Dr. Jerry Cooley’s Presentation on ACell MatriStem in Hair Restoration and Hair Duplication (Formerly Known As Autocloning)

I have been working with a new wound healing product called ACell MatriStem. It is FDA approved and is being used for numerous medical applications, such as treating war injuries and degenerative conditions.   I recently presented the results of my year and half work with ACell at the 18^th Annual Scientific Meeting of the International Society of Hair Restoration Surgery in Boston last week.   This is a recap of that presentation:

The purpose of my presentation was to describe my clinical experience over the last year and a half with Acell MatriStem – an FDA approved ECM wound healing agent – in my hair restoration surgery practice.

Background on Extracellular Matrix (ECM): The ECM occupies the space between cells and is part of every organ and tissue of every animal species.   ECM has “Xenogenic transferability”, meaning we can take ECM from various animals and use them in humans without fear of reactions because the makeup of animal ECM (e.g. cow, pig, horse, human).   Use of ECM in surgery has been found to enhance wound healing, promote tissue regeneration, and inhibit scarring.

ACell MatriStem = ECM derived from pig urinary bladder (UBM):

• Acellular  – all cells have been removed in the patented processing technique

• Non-crosslinked – will naturally degrade, with minimal inflammatory reaction

• Promotes angiogenesis- a key step in tissue regeneration

• Recruitment of adult stem cells- unlocks the body’s natural regenerative potential

• Antibacterial properties-unlike other implants, is not associated with increased infection

• Unique bimodal surface- (this makes MatriStem different from other ECM products)
  • Basement membrane layer
    • Conducive to epithelial & endothelial cell attachment & differentiation
  • Tunica propria layer
    • Organized connective tissue
    • Integrates into wound bed, supports vascular in-growth

ACell MatriStem contains:

• Structural proteins
  • Collagen types: I, II, III, IV, V, VI, VII
  • Proteoglycans

• Growth Factors
  • VEGF, BMP4, PDGF-BB, KGF, TGFbeta1, IGF, bFGF, EGF, TGFalpha

• Glycoproteins
  • Laminin, Elastin, Fibronectin

• Anti-Infective Peptides
  • 18 AMP’s have been identified in porcine tissue
  • Porcine defensin pBD-1

My research focused on four areas of hair restoration surgery:

• Punch harvest sites (small FUE and larger)

• Strip harvest donor healing

• FU grafting

• Hair Duplication (Autocloning) with plucked hair

Punch harvesting +ACell MatriStem – See Photos 1-3

My results suggested that:

• Punch harvest (1-3mm) with some follicle transection resulted in near undetectable healing and follicle ingrowth (photo 1).

• Punch without transection= depigmented soft normal skin without hair (photo 2)

• Control (no ACell)= depigmented hard spot = typical FUE/punch scar (photo 3)

• I did not observe new hair follicles but did observe what appeared to be enhanced regrowth from transected follicles as well as reduced scarring.   This suggests that ACell will not create new hair but will help regenerate hair if healthy follicle “primers” are present.

Strip scars (standard FUT harvesting):

My experience using Acell MatriStem led to these observations:

• Improved the Feel more than the Look of scars;   photographs don’t adequately show this effect (see photos 4 & 5).   I used Acell MatriStem sheet or powder, and in some situations both.

• Using ACell   made a good closure better and was especially helpful in re-excision of wide donor scars.   Photo 6 shows a patient with a 1.5-2.0 cm donor scar three months after excision with use of ACell.   Although greatly improved, there is still some ‘hairless gap’ which is related to the tension at closure.

• Using ACell did not save a bad closure (ischemia, infection)- for example, if there is too much tension when the strip is removed and the skin edges sutured/stapled, one can expect a depigmented ‘hairless gap’, but it will feel soft like normal skin.

• Resulted in SOFT tissue
  • Re-excision felt like virgin scalp- This could prove to be a tremendous benefit for patients undergoing subsequent strip FUT procedures.   In fact, this may be the strongest argument for using ACell routinely for strip harvesting.

• May be associated with prolonged redness (weeks to months) due to angiogenesis- this will fade over time

• Did not prevent depigmention or “hairless gap” if tension was present.

