FUE Extraction Tool Size: What is Optimal?

[Bill - Seemiller]

Dear forum members and physicians,

 

Follicular Unit Extraction (FUE) has really grown and developed over the last few years by a few leading physicians and certainly has patient interest.

 

From speaking with other patients, the three most enticing things about FUE surgery are that it is less invasive, healing time is minimal, and the potential for wearing their hair shorter (less obvious scarring) is greater.

 

However, there is much debate over FUE and its consistency in results. Is follicular unit extraction really all what it's hyped out to be? The lack of consistent and compelling photos has led to rightful skepticism.

 

But the purpose of this thread isn't to discuss its consistency in growth, especially because conversation is futile where only patient posted picture results can rightfully address this.

 

My question for other knowledgable forum members and physicians is:

 

What are the benefits and risks of the varying extraction tool sizes? Some physicians choose to use smaller extraction tools (as small as .6mm) while others use larger tools (1mm and larger).

 

What are the risks of using tools that are too small? What are the risks of using tools that are too large? What is the optimal size tool and why?

 

I encourage anyone who has an input on this to contribute to this discussion.

 

Best wishes,

 

Bill

[thanatopsis_awry]

Interesting topic...I would love to hear the rationale behind using the supremely small tools (.6mm), as well as larger ones, and when they are appropriate -- if ever...as I understand it, some doctors (I *think* Feller is one) often use different sizes (the Feller Punch is .75mm if I remember aright), though they never exceed 1mm....I beleive that Bart using exclusively .6mm, or something very close to that. Then there are clinics which either refuse to clarify or shade over in murkyness the size of their tools....I would also like to know *why* they would be cloaking their practice in secrecy, and what their motivation would be for using the tools they use.

 

I've assumed that the smaller tools can correspond to greater transection; while the larger tools leave greater scarring, and above 1mm can be tantamount to FUE-plugs.

 

There has been a lot of FUE discussion of late; but as you mention, it has been somewhat futile and has surrounded growth.

[the B spot]

Hi Bill-- this is an excellent topic. One that will likely see many different opinions.

 

Before I comment on punch size, I would like to address a mind-set that has recently become more prevalent, especially with younger men.

 

The idea is that losing a certain % of your donor by transection/no growth through fue is a fair trade for no strip scar.

 

I have thought long and hard about this and I guess as a young man, approaching your hairloss in this way is fairly logical and does leave one with options in the future.

 

Additionally, FUE would seem to allow us to be slightly more aggressive with hairlines and age. I stress the term "slightly" b/c there is a limit to any and all surgery, even if it sounds too good to be true.

 

I think the hardest mind-set to overcome is one of conservative donor management always. Please do not get me wrong, EVERY follicle is precious and irreplaceable, and EVERY effort should be made to promote this train of thought.

 

However, if a patient gets 1500 fue grafts and say 6% of the root/bulbs are crushed/transected on extraction/implantatio, and additionally, some 3&4 hair grafts are transected down to 1 & 2 hair grafts that are transplanted successfully, is this a successful fue session?

 

The patient has lost 90 grafts, so his total is 1410 GRAFTS/out of 1500.

In addition, he has lost some of his hair count as well.

Some would call this a success, others would be terrified of this result.

 

I guess the idea is to properly INFORM the patient, and let them decide.

 

Now to punch size.

 

Much has been made about punch size, specifically the .75 punch and the 1mm+ punches.

 

I really believe that dogmatically following any specific size, regardless of individual patient characteristics is slavish and not in the best interests of the patient.

 

I also believe that a greater portion of patients are eligible for .75,.8,.9 and POSSIBLY limited use of the 1mm punch.

 

A great doc will tailor his tools to the patients physiological make-up...we see this with custom cut blades, cut to fit each patient, why not the same with FUE?

 

We have one clinic that claims to only use the .75 punch.

GHI uses the .75 and uses both sharp and blunt.

I believe Dr. Harris uses .75, .9 and the 1mm punch, but uses a two step sharp/blunt technique (SAFE)

 

Dr. Feller will not exceed .9mm and goes smaller if the patient is a candidate.

