I introduced the use of the 0.75 mm punch in FUE procedures in spring 2003, and immediately noticed certain advantages it brought, as well as certain disadvantages. I have also noted over time that no single instrument or method works equally well with every patient and that every patient’s donor area was quite different from others’ and adapting to these very different is the only way to ensure success. With this in mind, I began to develop and design a number of different devices for the purpose, of a variety of different geometric shapes, which was quite an expensive process. As a result, we were careful about disclosures, keeping the details under wraps, and seeking patent protection for a number of these instruments. Right from the very early days, the plan was to offer both our procedures and our instruments to other practitioners through a license, giving us the option to continue developing further and better tools to help more and more physicians to abandon the currently used invasive, and unpredictable, strip procedure that is so prone to scarring.
In recent years newer and newer, and inexperienced, FUE physicians and small clinics which may not even have a single physician of the record, have been promoting the use of smaller punch sizes merely because they think that this will produce less scarring. This rhetoric has been a cause for much concern because we have learned from greater and longer experience that it is the ability to adapt to all the differences in donor areas that produce the most consistent results. These clinics have been promoting instrumentation for smaller punch sizes for over four years already, but continue to show inconsistent results. The fact is that some of these clinics promote such inconsistent techniques merely as a fear factor, to drive patients to them. The fact that they promote such procedures exclusively seems to suggest that they cannot have consistent results, leaving them with no other claim to fame to promote themselves. After all, would anyone be interested in a clinic that has purely hit and miss results, or shows very few positive results at all despite having performed the procedures for as long as four years.
Gradually, more physicians and more clinics without a single listed physician and without consistency in results jumped on to the single small punch bandwagon. From anecdotal experience, it has been apparent for many years that the punch size seems not to affect healing in any way. As a result, we have really never paid much attention to this punch size debate, or let it affect our procedures, focusing instead on the only thing that really matters – RESULTS!
Recently we set out to undertake a study on the issue, to show objectively that there really is no difference in the actual healing no matter what size punch is used, provided you are able to extract the hair. If you cannot extract the hair, the skin will just heal over like its original prior-procedure state, and both the donor area and the bald top area of the scalp will go back to looking exactly as they were. In the study we conducted, we compared the results from a 0.75 mm punch with those from a punch of significantly larger size. The results clearly showed that there was no statistical difference in the appearance of the donor area. Sometimes, in fact, often, the larger punch seemed to heal better, but the differences were slight and not significant statistically. In both cases, there was a slight reduction of color, caused by the removal of some melanin, and the decrease in blood flow.
What would happen if you were to remove an entire intact follicular unit from within the patient’s donor area? In real terms, you are eliminating a metabolically active physical structure from within the skin surface. This structure requires adequate blood flow to be able to survive, which also produces color, from the action of melanocytes. Melanocytes are the producers of melanin in the hair, as well as the colored shadow where hair approaches the skin surface. The blood flow to the follicles is also usually pink from the presence of extra oxygenated hemoglobin in red blood cells. When the hair follicles are removed, this reduces the pink hue from the blood supply as well as the dark color of the melanin. This often leaves a lighter area of skin in the location where the follicular group was. This lighter color remains the same no matter the size of the punch.
There are a few ways to try to minimize this discoloration effect, such as harvesting only from the non-pigmented grey hair population. Another option is to harvest just a part of any follicular group or to fractionate the chosen follicular group via poor technique, or even to place body hair within the extraction site.