hair transplantation. We then evaluated the efficiency of the transected follicles by checking the growth rate of each type of transection. This evaluaton is especially important for surgeons using FUE since transplanting the transected follicles is sometimes a problem.
MATERIAL AND METHODS
Using the follicular unit extraction technique, normal human occipital scalp hair follicles were obtained from 5 healthy male patients. A total of 45 hair follicles were isolated for each patient. The follicles were divided into three groups. Group A (N:15): The upper one third of the follicles were extracted from the donor site, leaving the remainıng two thirds of each follicle intact. Group B (N:15): The upper half of the follicles was extracted, leaving the remainıng lower half of each follicle ıntact. Group C (N:15): The upper two thirds of the follicles were extracted, leaving the lower one third of each follicle ıntact. Extracted follicles from each group were placed into the slits at the recipient site. To monitor the growth in each site, the area was divided into 1 cm2 boxes using permanent tatoos. Follicle count and thickness control was performed for one year by an independent third party
RESULTS
At the recipient site at the 15 follicles meanly 3 (2-4) of upper one thirds, 4.4 (2-6) of upper half and 6.2 (5-8) of upper two thirds were observed as fully grown after 1 year. The regenerated hairs were thinner than those from intact follicles. At the donor site a regrowth rate of meanly 12.6 (10-14) of extracted upper one thirds, 10.2 (8-13) of extracted half and 8 (7-12) of extracted upper two thirds was observed as emerging new follicles. The growth rate at the donor site and regrowth rate at the recipient site is given in Figure 1 and Figure 2 respectively.
Figure 1: UPPER 1/3 1/2 UPPER 2/3
Growth rate at the recipient sit
Figure 2: UPPER 1/3 1/2 UPPER 2/3
Regrowth rate at the donor site.
DISCUSSION
The hair follicle is a complex organism. It contains stem cells that not only govern the rate of cell loss, but also the regeneration of the hair during its life cycle. These stem cells are located at the bulb and outer sheath close to the erector pili muscle which is called the“bulge” as well. Oliver Et Al showed that rat vibrissae can still regenerate after removing the lowest one-third of the follicle. Similarly, Inaba Et Al, Kim and Choi proved that grafted hair follicles can regenerate after removal from the bulb. This data showed that the upper half of the follicle can regenerate outside of the bulb area. In our study we observed a growth rate of 29.3 % in the upper half of the follicles after 1 year. The regrowth rate was 76% at the donor site during the time period.
Recently, Rochat and Kobayashi proved the bulge hypothesis as true by isolating keratinocyte colony-forming cells from human hair follicles. They determined that cells were located in the follicular bulge area. This area is the outer root sheath to which the erector pili muscle is attached. This muscle is located nearly at the midportion of the follicle. Raposio Et Al identified these cells as follicular stem cells. Therefore, theoretically each half of the follicle should contain a stem cell reservoir and allow for new shaft production and hair growth which means an unlimited donor supply. They also transected hair follicles from the level immediately below the bulge area. They proved that the lower half of the follicle had the same growth rate as the intact follicle but that the upper half exhibited a reduced shaft production capacity. Although, the upper half of the follicle exhibited a reduced capacity for shaft production, it still had the capacity to form a hair shaft which means that it still contained some follicular stem cells. We have observed similar results ın our studies; just 13% of the upper one-third of the follicle can regenerate as a new follicle after transplantation. the upper half resulted in 20% and the upper two-thirds resulted in 33%. So we have observed that if only the bulge area is included in the graft the survival rate increases. If the transection level goes lower and the number of outer root sheath cells included in the graft increases, the survival rate will also increase, just like in the success rate in the extraction of the upper two-thirds of the follicles. This data supports the bulge hypothesis that implicates that the stem cell circulation begins in the upper outer root sheath and moves downward through the bulb area. Therefore, it is logical to include both stem cell locations and as much outer sheath as possible to increase the graft yield after the transplantation.
To our knowledge our clinical study is the first written study that compares trisected hair follicle growth and donor regrowth with single follicle extraction system. The most important problem in FUE procedures is the unacceptable levels of transection (damage due to cut hair follicles) in some patients. Sometimes surgeons are not careful enough when inserting the transected grafts into the slits. The results of our study reveals these transected new follicle can emerge in the recipient site. However, the number of new follicles depends on the transection level. New follicles are thinner than the original ones and they cannot cover the recipient site sufficiently. We think the bulge area stem cells can regenerate to build a new follicle, but without the bulb, the new follicle is thinner than the original one. We suggest that surgeons reconsider placing any transected follicle in the recipient site and maybe it is better to switch to strip surgery or to cancel the operation if the transection rate is above 10% in any patient.
We have also observed that in all FUE patients new hair follicles can regrow in the donor site. So we thought a kind of in vivo multiplication can be achieved so that the donor site can be harvested several times. This is basically true because we harvest the upper two-thirds of the follicles and 76% of the follicles regenerate at the donor site. This ratio increases as the level of transection gets higher ( 98% for the upper one-thirds). Also, new hairs emerge from 33% of these transplanted follicles in the recipient site. However, if a surgeon tries to extract the same follicle again it is really very difficult to extract the follicle intact. The punch suddenly buries into the skin and extracting the same follicle gets practically impossible.
In conclusion, the survival and growth rate of transversly sectioned human hair follicle increases as the level of transection decreases. However, we don’t recommend the surgeon to transplant the sectioned parts because the growth rate is not more than 33% and new follicles are so thin that they have no coverage effect. Also, at the donor site new follicle growth is observed but it is not possible to extract them again; therefore, the surgeon should be very careful with the patients whose transection rate is high during FUE procedures.