I am of the understanding that other docs do much of the same, Dr. Wolf for example.

 

I like the idea of not exceeding .9mm punches(ala Dr. Feller) it sets a nice bright line for both patient and doctor AND establishes a clear line of information and TRUST.

 

I also do not believe in going smaller than .75 there would really seem to be no need--- I could be wrong, but the .75-.9mm range seems almost perfect--- it allows some customization to the patient, limits the transection of adjacent follicles, and limits subcutaneous scarring. Going smaller would seem to tip the balance unecessarily toward more transection and poor growth

 

As the tumescence leaves the donor site, these extraction sites contract rather quickly, leaving less time for fibrous scar tissue to form. It stands to reason that if larger instrumentation is used, the contraction time will be longer, allowing more scar tissue to form.

 

Again, there is NO guarantee that larger instrumentation will leave noticeable scarring, just as there is no guarantee that using smaller instrumentation will guarantee no scarring---

This is a game of RISK MANAGEMENT--- logically it would seem that by reducing the size of the punch, you reduce the POTENTIAL for noticeable scarring-- not 100%, but by a substantially greater margin than if larger punches were used.

 

However, as punch size goes down, difficulty and risk of error would seem to increase, so a balance must be struck, IMO, and that range would seem to be .75 to .9mm punches.

 

Another issue is the actual patient themselves--- I spoke with one Doctor who said he had a patient that he scheduled for 2000 grafts over 2 days, but his grafts came out so easy with a .9 punch he did the 2000 grafts in about 4.5 hours with minimal transection less than 5%. However, one of his next patients scheduled for 1000 grafts had to be moved to 2 days b/c it took 5 hours just to get 500 grafts.

 

Again, balance... does a clinic check EVERY graft under a microscope after extraction? Do they keep a log of all transected/crushed grafts? Do they tailor punch sizes and do they disclose their sizes? Do they disclose an acceptable transection rate with the patient beforehand?

 

I don't know/have all these answers, and I still have many questions. I am still learning so much everyday and I am hopeful that 2008 will see many of these questions answered.

 

FUE is a great procedure--- good for a NW6? Probably not, IMHO (certainly not cost effective!!!)--- good for 2-3K grafts in your mid to late 20's with proper planning for the future?, Probably so. A great adjunct to your 3000K strip patient who needs 250 grafts for temple points and a hairline touch-up? Absolutely.

 

Balance, Balance, Balance--- Cause and Effect--- it never changes, just as math never lies.

 

Anyway, these are my PERSONAL observations, based on many, many, many conversations with people who do this procedure everyday--- I try not to think in terms of "right or wrong" but in terms of trying to balance the overall equation.

 

I hope this helps,answers questions, produces additional questions, etc...

 

Take Care,

Jason

[bverotti]

Based on actual results and witnessing many many pocedures, as opposed to talking about it with other people:

 

 

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.

 

BV

[the B spot]

Bart--I disagree with you to a certain extent.

 

I agree that the smallest possible punch should be used, but you cannot close off the possibility of using different sized punches.

 

Patients are different....and no one has proven that every patient is eligible for the .75, .8 punches for every graft.

 

There is not enough information about transection or growth.

 

I understand that you see procedures everyday, but your claims are unsubstantiated to a certain extent--- maybe some live videos or live patient demostrations at the conferences, etc....in order to see the .7 at work.

 

Again, .75-.9mm seems to be a solid range for punch sizes, IMHO and adjusting the sizes by patient seems logical and prudent.

I don't care about speed or how many grafts in one day a clinic can get-- I care about intact follicles and an extraction/implantation rate that provides acceptable tolerances using the smallest possible tools.

 

Take Care,

Jason

[Bill - Seemiller]

This is a great conversation so far.

 

I think B Spot makes a valid argument about the potential need of adjusting the size of the punch depending on the patient. I also agree that going too small or too large could be potentially problematic. It appears that the larger the punch, the greater risk of noticeable scarring whereas the smaller the punch, the greater the risk of follicle transection.

