How Microscopic Tools are Redefining Hair Restoration

A Look at Modern FUE Tool Development From an FUE Technique Perspective

The practice of hair restoration has never stood still, especially over the last 50 years. In this time, we have seen the incredible journey from the bushy, blotchy appearance of the transplant areas of the 1960’s and 1970’s right up until the natural and dense results that are now possible with state of the art FUE. This is no doubt an evolution with many interconnected factors; but at the center of this quiet revolution is a single concept: refinement. And perhaps the greatest example of this, if one were to pick one surgical area alone, is the development of Follicular Unit Excision and the central role that instrumentation and tool technology have played in making it the extraordinary procedure that it is today. This is why the trends of smaller and smaller, sharper and sharper, and even more customizable surgical instrumentation, is one that shows little signs of slowing down. The entire FUE paradigm was built on this one concept, which we have since evolved to new and unimagined levels. So let us first take a look at why this has been such a critical concept in modern FUE and the remarkable technology that has been birthed as a result.

As an FUE surgeon, if you do not understand the actual FUE procedure and what it was intended to overcome, then you will never fully understand the developments that have been made in its techniques and technologies over the last couple of decades. In summary, FUE is the process of extracting individual hair follicles from the donor area of the scalp with the most common areas being the posterior and lateral parts of the scalp, with this extraction being performed one follicular unit at a time. The advantages of this are numerous; they include avoiding the linear scar of follicular unit transplantation (strip surgery), faster recovery, and minimal invasiveness. However, and in direct contrast to FUT, with FUE there are far more subtle risks which have been the key factor in the decision to invest in evermore innovative technologies. The most important factor is that the process requires the surgeon to use a small hollow cylindrical cutting instrument, commonly referred to as a punch, which then rotates or oscillates around the hair follicle in order to score the skin and separate the targeted follicular unit from its surrounding tissue. The biggest and most critical risk of this is a phenomenon known as transection; when a hair follicle is accidentally cut, sliced, or damaged during this skin scoring and separation process. Transection is effectively graft death, so as you can imagine in a procedure where the total number of lifetime grafts is finite, and each one is extremely valuable to the patient, transection represents a permanent and irreversible loss of those grafts. The main goal and objective of tool technology, therefore, has been to try and decrease transection to as close to zero as possible. The reason for this is to preserve the patients donor resource as best as possible and to try and ensure maximum survival.

Of course, the most obvious and quantifiable trend we have seen with this, is in the reduction in punch size. Punches used in the early days of FUE could be as large as 1.5mm in diameter, but it wasn’t uncommon for early surgeons to use punches between 1.0mm-1.3mm in size. However, it was very quickly found that these larger punches were effectively acting like cookie cutters, with far too much tissue being removed around each follicle unit. Not only was this more wasteful in terms of overall tissue and scalp, but the increased size of punch diameter also led to increased risk of collateral transection to nearby non-targeted, un-harvested follicles and, ultimately, the overall long-term density of the donor area. Additionally, since each punch cut into the scalp and removed a full circumference of tissue regardless of the angle of the targeted follicle, the larger the punch diameter, the higher the probability of cutting across the follicle at a suboptimal angle and inadvertently transecting it. As punch sizes got smaller and smaller (standardly now from 0.7mm and 0.6mm and sometimes down to 0.5mm) there is a complete shift in philosophy away from the “extraction” mentality of the early days to an almost “preservation” mentality of the modern day, ultra-refined FUE surgeon. When a 0.6mm punch is used to remove individual grafts, this punch is so small that it is only slightly larger than the hair follicle itself. Since the average size of hair follicles ranges anywhere from 0.4mm to 0.8mm depending on the patient and their hair characteristics, a 0.6mm punch, means the surgeon is literally hugging the follicle with incredibly intimate precision. It scores the tissue that immediately surrounds the stem cell-rich bulge area of the follicle, but does not penetrate that all-important, nutritionally-rich bulge region at all. This, in turn, allows far less peripheral tissue to be removed, a massive reduction in transection rates, and the final result of such a meticulous approach are extremely small and virtually unnoticeable extraction sites that heal with an incredible speed and do not show after surgery in any way. The result is a much higher density of unharvested grafts in the donor area and almost 0% transection of the harvest yield which, of course, is a double-edged sword when it comes to the post-operative phase of treatment.

But of course, the entire revolution in FUE tool technology has not just been a trend in smaller diameters. The concept of sharpness has been totally redefined over this time period as well. If a punch is not razor sharp, then it is simply a dull instrument which will not cut tissue but rather, tear through it. This is a critical distinction as tearing creates a form of micro-trauma along the follicle sheath, damaging the architecture of the follicle which is vital to the survival of the graft. This blunt approach also necessitates more downward pressure and rotational force from the surgeon, which in turn can crush or deform the follicle and lead to graft death. Modern punches are now also exponentially sharper, often being single use, disposable punch instruments to ensure that each single extraction is performed with a brand new, immaculately sharp edge which can easily glide through the dermal skin tissue with minimal resistance. This entire concept of a “clean cut” is a mantra for the modern FUE surgeon, with sharp extractions ensuring that the outer root sheath of the graft remains largely intact and the dermal papilla, along with its crucial cocoon of supportive cells, is preserved for new life in the recipient area. The integrity of this architecture directly translates into higher graft survival and, of course, better hair growth. Punch sharpness is now ensured by very sophisticated metallurgy and laser-sharpening methods to create true “edge” that is counted in the micron.

