Coalition Surgeons

the B spot · #11 **Top** 03-13-2008, 06:29 PM

HLC... would you agree that .75 to .9mm punches provide a broad enough range to tailor punches to the needs of the patient?

Bill - Managing Publisher · #12 **Top** 03-13-2008, 06:51 PM

I found this information regarding FUE punch size and donor hair management on another forum. It was posted by BHR clinic. It's quite fascinating and makes a lot of sense. I'd be curious on member input on this.

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Follicular Unit Extraction/Donor Management & Punch Size

The safety zone for FUE can be measured and sectioned in to three areas; simply both sides and the back, then the total surface area calculated. The density is then measured in each area and an average overall density taken using a magnifying densometer; the natural FU groupings measured and an average taken including miniaturisation of hair in the donor safety zone.

The number of grafts available for extraction can then be calculated; taking into consideration not over harvesting and leaving the donor "moth eaten". To ensure not to over harvest there must be a limit to the number of FU that can be removed per cm2; removing much more than 27% per cm2 will noticeably thin the donor area and potentially cause obvious visible scarring over a large area of the donor.

The punch size used will affect the number of FU that can be safely removed; incorrect punch can increase transection of the removed FU, damage surrounding FU cause larger and more visible scarring. With a small punch there is a risk of transecting the FU being removed if the group is too large to be encompassed by the diameter punch, therefore cutting the FU causing the loss of a hair from that FU and reduce the total hair numbers placed. When a large punch is used it has the possibility to cut into an adjacent FU if the density of FU is high. This either means taking two genetic groups at the same time or splitting and transecting one of them, for example two 2 hair FU or maybe a 3 hair and a 1 hair in the same punch OR maybe taking an intact 3 hair FU and dissecting another and a likely conclusion is killing a hair and traumatising the surrounding hairs.

Included in this problem is the pattern of extraction; to use a large punch and over harvest in an area will leave obvious thinning and density changes in the donor; this will result in the donor potentially being too thin for further extraction even from a relatively small number being removed; say 2000; this has been called "hairless areas" but simple is larger scarring be it obvious or not OR overharvested areas.

The larger the incision made into skin has the potential for greater scarring; obviously the skill of the incision will have an impact but simply a larger hole is made in the skin tissue and more fibrosis is caused and greater pigmentation alteration; thus making the scarring potentially more visible and larger. If the larger punch is used and the extraction pattern not monitored to approximately 27% the donor can visibly lose density, because a "moth eaten" look on the scalp and make it almost impossible to harvest any amount of grafts.

Below is a section of a report made with Dr Bisanga a few years ago discussing the FUE procedure and the pros and limitations; it shows the effect of a 1.1mm punch on the surrounding FU and smaller punch on larger FU groups; also that a .75 mm punch can surround a 4 hair FU without transection and thus cause less potential scarring.

Follicular Unit Extraction when the limitations are adhered to can be an excellent form of hair transplant. The limitations are the use of the correct punch size, not to extract a combination of FU in one punch; not to over harvest the donor to extract more FU and leave the donor thinned.

Bill - Managing Publisher · #13 **Top** 03-14-2008, 10:11 AM

One comment about my above post...

I think this clearly presents a good case for particular cases, but I would agree that adapting tools to the patient needs is sensical. I can't imagine that a .75mm punch will fit perfectly around follicular unit grafts in every patient case.

Thoughts?

Bill

thanatopsis_awry · #14 **Top** 03-14-2008, 10:57 AM

Good write up -- the diagram regarding Bisanga is especially interesting to see. It seems to me that a range of sizes to adapt to a given patients physiology is best; and perhaps .75mm is a "sweet spot" that often balances out the patients' need for superior levels of transection and scarring. It seems that Bart finds .7mm to be ideal.

I can understand why doctors would put a complete moritorium on using >1mm, and also the motivation towards Bart saying "No need to EVER use an instrument larger than 0,8mm....0,7 gets the best out of 2 worlds : minimize tissue damage and still get all size grafts out intact." I'm not sure if I completely agree with the aforementioned, but I can't honestly say I have good reason to disagree with it either.

Ultimately, what *actually* works best in practice on a given patient is what should be used; and it seems virtually all patients fall into a general range, and their best interests dictate a max (>1mm). I could be mistaken, but I recall Bart mentioning his clinic using ".6mm", which is the smallest instrumentation that I have know of.

And the bottom line is that transparency w/ FUE is paramount; and it extends past before and afters, and includes candid disclosure of instrumentation used.

TheHairLossCure · #15 **Top** 03-14-2008, 07:02 PM

"HLC... would you agree that .75 to .9mm punches provide a broad enough range to tailor punches to the needs of the patient?"

I can't agree or disagree. Dr. Rose uses the .75mm as the smallest punch and 1mm as the largest punch. There are cases during which the 1mm is never used at all and other cases where the 1mm is useful. I will to need confirm this, but I believe that extracting 3 and 4-hair follicular units with a .75mm sharp punch can be very difficult, particularly if the hair-splay is wide. Getting intact grafts - if the groupings are large - is much easier with a 1mm.

If a patient only wants a .75mm and a .9mm like you described, he/she may have to expect only 1-, 2-, and some 3-hair groups. Damaging large grafts can be a factor with small sharp punches. So one can either opt for smaller punches and smaller grafts or larger punched and larger (but naturally occurring) grafts. (Another possibility is "blunt" FUE, but that may be a discussion for another time.

If a patient wants lots of hairs per grafts and is a good healer, I think using the 1mm in conjunction with smaller tools can be fine. If the objective is to use the smallest punches possible, use of the 1mm can be avoided.

the B spot · #16 **Top** 03-15-2008, 04:15 PM

Don't make me fight you HLC

Anyway, I can see your views and I have no issue with them, b/c you disclose information at your clinic.

Additionally, the response you gave shows you tailor your fue surgeries to the wants and needs of each of patient.

Good looking out,
Jason

TheHairLossCure · #17 **Top** 03-16-2008, 11:11 AM

Hmmm B-spot. I think you are reading an adversarial tone into my post. Please don't hit me!

To address the punch issue though, I think there is a problem with using big tools and the reason is simple. When virgin scalp patients look at FUE they are probably concerned about scarring. So there is no good reason to up the risk of creating white spots. Still, you and Bill correctly bring up the issue of follicular destruction. That really is not a huge issue if the doc and/or patient are flexible in terms of a) extracting smaller grafts or b) using (slightly) larger tools for big grafts. Now, that is not to say a doc should pull 90% singles because he/she wants to use a super tiny tools. Conversely, the doc (in my humble option) should not use 1.1s and 1.2s to get big grafts either. Those 1mm+ tool don't really serve a purpose anyhow.

TheHairLossCure · #18 **Top** 03-16-2008, 11:14 AM

BTW - Dr. Harris is a proponent of using the sharp punch to score skin and the dull to cut around the graft. Dr. Rose has partially adopted that approach in conjunction with the FIT/FUE punch and slot punch. As I am sure you know, using the dull punch can reduce the risk of slicing through follicles during extraction. It also means that, in some cases, a smaller punch can be used. So, there are ways to do your .75 - .90mm punch FUE. Still, I wouldn't wants to unnecessarily limit the surgery by totally ruling out the 1mm.

the B spot · #19 **Top** 03-16-2008, 01:13 PM

I would NEVER hit you!!!!

Thanks D,
Jason

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