 

I also agree in the very important point made about patient consent and transparency. It is a physician's ethical duty to inform the patient of not only the potential benefits, but also the potential risks, including the advantages and disadvantages of certain tool sizes, hair growth yield, risks of follicle transection, etc.

 

I'm not sure however, that I agree with this statement:

 

Additionally, FUE would seem to allow us to be slightly more aggressive with hairlines and age. I stress the term "slightly" b/c there is a limit to any and all surgery, even if it sounds too good to be true.

 

 

Jason, in your opinion, why do you feel that this might be possible? Technically speaking, I would agree that there is nore available donor hair with FUE however, extracting too much donor hair does not come without cost. The more hair taken, the greater the risk that a patient's donor area will look like swiss cheese.

 

Bart, I also appreciate your input as someone who sees actual results on a daily basis. I do agree however, with B Spot that some of your claims are unsubstantiated to a certain degree. Since you discuss in great detail the benefit of FUE, I would also like to know from your clinic's perspective, what you feel the potential problems are with FUE and how your clinic has overcome them. I am willing to keep an open mind as more evidence is unveiled. I do know that you offered both Pat and me to visit your clinic and observe a live surgery in action. Hopefully in the near future, one of us will be able to take you up on your offer.

 

I look forward to see how this conversation progresses.

 

Bill

[the B spot]

Bill, I think we have to reevaluate some of the axioms regarding age and hair transplantation.

 

Personally, I believe a cautious approach is best--- perhaps allow meds to stabilize the donor/crown region, etc.... but that is not being very realistic is it?

 

Remember when hair transplants or "plugs" were for those 40 and over going through mid life crisis?

 

We are seeing wave after wave of patients 21-28 who are balding--some slight some severely and they are not going to sit around and deal with this by shaving their heads and waiting until 30-35 years old--- these guys are very image conscious, they are building careers, having fun, being social etc... and being bald is not really an option.

 

I believe fue opens the possibility for transplanting these younger men--- in an ETHICAL and INFORMED manner to seek an appropriate hairline or crown touch-up in their 20's

 

By aggressive, I do not mean lowering hairlines, or over transplanting diffuse areas, I mean actually helping these people as opposed to turning them away to someone who will tell them what they want to hear.

 

Some of the pro's as I see it for fue in a younger man.

1. IF proper tools are used and IF care is taken to minimize transection, yield should be acceptable and scarring should be at a minimum.

 

2. No strip scar at 21, 22, 25, 28 etc.. so if money runs out or donor runs out a 1-2 guard buzz cut is a viable option, leaving a framed face and decent density. Obviously, this is contingent on NOT overharvesting the donor and leaving "gaps" (remember many of the strip scars we see today are easily covered with a #3-#4 buzz cut)

 

3. They can make the choice later in life as a more mature person to go with strip if their balding becomes more severe.

 

Cons:

1. There are going to be transections and lost grafts, probably more with fue than strip (Top doc reference)

 

2. The section of tissue that can be removed by strip later on, can have density reduced by up to 30%, limiting the amount of grafts available though strip.

 

3. Cost--- right now the average cost is about 8-10 per graft, and it is not going down any time soon, IMHO.

 

It is a fine line-- EVERYTHING we have been taught is about managing the donor, short and long term-- and I believe this can still be accomplished through education and information.

 

This will be done with the BEST docs embracing this procedure, explaining the pro's and con's, and treating people ethically.

 

Please do not get me wrong.. FUE can be over-sold and over-hyped, but so can strip sessions, so can session sizes, so can other techniques.

 

I believe we need to adjust to the needs of this age group, like we adjust the techniques and tools we currently use.

 

Oh, and BTW-- I have a lot of respect for Bart-- he is doing a great job posting on the forums and advocating fue. We don't see eye to eye on everything, but we both agree on wanting what is best for patients.

 

Jason

[Bill - Seemiller]

Jason,

 

I appreciate your response. There is some of what you are saying that I agree with, but I generally disagree.

 

Let me point out that you never really addressed the concern I posed above about more available donor hair . This is the heart of the matter of my disagreement with you.

