0.9mm FUE Punch - Thoughts?

[zenmunk]

I had a consult recently with a recommended doc. He told me he prefers 0.9mm punches whenever possible. Anything larger runs the risk of particularly noticeable scarring. Anything smaller runs the risk of transection and grafts which are too thin. He feels like it's an acceptable compromise.

 

What are your thoughts on 0.9mm punches regarding scarring and yield?

 

Thanks.

[jfables]

Probably sounds right. I have scarring from 1mm punches but none from .75mm. My yield wasn't so great from any size punch though. I think you would get some visible scarring from .9mm but it won't be too bad. Generally 1mm punches are obvious when your hair is shaved and still visible at 1 guard.

[HARIRI]

I agree with jfables, I would never go close to this. 0.9 mm is huge for me. What do you think that makes HT patients afraid from ARTAS Robot although HT surgeons swears by it. Its the 1mm punches used.

 

I do like manual FUE a lot because you can go all the way to 0.7mm. The smaller the punch the better especially if many grafts are extracted. Im pretty sure that this surgeon is using motorized FUE systems as long he mentioned 0.9mm.

 

So my advice is to do your research more and go for a doctor who can go below that (0.8mm and below). Good Luck...

[Blake Bloxham]

0.9 mm is currently fairly standard for FUE procedures. However, like Hariri stated, there are smaller punches used, and these are associated with additional pros and cons as well. Were you able to review any images of the healed donor region from the surgeon? This may be helpful to determine whether or not the 0.9 mm punch is keeping the FUE scarring to a reasonable level.

[chrisdav]

I think it would be good if some of the surgeons who perform FUE to give their opinions on the positives and negatives of the the extraction tools such as the different mm manual punch sizes, motorised tools,artas, neograft, the choi implanter as it is hard to find any information the directly gives a comparison of the lot.

[zenmunk]

Thanks for everyone's replies.

 

I think you would get some visible scarring from .9mm but it won't be too bad.

 

Agreed. Although, I was told my skin coloration would be an advantage regarding the appearance of scarring via FUE.

 

The smaller the punch the better especially if many grafts are extracted. Im pretty sure that this surgeon is using motorized FUE systems as long he mentioned 0.9mm.

 

So my advice is to do your research more and go for a doctor who can go below that (0.8mm and below). Good Luck...

 

Well, "the smaller the punch the better..." is debatable. The concern is transection and/or grafts which are too thin. With the current technology/techniques, there must be some compromise, but the question is what is the ideal compromise? I think once a punch size is chosen for a procedure, it's probably used consistently from beginning to end. A surgeon may adjust higher or lower as needed, but my understanding is s/he will largely stick to the chosen punch size. Therefore, it's important to decide on the correct size from the get-go. And, you are correct, this doc uses a manual motorized FUE tool.

 

My intention was to find a surgeon who will go with 0.8mm or less, but I'm concerned about yield. We'll see.

 

0.9 mm is currently fairly standard for FUE procedures. However, like Hariri stated, there are smaller punches used, and these are associated with additional pros and cons as well. Were you able to review any images of the healed donor region from the surgeon? This may be helpful to determine whether or not the 0.9 mm punch is keeping the FUE scarring to a reasonable level.

 

What are the pros and cons in your opinion?

 

No, I wasn't able to review healed donor images, but that's a very good idea. I will follow-up with the doc about that.

 

Harari, In light that you have a large strip scar on your head a 0.9mm FUE punch would pale in comparison in terms of scaring.

 

Spex, what are your thoughts on scarring for the average patient regarding use of a 0.9mm punch?

 

I think it would be good if some of the surgeons who perform FUE to give their opinions on the positives and negatives of the the extraction tools such as the different mm manual punch sizes, motorised tools,artas, neograft, the choi implanter as it is hard to find any information the directly gives a comparison of the lot.

 

I second this.

[zenmunk]

Minimal.

 

Whats your goal here.. to have a HT via FUE and then bic shave it all off ?

 

If so let me save you a fortune. Just shave it all off and dont get a HT.

