Dr. John Cole’s Interesting Thoughts on PRP and his Proposed new Study on PRP

US (Atlanta, Georgia) based Dr. John Cole is undoubtedly one of the world’s most respected hair transplant surgeons.  He has trained numerous other surgeons around the world over the years, and is almost certainly among the world’s five most experienced surgeons when it comes to the now dominant follicular unit extraction (FUE) method of hair transplantation.  In 2013, Dr. Cole received the prestigious ISHRS Golden Follicle award.  More importantly, over the years Dr. Cole has been at the forefront of testing out new procedures and techniques, and at adding his own cutting edge modifications to existing procedures. Some might consider a lot of these modifications to just be marketing gimmicks, but I think it is genuine interest on the part of Dr. Cole to improve the overall field of hair restoration.

In recent months, Dr. Cole has taken an active interest in improving the platelet-rich plasma (PRP) procedure.  I discussed this in several posts in the past year (i.e., search for “Dr. Cole” in here and here). PRP for hair restoration has taken off like wildfire in the past few years, but results have been extremely inconsistent.   Moreover, almost all hair transplant surgeons who offer PRP (often supplemented with ACell) treatments agree that patients will not regrow hair on totally bald areas of their scalps.  Nevertheless, many claim that PRP usually makes existing hair thicker and even regrows recently shrunken hair.  I am skeptical of the latter, but definitely not totally dismissive.  Over the years I have a read a few positive testimonials about PRP on hair loss forums from respectable long-term members, but none of these testimonials have suggested any miracle results.

Dr. Cole’s new PRP Study

This week Dr. Cole sent me an interesting e-mail about his thoughts on PRP and about his new study on PRP and I have pasted the contents of his e-mail below.   Note that I had not e-mailed him to ask anything about PRP, so this e-mail was Dr. Cole’s own initiative.  I have added some brief notes in red below and bolded some of the important parts of Dr. Cole’s e-mail.  I am curious to see what blog readers think.  As always, please try to stick to intelligent blog post related comments (unrelated comments about interesting new developments in the hair loss world are ok) and no insults:

Here is the current PRP study I am proposing. We have seen a 50% increase in hair density at six months with Angel PRP (see here) and a decrease with Regen PRP (see here) at that point, but there is an improvement in density and hair check at 12 months with both. That’s good. An increase in hair density is not enough. We need an increase in hair mass and hair check shows we can get this. It just proves that not all PRP is equal. Some are terrible. What we found with Regen PRP was that some growth factor concentrations were quite low. It suggests that some PRP kits produce better quality platelets because overall levels of platelets were similar. By the way, 1X levels of platelets just don’t work (I have read that 5X is the desired number). Don’t waste your time, nor you money on those. What we have not documented to date is a benefit from Acell (FYI — there are other extracellular matrix products out there too besides ACell), but our data is incomplete at this point, so I’m holding back on any conclusions on Acell. What I think Acell does with PRP is prolong the duration of growth factors by allowing a sustained release. The problem with Acell is that it is of porcine origin, which makes it intolerant to some religious affiliations. Thus we need to evaluate the benefits of microparticles such as dalteparin and protamine on the advantages of a sustained release of growth factors at some point soon. These much less expensive adjuncts to PRP would remove religious barriers, as well as, remove financial burden to patients. We know that Acell can help with follicle regeneration since we cannot locate up to 48% of FUE extraction sites (he is talking about hair transplant extraction here) when we apply it, but whether Acell stimulates stem cells in follicles in conjunction with PRP remains a mystery that we will solve soon. For now, we have to focus on higher growth factor concentrations obtained by sonicated PRP.

Accordingly, now we want to focus on sonicated PRP. At 3 1/2 months, I have found 64 out of 80 grafts growing. That’s amazing with sonicated PRP. The growth factor concentrations in sonicated PRP are off the chart high. As a result, we are engaging in a study in collaboration with the department of chemical engineering at the University of Michigan to investigate the effect of high concentrations of growth factors on the dermal papilla this year. We also want to look at the density of hair and the hair check and the diameter in a comparison of standard PRP with Acell and sonicated PRP with Acell.

