The size of punches is an important subject in FUE hair transplant and CIT techniques. It is also a strong marketing tool for some groups who attempt to mislead patients into believing that they can always use a small punch and they always get a high yield with little destruction to the follicles and follicular units. We are perhaps the most experienced in follicular unit extraction at this time with more than 300,000 grafts removed by our patented follicular isolation technique of extraction. We rely on this vast amount of experience to help guide us in the art of follicular unit extraction.
The Misconception of FUE Punch Size
Patients generally believe that a smaller punch results in a smaller scar. We believe this is not always the case. It definitely has not been studied. The general rule in skin surgery is that an incision smaller than 1.5 mm in size will heal without a visible scar to the naked eye. Therefore, in theory, there should be no cosmetic advantage to a smaller incision than 1.25 mm in diameter or 1 mm in diameter and there could be disastrous results from smaller incisions in regard to hair shaft damage. Furthermore, the total number of hairs transferred by using smaller hair transplant punches can be significantly less.
One must remember that individuals who have hair loss want hair in the areas where they do not have hair. The advantage of FUE is that it allows us to leave an imperceptible scar in addition to adding hair to the areas of loss. Adding hair can be efficient or inefficient. In other words, for every 100 hairs you attempt to move, you may move 92 to 97 intact hairs or you may move only 62 intact hairs. The ones you do not move are damaged in the removal process. If the damage ratio exceeds 8%, the process becomes very inefficient. You will not get as much hair from every graft as you desire. Your resulting coverage will be less. Furthermore, you will pay more for less hair. In general, punches smaller than 1.0 mm are good for two or one hair graft. If you attempt to move larger grafts than two hairs, your injury rate will increase and your efficiency will decrease significantly.
The Correct Approach
In our office, we average 2.49 hairs per follicular unit using our method called follicular isolation. This is about 25% more hair per graft than you can expect from the total use of a smaller punch. Furthermore, we are able to keep the transection rate at 8% or less. Often it is 3%, which is better than with most strip surgeries. We vary the punch size based on the size of the hair shafts and the number of hairs per follicular unit (technically referred to as the calculated density).
The hairs exit from the scalp in natural clusters. They are very close to one another on the surface. On the surface, the clusters of hairs are bound closely into one or sometimes more than one follicular canal. As they enter the skin, they begin to spread out. In hair surgery, we call this “hair splay”. A useful analogy is a bundle of flowers that are in a vase. At the top of the vase, they are very close to one another. As the flowers enter the vase, they progressively deviate from one another. Some vases are narrower at the neck and some are wider. The wider ones will not gather the flowers as close to one another at the neck. Some vases are wider at the base. In the wider ones, the hairs will be farther apart; there will be more splay or distance between the individual flower stems. On more narrow bases, the flowers will be much closer to one another. There will be less splay or distance between the individual stems. The same thing happens with the scalp’s donor area. In some individuals, there will be a wide variety of narrow bundles. In other individuals, there will be a preponderance of follicular units exhibiting splay. In other individuals, there will be a variety of bundles. Some have more splay than others and some have very little splay.
The Follicular Size
Another concept to understand is the size of the hair follicles and their surrounding dermal sheath. The average scalp follicle is 0.42 mm wide from the dermal sheath to the dermal sheath. A two hair follicular unit averages 0.82 mm wide. This means you can use a 0.5 mm punch all you want, but the two hair follicular units will not fit into it. In other words, you will need a little luck in your extraction process, a perfect incision, and no margin for error. You will have a lower yield and an inefficient procedure. A 0.75 mm punch will work, but the incision must be perfect. Humans are not always perfect. A 0.8 mm punch will work on the 2 hair follicular unit also, but the human must also be perfect. The 0.9 mm punch provides a larger cushion and we have used it quite often for 2 hair grafts, but it is not possible to use it on every patient or every 2 hair grafts. The 1 mm punch provides a larger cushion for human error and a very high yield with most grafts and in most individuals.
As the size of the follicular unit increases, the width also increases. This can present an increasing problem for the hair restoration surgeon. In our office, the average follicular unit has 2.49 hairs. Therefore, we must tailor the punch to the patient and to the follicular unit. In other words, if you want a more efficient procedure, the procedure must be customized to the patient and the follicular units. Otherwise, you will have a far lower efficiency ratio and a lower yield. You will pay more for less hair and you will unnecessarily put donor hairs at risk. The ideal donor result is important, but the yield should be a chief consideration for the hair restoration surgeon and the patient.
To date, we have not noted an increase in scar formation from the use of larger punches. Larger punches have not shown more collateral damage or shock loss to surrounding hairs in the surrounding follicular units. This has not been studied yet, however. The main problem with follicular unit extraction remains the removal of a follicular unit from the natural follicular geometry of the donor area. This problem is the same regardless of punch size.
Dr. Cole’s Smallest Punches Slams the Door on Strip Surgery Benefits
We’re always excited to share new developments within the industry and refinements to the Cole Isolation Technique (CIT), particularly those that may make quality hair transplantation more accessible to the masses. Dr. Cole was the first physician to use a punch smaller than 1 mm, created the only patented instruments with depth control available, and will soon offer the fastest and safest motorized extraction device on the market to other physicians in his network.
Over the past couple of months, Dr. Cole has been using his new motorized equipment, which has made the extraction process faster than ever and has allowed his clinic to take on more and larger cases than ever before. Today, he was able to cut 1,000 grafts in under an hour (including the time it took to administer anesthesia, prepare the donor area, and make the extractions).
His new equipment is allowing safer extraction of grafts using smaller and smaller punches. As we continue to gain experience with this instrumentation, we anticipate physicians will be able to roll back pricing for patients and make quality hair restoration surgery more affordable for hair loss sufferers throughout the world.
With the speed with which large procedures could be completed and the lower cost being two of the only advantages strip surgery offers over CIT, we may just be heading in a direction in which strip surgery will become obsolete in the coming years. Dr. Cole’s new instrument is capable of extracting 2,000 grafts in one hour excluding the time it takes to prepare the donor area for harvesting. It would take a team of trained strip technicians 5 to 10 man-hours to cut the same number of grafts under a microscope. The last technical barrier between strip surgery and FUE has just been broken; it has been crushed. For example, today, Dr. Cole was able to remove 1,000 grafts in under an hour. It can easily take that long just to remove a strip of tissue and suture the wound with strip surgery. It then takes surgical techs an hour for every 200-300 grafts they cut (something that is left only in the physician’s capable hands with CIT).
CIT, or Cole Isolation Technique, is Dr. John Cole’s proprietary follicular unit extraction method. Dr. Cole pioneered his technique back in 2002, and it has since evolved into the highly refined CIT method. CIT involves the use of specially designed CIT instruments to remove follicular units individually. These follicular units, or grafts, are then artfully placed in the thinning or balding areas, from which they eventually grow as if they are native hairs. CIT allows Dr. Cole to maximize the available donor area for harvesting and to cherry-pick the follicular units that will produce an optimal yield. Most importantly, it’s unlikely with strip hair transplantation, CIT will not leave a tell-tale linear scar.
