Not all FUE punches for hair restoration are created equally.  Other than the punches Cole Instruments created, FUE punches have a thicker wall and are not as sharp.  Cole Instruments created the thinnest wall and sharpest punches on the market.  This is very important to the success of FUE hair transplant surgery.   

Removal of hair follicles in FUE depends on two forces.  One is the axial force or the inward pressure on the skin.  The second is the tangential force created by rotation or oscillation.  Both forces will be less with a thin wall and a sharp punch.  Lower forces create less fluid movement of the follicles.  This helps to reduce follicle transection or amputation of the follicles, which often results in such damage to the follicle that follicular survival is impaired.   

Cole Instruments recently created a new surgical punch that is serrated.  These punches reduce the surface area in contact with the skin. This reduces the force required to incise around the follicles even more.  Cole Instruments calls these new punches, the Surrounded punch.   

The Cole Instruments Graft Chiller Plate reduces the temperature of the follicles so that any follicles traumatized by extraction have a higher probability of survival. Follicle trauma with the Cole Punches and other extraction tools is very low compared to other FUE punches and extraction tools, however.  

There are numerous instruments for creating recipient sites.  These include custom made blades, hollow core needles, solid core needles, sapphire blades, and SP 89 – 91 blades, as well as other less commonly used items.

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Custom Made Blades:

These consist of razor blades cut to a specific size.  We first began using these in 1991 as an alternative to the use of scalpel blades for micro and mini grafts.  Of the ensuing years, the number of recipient sites increased from under 100 in an average case to well over 1000.  Eventually, the number of recipient sites exceeded several thousand sites.  Custom made blades allow the physician to prepare specific size blades for grafts that contain a specific number of hair.  For instance, the physician might use a 0.7 mm to 0.9 mm blade for single hair grafts.  He might use a 1.0 to 1.1 mm blade for two hair grafts.  He might use a 1.2 to 1.4 mm blade for grafts containing more than 2 hairs.  Each physician has his own idea of the ideal blade size for his grafts that contain a specific number of hair.  In general, it takes more skill by the surgery staff to insert grafts of a specific size into the smallest recipient sites.

There are two types of blades that are used to make recipient sites.  One is the double edge blade.  This is much sharper.  The diameter of the blade is only 0.1 mm.  This blade will stay sharp for several thousand recipient sites unless you damage the cutting edge.  Occasionally, these blades will dull more easily when cutting into scar tissue or in when they hit the skin in thin scalps such as those you might encounter from a scalp reduction.  If they hit something hard such as a surgical tray or counter, they will dull quickly.  They are not good for stick and place as they tend to dull easily when used for stick and place.

The second type of blade is a single edge.  This blade is 0.25 mm in diameter and is stronger.  It also is not as sharp as the thinner walled double edge blade.  These blades are good for smaller recipient sites such as the 0.7 mm site because the added wall diameter adds additional strength to the blade.

Some physicians prefer the thinner sharper double edge blade such as the author.  Others such as Dr. Wong prefer the thicker walled single edge blade.

Needles:

There are two types of needles.  One is the hollow hypodermic needle.  The second is the solid core needle.  The solid core needle will stay sharper longer than the hollow hypodermic needles that are made of a softer metal.  Smaller hypodermic needles will stay sharper longer than the larger gauge needles.  The smaller needles include anything  a 20 gauge needle and 21 gauge needle.  The larger 18 gauge and 19 gauge needles will generally stay sharp for about the first 80 to 100 grafts.  The advantage of the solid core needle is that it will stay sharp for several thousand-graft sites provided that you do not bend the tip of the needle by allowing it to hit the skull or to hit a hard surface.  “Dinging the tip” will create a bur on the needle and cause it to dull immediately.  Thus, if you want to get the maximum benefit from solid core needles, you should do your best to protect the tip.

Hollow core needles also in theory will bury some epidermis into the lower layers of the skin.  Some feel this leads to cyst formation.  The author did not find this problem to be an issue with hollow core needles.

SP 89-91

These are quite common and are used by many physicians.  They dilate and cut the sites.  The diameter of the blade is about 0.5 mm.  These do not fit into the Counting Incision Device at this time, but we are working on an adaptor for that will facilitate their use.

Recipient site size

Currently, there is no data to support the advantage of smaller recipient sites.  One can anticipate a higher density with smaller recipient sites, but higher densities can also affect the yield from your grafts.  Slightly larger sites allow for less trauma when placing the grafts by your technicians.  Furthermore a slight larger site will result in less pressure on the grafts from the walls of the recipient site.  Forces in a recipient site on a graft come from two sources.  One is the force of the walls of the recipient site on the graft.  The second is from the graft onto the recipient site.  This compressive force, if great enough, can affect circulation to the graft in a negative manner.  For this reason, the author prefers a more comfortable site for the grafts.

One should also recognize that grafts have a tendency to pop in some patients.  Patients with hard skin and little elasticity have little give in the skin.  There is also less compression due to elastic recoil on the graft once it is placed into the recipient site.  This can lead to graft popping.

Graft popping can often be overcome by trying a variety of instruments to make a recipient site.  One might start with custom blades of a specific size and find there is popping.  One can then change to a larger or smaller blade.  Alternatively, the author often finds that changing to a needle to make recipient sites is of benefit.  With very large grafts and a rock hair, inelastic skin, the author has even found that 16 gauge needle sites were the only way to minimize popping.