• Comment:   When people talk about “Donor Scars”, they are referring to different elements which include the hairless gap, depigmentation (the white line), as well as the hard, thick scar that can form.   Proper use of Acell MatriStem can prevent the true scar formation but may have no effect on depigmentation or the hairless gap, depending on how much tension or lack of oxygen (ischemia) is present.

ACell and Follicular Unit grafting (standard hair transplant)

Acell MatriStem powder

• Mixed with saline and applied to grafts

• Resulted in better than expected robust growth
  • See photos 7&8
    • Photo 7:   2000 grafts at 8 months
    • Photo 8: 2200 grafts at 12 months

Hair Duplication (Autocloning)

Almost ten years ago, Gary Hitzig MD began experimenting with using plucked beard whiskers as grafts for transplanting.

Historical timeline:

• 2000 – Use of plucked beard whiskers as grafts (Hitzig)
• 2008 – Use of plucked whisker combined with use of ACell (Hitzig)
• 2009 – Use of plucked scalp hair as grafts with ACell (Cooley & Hitzig)

Plucked hair:   contains epithelial cells & stem cells

• Gho CG et al.   Human follicular stem cells: their presence in plucked hair and follicular cell culture. Br J Dermatol. 2004 May;150(5):860-8.

• Roh C et al.   In Vitro Differences Between Keratinocyte Stem Cells and Transit-Amplifying Cells of the Human Hair Follicle J Invest Dermatol 125:1099 -1105, 2005

Clinical examples

• Photo 9:   photo of plucked scalp (left) and plucked beard (right);   the light border around the darker hair shafts contain living cells.   Note how much thicker the beard hair is.

• Photo 10:   The ‘donor area’ is plucked and when photographed 5 months later, is completely filled in again with new hair.

• Photo 11:   100 plucked beard grafts in crown;   the patient reports that it felt like beard stubble for about  6 months before natural scalp hair began to grow.

• Photo 12:   crown grafting shows success of plucked scalp vs plucked beard.   In numerous patients tested, plucked scalp hair worked better.   In this case, only 100 hairs per side were placed.

• Photos  13 &14:   plucked moustache hair planted in the crown after applying ACell MatriStem biopsy of the hair showed completely normal microscopic anatomy, including sebaceous gland and dermal papilla.

• Photo 15:   Plucked scalp hair growing in a thinning crown, about 200 hairs placed.

• Photo 16 :   Plucked beard results:   4 whiskers placed in the same site results in 4-haired follicular unit (right arrow);   nearby is a whisker that did not produce hair and is still present 6 months after the procedure (left arrow).   Biopsy of the 4 hair graft shows normal follicular unit histology on cross sectioning.   The patient is using a hair fiber camouflage product which can be seen as small flecks on the surface of the skin.

• Photo 17:   Donor scar corrected with combination of FUE and hair duplication (autocloning).   We treat many of the patients who come to us with wide donor scars with this technique.   We currently do not see as good of results using the plucked grafts into scar tissue which is why we combine it with FUE.   We predict that, as the procedure is refined, the success rate for grafting into scars will improve.

Conclusion :  Acell Matristem has diverse applications in hair restoration surgery:

• Enhances punch & strip healing
  • Results in “Soft” tissue (vs fibrotic scarring) but does not prevent depigmentation or the hairless gap.   Good closure principles must still be followed and excellent technique is required to ensure good results.

• Enhances results of FU grafting:   Grafts appear thicker, more robust.   Further study will help quantify and explain this result.

• Facilitates follicle regeneration from implanted plucked hair (hair duplication formerly known as autocloning)
  • Questions:
    • Are these regenerated hairs androgen sensitive? Part of the hair follicle (epithelial) is derived from the androgen insensitive donor area but is the mesenchymal (i.e. dermal papilla) derived from the androgen sensitive cells?   Time will tell.
    • Will these regenerated hairs   go through the normal hair cycle?   In other words, will they grow during a normal anagen phase, shed, and then regrow for subsequent cycles?   We plan to pluck some of the regenerated hairs to see what happens.
    • These results are very exciting but require more research and long term observation to fully understand what role this technology will play in hair restoration surgery.

©Jerry E. Cooley, MD

Jerry E. Cooley, MD

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David – aka TakingThePlunge
Assistant Publisher and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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