Category Archives: John Cole

Dr. John Cole’s Interesting New Study on PRP

US (Atlanta, Georgia) based Dr. John Cole is 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 PRP for hair loss in numerous posts. PRP for hair growth 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 or telogen hair. I am a bit skeptical of the latter, but not entirely dismissive. Over the years I have read a few positive testimonials about PRP on hair loss forums from respectable long-term members. However, none of these testimonials have suggested any miracle results.

Dr. John 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 with no insults. Unrelated comments about interesting new developments in the hair loss world are ok.

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 think there are rare cases where you can bring back dead hair), 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).

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).

Regards,

Dr. Cole

Brief Items of Interest, October 2015

Hair loss news first:

— Prolific hair loss forum participant “Hellouser” is planning to attend the 9th World Congress for Hair Research in Miami from November 18-21, 2015. I suspect that this Congress will be the best one yet. Last year I asked blog readers to raise funds for “Desmond” from Australia to go to the 8th World Congress for Hair Research in South Korea, and this year I am asking people to help raise funds for “Hellouser” from Canada to attend this Congress in the US. Desmond’s videos from last year’s conference were excellent and an absolute must watch. I hope “Hellouser” also manages to film many of the most anticipated presentations this year. Please see his gofundme page for more.

— I covered Samumed in a detailed post last year.  It seems like the company updated its clinical trials page last month and might still be recruiting volunteers (although one forum member said they stopped after getting too many calls). I called their Ohio testing location and left a voicemail on 10/16/15 and will update this section if they call me back. Update: Ohio location staff called me back on 10/19/15 and are still accepting volunteers this week.  Perhaps of more significance, Samumed is a Silver level sponsor of the earlier mentioned upcoming 9th World Congress for Hair Research. They are clearly not going away, and their Wnt pathway activation strategy is entirely different from what other companies such as Allergan, Histogen and Replicel are doing.

— An interesting new study tiled “The In-Vitro Development of Polarized Hair Bearing Skin” using LGR6+ epithelial stem cells. A bit too technical for me to analyze in detail in this brief updates post.

— Dr. John Cole made an interesting update to his “looking for PRP volunteers” thread (NO LONGER THERE AS OF 2016) on the Bald Truth Forums. In his own words, he is trying out the following formulations:

“1. PRP plus calcium gluconate (CG) Vs. PRP plus CG plus recothrombin
2. PRP plus calcium gluconate (CG) Vs. PRP plus CG plus autologous thrombin
3. PRP plus calcium gluconate (CG) Vs. PRP plus CG plus ACell
4. PRP plus calcium gluconate (CG) Vs. PRP plus CG plus AmnioFX
5. PRP plus calcium gluconate (CG) AmnioFX plus ACell Vs. PRP plus CG plus AmnioFX
6. PRP plus calcium gluconate (CG) Vs. Ultrasound cell lysis to release growth factors of PRP plus CG
7. PRP plus calcium gluconate (CG) Vs. PRP plus CG plus dalteparin plus protamine microparticles.”

— While we are talking about the details of PRP, on October 10 Dr. Jerry Cooley posted the following on the Hair Restoration Network forums:

“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.”

— And yet more on PRP:  Dr. Jeffrey Rapaport keeps getting great publicity on his PRP treatment for hair.

FYI:  Although I discussed PRP a lot in this post, I still think its a gamble when it comes to growing back lost hair. If you do go for this procedure, it is probably worth contacting Dr. Joseph Greco first (search this blog’s “Categories” menu for more on him) and then contacting other doctors for a second and third opinion. [Update: Dr. Greco sent me some feedback that I have pasted in the comments to this blog post].

And now on to medical items of interest:

Deleting genes could bolster lifespan by 60 years. Only done in yeast cells as of now, but perhaps Liz Parrish can help speed this up in humans too?

George Church and colleagues do it yet again. They modify 62 genes in pigs used the CRISPR/Cas9 gene-editing technology. Humanity is a giant step closer to the day when organs can be harvested from pigs and implanted into humans without fear of rejection.

— If organ donations from pigs take too long to become a reality, there is always the possibility of ever improving artificial organs. The third ever patient to be fitted with an artificial Carmat heart is doing well six months post transplant. He is 73 years old. The first such patient died 2.5 months after getting an artificial heart and the second such patient died 9 months after getting an artificial heart  due to a motor control malfunction.

— I was unaware that earlier this year US based Alcor cryogenically preserved its youngest ever patient: a two-year old Thai child (just her brain). Now the BBC has published a very good article with video covering the family. Both parents are highly educated medical scientists and really believe that we are not too far from when science can bring back the dead, so long as they or their brains have been frozen immediately upon death. I am very creeped out by this, but at the same time fascinated. The parents seem like very reasonable and compassionate human beings. Also see this interesting new article on the science behind cryonics as well as last month’s NY Times front page article on Kim Suozzi’s brain preservation via cryonics.

An interesting side note: I once met this lady at a conference and she told me that she was involved in the freezing of baseball legend Ted Williams at Alcor in 2002. She told me that even at the age of 83, his legs were extremely muscular!

— A good article on Japan’s push to lead the world in stem cell research, including fast tracking clinical trials. We in the hair loss world know all about this and are hoping that many western companies take advantage of these favorable laws and conduct their trials in Japan.

— DARPA seeks to treat bodies with light, electricity, sound and magnets.

— Instead of obsessing over Lamar Odom, the US media should be covering stories such as the ones above, or this one that will make you all fuzzy inside. Pipe dreams of course.