Punch, how to extract follicular units in hair transplantation.
The term punch refers to the instrument used as part of the surgery of baldness to perform the extractions of follicular units, or graft, necessary to fill the glabrous areas of the scalp.
It is a cylindrical-shaped surgical instrument characterized by a pointed end, developed to create a gap in the skin during hair transplants with FUE (Follicular Unit Extraction) procedure.
It works through an action of rotation in both directions and pressure on the skin made by the fingers of the technician. The sharp tip is placed against the skin at the follicular unit that is to be taken, and the tissue is cut to a depth of between 3.5 and 4 mm. This is generally the depth of a hair in the skin. Once the desired position is reached, the follicular unit is gently extracted using forceps.
Sharpened end vs. Blunt end
While it is true that the sharp punch tip allows the technician to separate the grafts from the surrounding tissue with ease, in some cases practitioners use a punch with a blunter, or rounded, tip, as this would allow them to reduce the risk of transection (graft breakage). At the same time, however, it makes skin perforation more difficult.
To overcome the limitations of both instruments, some technicians puncture the skin with a sharp punch, and then achieve the required depth using a blunt one. The choice of instrumentation is then up to the surgeon.
Evolution of punches
In the past, the diameter of the instruments used by baldness surgeons was very large. In the 1950s, Dr. Orentreich, a pioneer of transplantation in the Western world, used a 4 mm punch.
We can understand how extreme these dimensions were by comparing them to today. The punches used today have a diameter of less than 1 mm.
Clinics generally use punches with a diameter of 0.8 – 1.1 mm.
Some technicians even use punches with a diameter of 0.6 to 0.75 mm.
Advantages given by such minimal dimensions include:
- improved tactility, which reduces transection rate
- the incisions are smaller, which significantly reduces the risk of complications and the formation of visible scar tissue;
- a greater number of incisions can be made with less compromise to the donor area
Punch sizes and surgical results
As we have indicated, the punches used for FUE hair transplantation have a diameter that varies between 0.6 – 1.1 mm. The choice of the size depends on some factors such as in particular:
- size of the patient’s follicles
- number of hairs present in each follicular unit
- patient’s expectations: for some the scarring outcome is of no importance, as long as the density obtained in the recipient area is satisfactory;
On the contrary, other patients wish to wear their hair very short and consequently visible scars in donor area would represent a major aesthetic discomfort.
Experts say that the quality of wound healing and the quality of the extracted grafts depends on the diameter of the punch used.
If you opt for a punch with a larger diameter, it is easier to completely surround and encapsulate the follicular unit without damaging it. At the same time, however, the scarring outcomes will be larger in size and will, consequently, be more visible.
The diameter of a follicular unit is much larger if it consists of multiple hairs. Using a punch with an excessively small diameter would lead to a longitudinal split of the follicular unit. This would result in exclusivelysingle grafts (with only one hair). Of course, the size of the wound would be unimportant, however, the probability of obtaining a good density in the recipient area would be extremely low.
Remember, also, that once the donor area is damaged, it will not be possible to repair it.
Motorized punch
For several years, some transplant clinics have been using a motorized punch. This technology is often the subject of harsh criticism from those in the hair restoration world who prefer a manual approach.
Among the criticisms are:
- Inability to perceive through touch the transition zone from the follicular unit to the surrounding tissue
- Follicular units may be damaged due to excessive twisting
- Follicular units are subjected to excessive stress and, in some cases, to above-average heat caused by the mechanical action of twisting.
Clinics that use motorized punches state that the main advantages are:
- lower transection rate given the stability of the insertion axis in the skin;
- lower effort for the technician;
- greater extraction speed