 

The purpose of a HT is to be able to regain your hair and in order to achieve the best illusion from any HT you need to grow your hair out. A very short grade in the donor region will cover any scaring caused by FUE on a 0.9 mm or even 1mm. I have had a 0.8, 0.9 and 1mm used on me and unless i bic shaved my hair off its pretty difficult to find any FUE "scaring"

 

Try not fixate too much. Patients that tend to be a little too fixated on specifics generally tend to be the ones who are least satisfied as expectations of what can actually be achieved differ from what the patients wants in their ideal world.

 

HT is not an exact science, patients vary - Try understand what your own prioritises are here from the process of a HT and keep expectations and reality in check :cool:

 

Thanks for your reply. My goal is not to get a HT and shave it all off. I agree that approach would be a waste. I would, however, like the option to buzz to a number one on the clippers and not have the scarring appear too noticeable. In the real world, who actually stares at the back of a person's head? Very few people unless there is something very unusual going on. I imagine the scarring from a 0.9mm punch would not draw much, if any, attention for the average patient with a #1 buzz.

 

Regarding yield, do you think there is much difference between 0.75mm, 0.8mm and 0.9mm punch sizes? I mean, in terms of the dangers of transection and grafts which may be too thin? Thanks.

[Mickey85]

a recommended and prominent fue surgeon(50% of his practise) told me that most of the time its not just one punch used. if a multi hair graft needs to be extracted, a larger punch(.9mm for example) is used. if a single hair needs to be extracted, a .75mm punch is used etc. For the clinics claiming a .9mm punch avoids transection, how about the neighboring hairs nearby? The wider the punch the more area is damages. I would not go to a clinic where only one punch is used personally. Everyone has different caliber hair and the caliber is not exclusive on any one patient. Some hairs are thicker/stronger in some areas of the donor area. To use just one diameter punch for the whole head would not be smart in my honest opinion. I know Lorenzo and Feriduni use punches ranging from .75 up to .9mm, maybe even 1mm(not too sure on the 1mm part).

 

One size does not fit all.

Edited January 24, 2013 by Mickey85
Spelling and grammer corrections.

[Mickey85]

Harari, In light that you have a large strip scar on your head a 0.9mm FUE punch would pale in comparison in terms of visible scaring.

 

forgive me if i sound like a drama queen but i find this sentence slightly insulting and condescending, as well as being insensitive to Hariri who is a repair patient. i'm sure he knows that a .9mm punch would 'pale in comparison' to his scar and im sure he knew that whilst he posted what he did. with your logic anything reasonably smaller than his scar would be acceptable then? A 1.5mm punch? How about a 2mm punch? That "pales in comparison" doesn't it? Does Hariri having a larger than average strip scar(that was not of his choosing) negate his opinion of not going to a doctor who uses anything larger than .8mm punch? Surely your comment has nothing to do with the fact to Dr. Feller uses a .9mm punch... Mere coincidence?

 

i dont share the same opinion as hariri in regards to punch sizes and their attributes but your post seemed very off...

Edited January 24, 2013 by Mickey85

[s2thoudriver]

Any decent FUE surgeon will use multiple punch sizes depending on the follicle they are targeting.

 

For example, a 0.9 is used for extracting a batch of quad, triple hair grafts, 0.8 used for the batch of double hair follicles and 0.7 used to extract single ones.

 

(don't quote me on the exact 0.XX sizes as i forgot to ask)

 

I know they used at least 3 different sizes when punching the 2,800 out of my scalp. The result.... undetectable scarring and from what i can see, no loss of yield due to transected follicles.

 

Hope this helps

 

Rob

[Mickey85]

Any decent FUE surgeon will use multiple punch sizes depending on the follicle they are targeting.

 

For example, a 0.9 is used for extracting a batch of quad, triple hair grafts, 0.8 used for the batch of double hair follicles and 0.7 used to extract single ones.

 

(don't quote me on the exact 0.XX sizes as i forgot to ask)

 

I know they used at least 3 different sizes when punching the 2,800 out of my scalp. The result.... undetectable scarring and from what i can see, no loss of yield due to transected follicles.