I want to emphasize that across the board all patients in our study done in conjunction with Chiara Insalaco, a plastic surgeon from Rome, had an initial decrease in hair density and hair mass (Hair Check). This reduction in density and hair mass mimics the effect we see from Minoxidil. I speculate that all patients undergo a transformation from the telogen (resting) phase to the anagen (growing phase) with high quality, concentrated PRP. Anagen effluvium leads to an initial period of shedding, which means that patients get worse before they get better. Just as an adult tooth pushes the baby tooth out of the way, the anagen hair pushes the telogen hair out of the way. We noted this right away with hair clippings. We found that the percentage of shorter hairs was much higher following treatment with PRP, and the proportion of longer hairs was much lower following PRP. Over time both density and length increase, which leads to an increase in hair mass closer to 12 months following treatment with PRP. Dr. Insalaco and I counted every hair that we clipped in the study area and grouped them by length. Following PRP, the number of longer hairs drops. However, it recovers and exceeds the number of pre-treatment long hairs following the injection of PRP. Based on these findings, I would recommend a high-quality PRP every 6 to 12 months as a maintenance treatment; however, the duration of this benefit remains unknown.

What PRP will not do is to improve the quality of miniaturized hair for the most part based on our global photography. Years ago in 1999, I found that the last thing lost as follicular unit density, while the first thing lost was hair density in androgenic alopecia (confusing sentence). The prompted me to recommend the use of retardants to hair loss early on before the loss of follicles. My conclusions were antecedent to those later proposed by pharmaceutical companies and other researchers. There are no means to bring follicles back once lost (I am not so sure.  Please read this Dr. Cole), and PRP fails in this objective too. However, unlike products that retard the formation of DHT, PRP carries no unpleasant side effects such as a persistent loss of libido and depression (I do not buy the theory that DHT inhibitors causes depression — maybe depression due to other side effects). As such, PRP seems to be highly preferable to the use of chemicals that can cause long-standing physiological consequences.

We are fortunate to have an article publishing this fall with Pietro Gentile, also from Rome, Italy, documenting the benefits of PRP. We are lucky to have the opportunity to study the combination of PRP and adipose enriched stem cells on hair loss with Dr. Gentile. We are also affiliated with Paul Rose and Bernie Nussbaum in a similar study in Miami. However, the capacity to study adipose enriched stem cells is far greater in Italy than in the USA (Dr. Joseph Greco’s work and collaborations seem to also support this theory when it comes to PRP). With this in mind, Dr. Insalaco and I are forming an office in collaboration in Rome, Italy with the intent to further study the benefits of regenerative medicine on hair loss. Dr. Insalaco spent the past year training with me in my offices in Los Angeles and Atlanta. She plans to open both a hospital and private practice research center focused on the treatment of hair loss in Rome, Italy. I will be assisting her in this enterprise because she is a gifted surgeon and meticulous researcher. I look forward to continued collaboration with her.

I was thrilled to speak at the 7th conference on regenerative medicine in Rome last December and look forward to speaking at the 8th conference on regenerative medicine in Rome next December. The future of PRP seems to be a combination with adipose enriched stem cells, and there is not a better place to study this than in Italy at the moment (There are also many ongoing studies on ADSC in the US.  I mentioned two in here towards the end of the hair loss section).

So here is the study as follows:

The current study model is to apply Angel Arthrex PRP at a 2 or 3% hematocrit on one side and to activate this with Calcium Gluconate on one-half of the scalp. We have found that calcium gluconate activation offers no statistical difference from PRP activated by bovine thrombin, and it is quite safe. Bovine thrombin carries the risk of a hypersensitivity reaction or antibody response to the foreign thrombin. There are no documented cases of plasmid transmission from Bovine thrombin, but this is a concern some have. Plasmids seem to come only from the bovine neural tissue. Calcium gluconate, on the other hand, is quite safe. On the other side of the scalp, we are applying sonicated PRP. We know that sonicated PRP helps promote far faster hair growth from transplants than standard PRP. However, we are no sure if sonicated PRP will produce a better response in areas of hair loss. An evaluation of density and hair mass are the purpose of the study.