Perhaps the most recent, and advanced development in the modern surgeon’s ongoing battle to prevent transection is the trend towards extreme punch customization. Gone are the days of the one size fits all FUE tool approach of the early 21st century. Surgeons are now fully aware that successful harvesting must take account of a wide range of patient-specific factors and that hair follicles are far from a homogeneous tissue type. They can vary wildly in diameter, angle of entry, depth within the scalp, and even the shaft curvature. The punch technology has had to adapt accordingly, with tremendous diversification in the types of available punches now present. Instead of being limited to simple 90 degree tip angles, surgeons now have at their disposal a full armory of tools with different tip geometries, with sharp, tapered punches being great for the typically denser, more fibrous Caucasian scalp tissue, and blunt or flared punches to “dissect” away surrounding tissue and “slide down” the follicle as a safety feature in the case of curved or irregularly angled follicles which would otherwise be transected by a sharp, straight wall tip.

In addition to tip geometry, this new level of customization in FUE tools extends to the motors and movements used as well. Now fully robotic or automated, the FUE devices of today have a range of rotational movements from which to choose. Oscillating punches, which move back and forth in a very tiny arc, are often preferred as they do not catch as much hair and have a lower avulsion rate (pulling the graft out by the root) when compared to their 360 continuous rotation counterparts. There are even devices which allow for variable oscillation speeds and depths, which can be adjusted based on the properties of the donor area at hand. This is the height of refinement in FUE extraction: the surgeon, at the helm of a top of the line, automated or robotic device, choosing a 0.7mm, ultra-sharp, slightly flared, oscillating punch to perfectly match the specific follicular unit being targeted, at that time and with that scalp tissue. It is a dynamic, adaptive, and evolving approach and one which is what separates modern, high yield FUE from its more primitive, blunt predecessor of yesteryear.

Of course, the result of all of these refined techniques and tools is that the benefit is not only felt in the operating room, but it can also be seen by patients with their own eyes. The most immediate and most visible impact is on the donor area. With smaller punches and minimal transection rates, the donor zone can now maintain its natural and undisturbed appearance. Tiny pinpoint scars from 0.6mm extractions heal so well that they are impossible to notice with the naked eye, even at very short haircuts. This allows patients the freedom to wear their hair as short as they like without having to worry about the cosmetic evidence of their surgery. Further to this, minimizing damage to surrounding follicles also has the long-term benefit of preserving the integrity and density of the overall donor reserve, a crucial consideration for patients who may require a second or even third procedure in their lifetime.

In the recipient area, the impact of this drive towards smaller tools is just as profound. The more grafts that survive, the better the density and coverage in the transplant area will be. But beyond graft survival alone, smaller extraction tools also allow the surgeon to harvest smaller single-hair grafts which are crucial to creating a soft and natural hairline, as well as the ability to use these tiny grafts alongside the survival of larger multi-hair grafts for density in the area behind it, to allow the hairline and pattern of growth to perfectly mimic the design created by nature, with no visual signs of surgical intervention left behind. The minimized trauma from such small, sharp tools also lends itself to a far better post-operative experience, with much less swelling, discomfort, and, critically, a dramatically faster healing time. Recipient sites are so small that there is almost no crusting and transplanted hairs settle in much more quickly which also often leads to a shorter “ugly duckling” phase and a faster time to seeing the final result.

The challenge with ever smaller and more refined tools, as is the nature of all advancing technologies, is that the skill level required to work with them also becomes elevated and far more difficult. A 0.6mm punch leaves the surgeon with virtually no margin for error, and the procedure as a whole requires a far greater degree of concentration and steadiness than ever before. It is also a much slower process, with extracting thousands of grafts with such a fine instrument taking significantly more time than the larger, less refined tools, with implications for surgical time and graft viability outside of the body. There is also a point of diminishing returns here as well, since while a 0.6mm punch might be ideal for fine Caucasian hair, it is likely far too small and fragile for successfully harvesting coarse, curly or Asian hair, with its far larger follicle diameter, thicker outer root sheath, and, crucially, its deeper, more subcutaneous location in the scalp. In these patients, an 0.8mm or 0.9mm punch might in fact be safer to use to avoid compressing and crushing the graft between punch and underlying tissue. The future is, therefore, more likely to lie in not a one size fits all “the smaller the better” dogma, but an increasingly intelligent and adaptive technology which can recognize and accommodate these variabilities in real-time.

Already this has begun with the likes of the ARTAS Robot and other such platforms which are the next logical stage in the refinement journey. These types of systems use very sophisticated imaging algorithms to identify individual follicles and target them with near superhuman accuracy. They can then, automatically and in real-time, measure the angle, depth, and density of each individual follicle and dynamically adjust the punch parameters (size, oscillation, depth) for every single extraction. The level of refinement and customization which this offers is a complete game-changer in the ability to remove grafts with submillimeter precision, and by removing this one element of human variability and fatigue, transection rates are driven ever lower still. With continued AI training on vast datasets of successful and unsuccessful extractions, it will also likely become able to preemptively adjust for and avoid curved or atypically angled follicles entirely. The future could also see the development of more advanced punch materials, like diamond coated tips for ultimate sharpness and durability, or even flexible and smart punches that are able to navigate around follicles instead of simply cutting towards them.

The continued push towards ever smaller, sharper and more customized FUE tools, however, is much more than just a story of technological innovation in the world of hair restoration. It is the central narrative which has defined the development and evolution of the FUE procedure in its entirety. The punch itself, now a wondrous thing of micro-engineering at 0.6mm, is the physical manifestation of a deep and abiding respect for the fact that each patient has a finite donor resource, and a commitment to providing not just growth, but undetectable, natural, and dense results that the patient can be proud to show off to the world. This drive to maximize survival and minimize transection has transformed FUE from a niche alternative to FUT into a truly refined art form, and, hopefully, we will continue to see this focus on smaller, sharper, and more adaptive tools drive patient outcomes to even greater levels in the years to come.