 

Hope this helps

 

Rob

 

BOOM! Someone who gets it! One size does not fit all guys!

[zenmunk]

a recommended and prominent fue surgeon(50% of his practise) told me that most of the time its not just one punch used. if a multi hair graft needs to be extracted, a larger punch(.9mm for example) is used. if a single hair needs to be extracted, a .75mm punch is used etc. For the clinics claiming a .9mm punch avoids transection, how about the neighboring hairs nearby? The wider the punch the more area is damages. I would not go to a clinic where only one punch is used personally. Everyone has different caliber hair and the caliber is not exclusive on any one patient. Some hairs are thicker/stronger in some areas of the donor area. To use just one diameter punch for the whole head would not be smart in my honest opinion. I know Lorenzo and Feriduni use punches ranging from .75 up to .9mm, maybe even 1mm(not too sure on the 1mm part).

 

One size does not fit all.

 

Thanks for your reply, Mickey85. It's interesting that the surgeon you're referencing said most of the time it's not one punch used. I have no doubt whatsoever that surgeons will use different punch sizes during a procedure. However, the frequency with which they switch them out probably varies greatly. For example, one well-respected rep. from a top-notch clinic has stated on a different forum:

 

"For punch sizes for each patient, from what I've seen at our clinic and others I've visited, typically, one size punch is used through-out the whole procedure. You get into a mode with the punch and try to extract multiple fu in one punch. Be interesting to hear if this is not the case."

 

With clinics like that, I presume the hairs are then dissected under microscope for singles, etc. as opposed to concentrating too much on extracting singles with the punch. So, different clinics approach it differently, I suppose.

 

Regarding transecting hairs nearby, that will vary from patient-to-patient according to their density, I guess. If one has especially high density, then clearly using the smallest punch one can safely use would be prescribed.

 

I'll ask you the same question I asked Spex: Regarding yield, do you think there is much difference between 0.75mm, 0.8mm and 0.9mm punch sizes? I mean, in terms of the dangers of transection and grafts which may be too thin? Specifically, I mean transection of the graft being extracted, not just the surrounding grafts.

[s2thoudriver]

I've always got it Mickey85, i'm just ensuring others do too :-)

 

One thing that supports using different size punches is to minimise scar tissue too by minimising the flesh around the follicle by reducing the punch size for follicles with less hair in.

 

Helps stop the bumpy effect on the scalp when healed.

 

Rob

[Mickey85]

Thanks for your reply, Mickey85. It's interesting that the surgeon you're referencing said most of the time it's not one punch used. I have no doubt whatsoever that surgeons will use different punch sizes during a procedure. However, the frequency with which they switch them out probably varies greatly. For example, one well-respected rep. from a top-notch clinic has stated on a different forum:

 

"For punch sizes for each patient, from what I've seen at our clinic and others I've visited, typically, one size punch is used through-out the whole procedure. You get into a mode with the punch and try to extract multiple fu in one punch. Be interesting to hear if this is not the case."

 

With clinics like that, I presume the hairs are then dissected under microscope for singles, etc. as opposed to concentrating too much on extracting singles with the punch. So, different clinics approach it differently, I suppose.

 

Regarding transecting hairs nearby, that will vary from patient-to-patient according to their density, I guess. If one has especially high density, then clearly using the smallest punch one can safely use would be prescribed.

 

I'll ask you the same question I asked Spex: Regarding yield, do you think there is much difference between 0.75mm, 0.8mm and 0.9mm punch sizes? I mean, in terms of the dangers of transection and grafts which may be too thin? Specifically, I mean transection of the graft being extracted, not just the surrounding grafts.

 

Definitely. If they try to use a .75mm punch on a triple or quadruple hair graft, the chance of it surviving would decline. If the use a .9mm punch on a single hair graft chances are great that it will yield but you risk not only damaging hairs around it but also creating a scar that is not optimal.