Sonicated PRP is PRP prepared by exposing your own PRP to a higher energy sound wave intended to lyse the platelets and release a much higher concentration of growth factors than can be obtained through activation with calcium gluconate. Some growth factors are increased by 5 to 8 times the concentration of growth factors activated by calcium gluconate. Sonicated PRP is also very safe. Sonicated PRP requires the use of an expensive machine designed to deliver a known energy for a variable duration of time. We have found that sonication for 30 seconds on and 30 seconds off for a total of one hour produces the highest concentration of growth factors.

The typical cost for PRP is $5000.00 for three treatments. In the study, you will receive three treatments for $750.00 each.

In this study, we will not perform a trichoscan. A trichoscan requires us to trim to 1mm approximately 2 cm2 surface area of hair. Trimming just over 2 square cm can be difficult for individuals to conceal. Therefore, we will be looking at density, diameter, and the hair check because this requires a much small surface area of hair trimming and should not be noticeable. While we did see a positive response on the trichoscan in our previous study, we are eliminating this from the present study. The hair check will require your hair be at least 2 inches long for present and future follow-ups.

In the study, we will want to see you at 3, 6, and 12 months following treatments. We recommend the following treatment protocol. However, we would accept a single treatment provided you make your follow up appointments. We recommend the first treatment at day one, the second treatment at day 90, the third treatment at day 180. However, a single treatment is also possible.

We also know that almost all women respond to PRP. Furthermore, we have a new exciting product for men and females that is a Wnt up regulator (I am skeptical that an individual doctor can develop this when companies can not/are not, but glad Dr. Cole is trying out new things). The Wnt pathway has been shown to increase hair growth. In a study performed by Antonella Tosti, she found this product improved the Hair Check in the female population of patients she studied. She did not examine this product in men in her study. A positive response in the hair check is a more significant response than an increase in density because an improvement in hair mass ensures better coverage.

I can send you some specific one-year data on both Regen and Arthrex if you like (I do not plan to ask for this).


Dr. Cole

List of Surgeons who Offer Body Hair to Head Hair Transplants

In 2013, I wrote two posts (see here and here) on body hair transplants (BHT) where surgeons move body hair to the scalp in the event of donor hair shortage at the back of the scalp in the permanent zone of severely balding people.  This type of procedure has some drawbacks as I discussed before, and body hair is virtually never as good or reliable as scalp donor hair. Nevertheless, there have by now been thousands of BHT cases performed worldwide with many satisfied patients.  In most cases, body hair is added as an adjunct filler to scalp hair during a hair transplant procedure, although I have also seen videos of excellent body hair only megasession hair transplant procedures.  The increasing popularity of BHT makes sense when one considers that a large portion of balding men tend to have a lot of body hair.

Below is a list of surgeons who offer body hair transplants around the world.  I only included those that have devoted pages of their websites specifically to BHT or have presented interesting BHT case examples on their sites and/or hair loss forums.  From my years of reading hair loss forums, I would guess that Dr. Arvind Poswal (India), Dr. John Cole (US) and Dr. Ray Woods (Australia) are probably the most experienced surgeons in the world at performing body hair to head hair transplants, although I could be off and you should conduct your own research.  Virtually all surgeons seem to find beard hair as the best type of body hair to be used for moving to the scalp, although some prefer not touching facial hair due to fear of potential permanent scarring.  Most surgeons seem to find chest hair to be the second best candidate to move to the scalp.

Note that for many people hair transplants represent a “cure” for hair loss so posts such as this are important.  Moreover, if you browse all the links below, there are some fascinating before and after transformation photos and chest/beard/other body area post extraction healing photos that are worth checking out.









  • Dr. Coen Gho (scroll down the page to get to the BHT section).





United Kingdom

United States of America

Clinics Present in More than one Country

Brief Items of Interest, August 2016

Hair loss news first:

Update: Histogen gets funding from China and also targets the Chinese market.

Kyocera updated its article on the biggest news of this year in the hair loss world.  They plan to conduct clinical research in Japanese fiscal year 2019 (i.e., between April 1st 2018 – March 31st 2019) and put the technology into “practical use” in 2020.  Interesting quote:

“While various methods are under evaluation, Kyocera’s piezoelectric technology is of particular interest as a means of discharging small amounts of viscid cells in a precise manner during the cell processing process.”