 

Whether the coin lands on heads or tails, donor supply is still finite and limited per patient, hair loss is still progressive and unpredictable, and long term strategic planning is still vital. I think we agree on these points.

 

I disagree entirely with your "pro" point 3. In my opinion, going from FUE to strip is counter-productive and defeats the primary drive for FUE in the first place (no linear scarring). Given the possibility of bad fibrous scar tissue with FUE, there is likely to be damage to the surrounding hair follicles and when the strip is removed, there is a chance that a number of once viable hair grafts will be damaged and not able to be used for surgery, again reducing the amount of overall "usable" donor hair.

 

Therefore, I typically argue that if a patient wants to make the MOST out of their "usable" donor hair supply, max out with strip first, and then go to FUE, not the reverse.

 

Personally, I do not see how FUE opens up a possibility anymore than strip to transplant on younger men, unless you are talking solely about the possibility of less obvious scarring. Unless one can conjure a more abundant donor hair supply, I do not believe that FUE opens up the possibility of transplanting on younger men (or women).

 

I believe also that there is a similar amount of available donor hair with Strip and FUE (assuming you want to avoid the swiss cheese look) however, with FUE, there is less "usable" donor hair. Using a strip (max out first) and then FUE (afterwards) combination gives the patient the chance to restore the greatest amount of hair.

 

Given also that the majority of reputable physicians agree that growth yield can be much lower (based on risks of follicle dissection during extraction or damage during placement), I would argue that it is not in the patient's best interest as they are losing valuable donor hair. HOWEVER, clearly if the patient is informed of this and makes the choice to proceed, that is their prerogative. It's about informed consent, we clearly agree on that point.

 

Good discussion and debate. Hope we keep it going and others chime in.

 

Bill

[the B spot]

Bill,

I never said anything about a patient wanting make the most out their donor-- I said we needed to look at the needs of those who are accepting fue, fully informed, avoiding a strip scar in their 20's which will lock them into one type of surgery.

 

I do not necessarily believe that fue will increase the donor availability substantially above strip at the end of the day--again, for some patients yes, others no.

 

I am focusing on the "options" of a younger man, not overpromoting the use of fue over strip or vice versa--- if a patient is fully informed as to his or her choices and they are not asking a physician to compromise ethics, then everything should be fine.

 

Again, I understand the drawbacks and limitations of both types of surgery--- my only intent is to try and understand and remember how I felt when I lost my hair at 23-24 and apply that in a fairly safe manner.

 

Also, much of my opinion is based on going forward in a safe manner, not overharvesting and using smaller tools.

 

You are 100% right about doing strip first, then fue to maximize all donor available.

 

I hope this helps clarify my position-- I am not trying to be "right" per se, just trying to help establish an alternate position.

 

Take Care,

Jason

[TheHairLossCure]

As far as I can tell, most reputable doctors are not using punches greater than 1mm in diameter. Also ??“ and don't for get this part ??“ most reputable doctors are not using punches smaller than .75 in diameter either.

 

The recent "online backlash" against large punch FUE has certainly raised some awareness about the procedure. At the same time, I think it has created some misconceptions too. For example, in this thread very thread posters have mentioned the use of .6 and.7mm punches as if it is standard practice in FUE. It is not. I am sure if you asked most seasoned FUE physicians, they will tell they do not use punches this small. (Disclaimer to Bart: I am not saying the .7mm is necessarily bad or evil since I wouldn't know. It is just uncommon.)

 

.75mm ??“ 1mm is common in FUE. Many surgeons feel it is difficult to remove intact grafts with tools smaller than .75. Many also feel it is unnecessary (and risky) to use a tool bigger than 1mm. That is my sweeping-generalization-FUE-rationale Nobody can predict who will scar with what punch. It is up to the surgeon to use tool big enough to remove a full follicular unit...and no bigger.

[the B spot]

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

[Bill - Seemiller]

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.

 

-------------

 

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 - Seemiller]

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]

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]

"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]

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]

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]

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]

I would NEVER hit you!!!!

 

Thanks D,

Jason