 

You want a clinic who is in the middle ground. A clinic which openly promotes that it only uses .75mm punches exclusively may do so merely to make the procedure look more pleasing to those who care for such details. Not to mention the potential graft damage on multihair grafts. A clinic who uses .9mm or 1mm(clinics like that exist) solely are creating scars that are larger than what they could be. Do these details matter to you? If they do, I highly recommend seeking a clinic who use an array of punches throughout the procedure.

[Raj Jayukdht]

Would be nice to get a surgeon to reply to this thread??

[Mickey85]

Mickey,

 

I am friends with Harari on and offline and have been for a couple of years - so I think he knows only too well my comment is in no way meant to be insensitive or condescending as you are trying to imply.

 

The point being; a patient who has an existing strip scar, even a great one, can't cut below a grade 2 so therefore a 0.9mm FUE scar would still not be visible on such a low grade.

 

Harari can not go that low, as we all know, due to his poor strip scar from his original HT and the likely hood is he will not be able to go that low even with a scar repair as I'm sure he is well aware of too - so therefore making any FUE scaring from a 0.9mm will never be seen.

 

I was simply trying to highlight that fact.

 

Each to their own - and for your information Dr Feller does use 0.8mm tool

 

 

My opinion is somewhat changing on larger FUE sessions as i've seen several in person recently and I speak to many patients. FUE extractions tools should and do vary in size and a competent surgeon will have a variety of size tools in order to harvest different size grafts safely and create minimal scaring/trauma.

 

I'm actually starting to get a better feel and understanding on FUE even now despite your opinion on me mickey85. We are on the same wavelength just possibly not the same page :cool:

 

Peace out!

 

And Hararai brutha - if my comment did in anyway upset you ..you know it wasnt meant too hey - how many times have we discussed and debated FUE /strip etc on the phone :cool:

 

No worries, just in text, things can be taken the wrong way. I didn't know Dr. Feller now uses a .8mm punch, apologies on that.

[zenmunk]

My understanding is the thickness of the graft, the amount of tissue where the stem cells live, etc., is important for yield. It follows that the smaller the punch, the thinner the graft. Does this concern anyone?

[GNX1]

to have a debate on punch size and what the end results will be is impossible to say.

 

it depends on how many grafts are removed, how close the grafts are that were removed, skin color, hair color of graft and graft size ie: 1's,2's,3's,4's.

 

less pigment at the extraction site is often referred to as scar tissue by those who criticize FUE and those who promote strip surgery. these are not scars. they are simply areas of less pigment due to less blood flow and less melanin than the surrounding areas have.

 

a single follicle and its sheath are about 0.4 mm wide and a two hair follicular unit is 0.8 mm wide. any doctor worth a chit imo will have to use different size punches for different size follicle units.

 

most loss of color from the extraction site is a results of reactive hypopigmentation where the bodies autoimmune response attacks the melanocites and the other is due to the bodies reduced blood flow to the area where the follicular unit was taken.

 

the body will not send as much blood flow to an area if it no longer has a cluster of follicles in need of said blood.

 

the punch size should be customized to the target fu.

[zenmunk]

I'm actually starting to get a better feel and understanding on FUE even now despite your opinion on me mickey85. We are on the same wavelength just possibly not the same page :cool:

 

Could you elaborate on this statement, Spex? What do you mean by "better feel and understanding"? What have you learned or observed that may be valuable information for us? Thanks.

[zenmunk]

the punch size should be customized to the target fu.

 

Thanks for your reply. In your opinion, is it common practice for most clinics to customize the punch size to the target fu?

[GNX1]

Thanks for your reply. In your opinion, is it common practice for most clinics to customize the punch size to the target fu?

yea if they are worth a chit. the average punch size is between 0.8 mm to 1.0 mm. 1.0 mm punch seems to be more evident when doing repairs. although I believe Dr. ©ole uses a .75.

 

many FUE doctors have tools that other FUE doctors dont. its not apples to apples.

 

then there is the debate over the inner and out diameter, wall thicknes, sharpness, manual/motorized, blablabla....