PGD2 inhibitor Fevipiprant could be a miracle treatment for asthma.  I am still hopeful that Setipiprant will be better than expected when it comes to treating hair loss.  Worth listening to Kythera CEO’s interview here if you haven’t already.

— More evidence that enhancing the β-catenin signalling pathway in dermal papilla cells allows faster and denser hair growth.

— New findings from a Stanford University (US) and A*STAR (Singapore)’s Institute of Medical Biology collaboration:  Wnt signalling plays a critical role in hair follicle stem cell maintenance. Interesting quote:

“Compounds, particularly those which have already been established to be Wnt activators, can now be tested against cultured HFSCs to see if they do stimulate hair regrowth. The scientific community may also be able to culture HFSCs more efficiently by tweaking Wnt signalling to the optimal levels.”

New interview with Replicel CEO Lee Buckler.  Important part is around three minutes in.

— New article that covers Dr. Christiano’s company Rapunzel as well as other relevant subjects including Samumed, Vixen/Aclaris and Dr. Joseph Greco.

— Hairlosstalk is interviewing Dr. Gail Naughton of Histogen this week.  Unfortunately the questions are already finalized, but its still worth a gander through this thread.

— New study from China: “Hair follicle and sebaceous gland “de novo” regeneration with cultured epidermal stem cells and skin-derived precursors.”

Cellmid to enter US hair loss treatment market.

— Dr. Cole’s office sent me an update on PRP and ACell recently.  I think they sent out a mass e-mail on the subject since its contents were also pasted in here.

— Joe Tillman discusses his Dr. Cooley PRP treatment results.

Healeon Medical is starting a new clinical trial in Honduras that will “evaluate the safety and efficacy of the use of a biocellular mixture of emulsified adipose-derived tissue stromal vascular fraction (AD-tSVF) and high density platelet-rich plasma concentrate (HD- PRP) as compared with adipose-derived cell-enriched SVF (AD-cSVF) + AD-tSVF and HD- PRP concentrates in treatment of androgenetic alopecia (AGA) and Female Pattern Hair Loss (FPHL).”

— Dr. Jeffrey Epstein is conducting the “first ever FDA-approved study in the US on the use of fat-derived stems cell for the treatment of hair loss in men and women.”  If you are near Miami, perhaps worth a visit.

My note: All of the last four points cover treatments that are highly controversial and far from guaranteed to work.  Buyer beware.

On a less serious train of thought:

Eat curry to prevent hair loss.

— He says that black guys do not always pull off the bald look.  I still think he pulls it off.

UK celebrity funnyman divorcee gets a hair transplant to prepare for online dating so as to not look like a thug.

When Homer Simpson got hair due to a miracle drug call dimoxinil.

Our lack of body and scalp hair may have allowed our species to thrive.

And now on to medical items of interest:

— Last year I discussed the inspirational Zion Harvey after he got a double hand transplant.  He had lost both his legs, both his hands and his kidney to a childhood infection.  One year after his double hand transplant surgery, here is the result:

Chinese scientists to pioneer first human CRISPR trial.

— “Bio is the new digital.”  Great article from Taiwan that is a must read after translation.  Boston is to biotech what Silicon Valley is to information technology.  In the hair loss world, it seems like New York and San Diego (see here) are far more important than Boston, but perhaps we will see some surprises from Boston soon?!

— Two stories on aging in the Economist in the past week.  Here and here.

Excellent article on human enhancement.

Dr. David Sinclair’s presentation on ageing and lifespan extension.

— At least androgens have some benefits such as telomere length extension.

Dr. George Church on the future of genetic engineering.

— Genetic engineering will change everything.  Very optimistic video:

Gene therapy cure with a money-back guarantee.

— Using a patient’s own stem cells and a 3D printer, scientists have genetically engineered a “living hip” that will cease pain.

— Cornea cells successfully grown and implanted to cure blindness in animals.

Peter Thiel is a fan of parabiosis.

Update on Dr. Frankenstein.  Full body transplant scheduled for December 2017.

— Scientists just created nanorobots to travel the bloodstream and fight cancerous tumors.

A Hair Loss Blog