Punch Size Comparison Study in Hair Transplant Surgery

In the spring of 2003 I first introduced the 0.75 mm punch to FUE. I immediately noted that I it had certain advantages and certain disadvantages. I also noted that no single method or instrument worked equally well on all individuals. I found quickly that no one technique or procedure worked equally well for ever patient. It became apparent that every donor area was different and one had to be able to adapt to these difference. For this reason, I began developing a number of different devices of a variety of geometric shapes. All of this development was quite costly. Therefore, we were quite careful about our disclosures and we also sought patent protection on a number of the instruments. From the early days we planned to offer our procedure and instruments through a license so that we can continue developing better tools and instruments that we hoped would encourage more physicians to abandon the invasive, unpredictable scar prone strip procedure. That time is near.

Over the past years, we have heard many new, inexperienced FUE physicians and inexperienced FUE clinics (many who do not even list a physician of record) promote smaller punch sizes exclusively because they produce less scarring. Over the years we have listened to this rhetoric with concern because we know from greater experience that one must be able to adapt to the differences in the donor area if you are going to produce consistent results. Some clinics have now been promoting such instrumentation for over 4 years yet they continue to produce inconsistent results. Our concern is that some clinics promote such techniques as a fear factor to garner patients. Promoting such a procedure exclusively suggests that they do not have consistent results and therefore have no other way to promote themselves. Let’s face it, who would want to go to a clinic that has hit or miss results or very few results despite claiming that they have performed the procedure for over 4 years.

Gradually more and more physicians or clinics without listed physicians and no consistency in their results have begun to beat this single small punch drum. Anecdotally, we have known for years that punch size does not affect healing. Therefore, we have never allowed this punch size discussion to affect our procedure. Rather, we have continued to focus on one thing….RESULTS. More recently we decided to do a study and simply show objectively that there is no difference in healing regardless of what size punch you use. This is of course provided that you are able to get the hair out. If you are not able to get the hair out, the skin will heal just like it was prior to the procedure and both your donor and bald top of the scalp will look exactly the same.

In this study we compared our 0.75 mm punch with a punch significantly larger. The results of this study showed there was no statistically different appearance in the donor area. In fact the larger punch healed better, but the difference was not statistically significant. In both instances there is a slight reduction in color due to the removal of melanin and a decrease in required blood flow.

What happens when you remove an intact follicular unit from the donor area? You eliminate a metabolically active structure from the surface of the skin. The structure requires blood flow to survive. It also produces color through the function of the melanocytes. Melanocytes produce melanin that can be seen in the hair and also as a colored shadow as the hair approaches the surface of the skin. Blood flow to the hair follicles is pink due to the presence of oxygenated hemoglobin in the red blood cells. Melanin produces a dark hue in the surrounding skin. When you remove the hair follicles, you reduce the pink color and the dark hue of the hair shafts. This can leave a lighter colored area of skin where the follicular group used to exist. This lighter color is equal regardless of whether you use a very tiny punch or a slightly larger punch.

There are a couple of ways to minimize this affect. One is to harvest only non-pigmented or grey hairs. Another is to harvest only a portion of a follicular group. Another is to fractionate the follicular group through poor technique. Still another is to place a body hair in the extraction site.