 

If you harvest only 1000 grafts over the full donor area u wont see chit imo. but after removing several thousand grafts the missing hairs can certainly create a non-uniform pattern and therefore can be more noticable when cutting down to a #1 or of course shaved. FUE surgeon artistic skill plays a role of course.

 

no matter what it will almost always look better then a strip scar will on AVERAGE.

 

personally, im not all that concerned with the appearance of thinning out the back of my head via FUE. lets face it, if you were a NW4 or 5 for example and took all the hairs on ur head and distributed them equally thruout ur head you would look like many people do natually who dont have the same density as some others do.

 

so, if im removing 3000 hairs from the back of my head to place in the thinning areas I will now have less density in the donor area that is spread out. thats not necessarily a bad thing cause now it looks more uniform.

 

the top of ur head will almost always have less density then the sides and rear even on a guy with a full head of hair usually.

 

one size does not fit all. there is no logic to using a 0.75 mm punch or smaller to remove a 4 hair FU. but by the same token, there is no logic to removing a single hair graft with a 1mm punch either.

 

any doctor doing FUE should have the skill to use either large or small punches depending on the circumstances, or should not offer FUE at all.

 

imo the procedure has to be tailored to the individual. if the doctor cant do that then he has no business doing FUE. maybe its easier for him but I cant see how that benifits the patient.

[Dr. Carlos Wesley]

Follicle transection rates depend on the patient characteristics as well as the inner diameter of the punch. Among the field's most experienced practitioners of FUE, transection rates range from 2% to 8.5% for the 1-mm punch and from 3% to 10% using the 0.75-mm punch. A 1-mm punch can exact an average graft of 2.5 hairs/graft, while a 0.75-mm punch yields approximately 2.1 hairs per graft. I think most of us on this forum agree, however, that punches of 1mm or larger can result in visually unacceptable donor area scarring.

[zenmunk]

Very interesting, thanks GNX1.

 

Dr. Wesley, thank you for chiming in. Do you subscribe to the practice of varying punch size in the manner described here? For example, a 0.9mm punch for multi-hair grafts and perhaps a 0.75mm or 0.8mm punch for single hair grafts? Or, do you largely stick with one punch size throughout a procedure?

[Chris12]

Hey Zen,

 

I am seeing more consistency with larger FUE sessions for sure - and especially from certain practises. I have met a number of patients of late who wanted my opinion on their HT's who had larger FUE and i've been pretty impressed. It's just very important the patient understands all the risks involved with FUE and surgery in general. I like all others here learn more and more everyday and im open to it too.:cool: I only ever have the patients best interest at heart and it's important they make their own informed decision based on their own research.

 

If it's only FUE you want then my advice is research the crap of all the risks and meet actaul patients. Keep sessions sizes realistic and be aware we are all different in terms of physiology too. Different clinics who all have good consistency with FUE will all tell you FUE can be a little unpredictable, they should do, as thats the truth. Different clinics have different opinions, philosophy and approach along with protocols. Few FUE clinics do it the same way so just get a good feel for the doc and his own way of doing FUE as it's important you feel confident the doc performing on you can genuinely do what he says he can.:cool:

 

Best

S

 

I think it is really positive that big names like you are explaining the pros and cons of fue with an open mind. Everybody would benefits if you or even guys like Joe tronic could help people that do not want fut and that are looking for more than 2000 grafts fue. Currently there is not real spokesperson that can guide new candidates. However, it does not necessarily means being a fue advocate and fut benefits should also be stressed until the day fue gives as much consistency as fut. But i think it would benefit everybody

[Dr. Carlos Wesley]

I do vary FUE punch sizes on my patients (0.75 - 1 mm). Generally, I prefer utilizing 0.8 and 0.9 mm FUE punches to "cherry pick" specific types of grafts for different regions of the recipient pattern. Much of the variety also simply comes from the area of the donor scalp from which the grafts are harvested. Most coarse 3's and FF's (follicular families) come from the occiput (back of the head) while the fine 1's and 2's can be found more frequently in the temporal area.