The authors experience in patients with African American decent resulted in better results from using SP 89 to 91 sites.   The SP 89-91 blades are quite thick in diameter and seem to dilate the incision as well as make an incision.  Skin in African American patients is often much harder with less elasticity.  Not only did the SP blades work well in the Negro patient, they also resulted in better growth in the author’s hands.

Incision Site Depth

It is important to control the depth of your incision for a variety of reasons.  Minimizing the depth will reduce bleeding.  Reducing the depth causes less tissue destruction and a lower probability of tissue necrosis.  Reducing the depth can minimize the risk of burying grafts that can lead to pitting.  Reducing the depth protects the tip of the cutting edge of the instrument you use to make sites by eliminating the risk of hitting the skull.   The Counting Incision Device (CID) has a depth control mechanism.

In general, Caucasian grafts are between 4 and 5 mm long.  Usually you can make your recipient sites 4 mm deep.  With longer follicles, you might want to increase the depth of your incision sites up to 5 mm.  Many Asian patients have follicles that are even deeper.  In these patients, the follicles may be longer than 5 mm.  In such instances, you may find that a depth of 5 to 5.2 mm is required.

The Counting Incision Device (CID) is designed to hold the custom blade or needles.  It does not currently hold the sapphire blade or the SP 89-91 blades.

Recently, Dr. Cole visited HDC in Cyprus to allow the staff physicians there to experience the new items available from Cole Instruments.  Dr. Cole originally trained the staff at HDC in both FUE and strip surgery in 2003.  Since this time, HDC has done a wonderful job and produced many outstanding results for their patients.

Dr. Cole demonstrated his new Power Cole Isolation Device, PCID, along with his new line of punches.  The staff physicians were able to see the advantages of the punches Dr. Cole manufactures along with the speed and accuracy of the PCID.  Dr. Cole easily extracted grafts on a patient using the 0.85 mm punch set at a 2.3 mm depth.  The patient had a previous strip procedure at another clinic and desired to fill the area in with additional hair, as well as treat the unsightly strip scar.

Dr. Cole then discussed the advantages of sharp punches over dull punches along with the theories behind FUE harvesting of grafts with minimal transection.  The staff was very pleased with the sharp, thin walls of Dr. Cole’s punches.  They immediately ordered 30 punches for use on their patients.

 

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Introduction

FUE is becoming increasingly popular with both physicians and patients. As patient demand increases, the need for more physicians to provide the procedure is essential. Unfortunately, the procedure is difficult to learn for many physicians. There is a need to reduce the learning curve so that consistent results are possible. In addition, there is a need to provide logistics so that physicians are able to carry out large procedures in a shorter span of time. This presentation will detail how to provide the FUE rapidly while insuring quality grafts that insure consistent results.

Methods

I will discuss the overall planning and design I use to produce large procedures exceeding 2000 grafts with speed and efficiency. This discussion refers primarily to patients who are a Norwood class 3 or greater.

Results

Proper planning and instrumentation allows physicians to provide well over 2000 high quality grafts to a patient in a single day.

Discussion

Patients with advanced degrees of hair loss are often treated with between 2000 and 3500 grafts to the frontal 1/3Rd of the scalp. Such large sessions require considerable planning and expertise in order to perform in a timely fashion.

I begin by determining the surface area we will treat in a similar manner as that one does in strip harvesting. I then design my donor area. I split my donor area into 8 major regions and 6 minor regions. I design the donor area using a donor template that I attach to the patient’s scalp with an elastic band. The template allows me to design a consistent donor area for each patient. The template has holes in it large enough to place a dot with a gentian violet marker. Once each dot is made, the template is removed and I draw in the boxes by connecting the dots with a gentian violet marker.

Speed in any procedure depends on subdividing the work among as many individuals as possible so that multiple tasks are carried out simultaneously. The objective is to get as many hands as possible on the scalp at one time. Patient positioning plays a major role here. More hands can come in contact with a patient who is in the seated position so more simulataneous tasks may be carried out.
Once my boxes are designed dividing the donor area into 14 distinct regions, I will anesthetize two of them. I anesthetize two boxes that are widely separated from one another. I begin by anesthetizing box 2 and box 8 quite often because each box yields a different type of hair in terms of caliber, calculated density, and propensity to loose pigment. The wide separation between these two boxes allows two people to work in the donor area simultaneously. I begin by using a test kit. My test kit contains different diameter punches that may be set at an infinite number of depths. I choose the appropriate size punch and depth from the test kit. Once I choose my punch, I will either mount a the desired size on the Programmable Cole Isolation Device or I will mount the punch on a manual handle. I then begin extracting follicular groups. After cutting 50 to 100 grafts, I will move to the opposite side box, for example to box 8. While I move to the opposite side, my assistant begins removing grafts from Box 2 using the ATOE or aide to extraction. At the same time we begin evaluating our transection rate. Based on the transection rate, we will make changes if necessary to improve the quality of the grafts. I also get continuous feedback from my staff regarding the depth of the incision and the quality of the grafts. At any point they will notify me if the quality is compromised. While my staff member removes grafts from Box 2, I will begin cutting grafts from Box 8. I can usually cut much faster than my assistant can remove. After cutting approximately 100 grafts from Box 8, I will mark an area on the top for local anesthesia. I will generally begin centrally so that three or four people can work simultaneously. While my Registered Nurse gives anesthesia, I begin extracting from Box 2. My assistant continues to remove grafts from Box 8. My assistant removes 25 grafts at a time and places the 25 grafts on a pad. The pad is then placed in a chilled holding solution. As soon as the anesthesia is delivered, I begin making recipient sites on the top. Often times I give PRP, Thrombin, and Acell prior to making recipient sites. As soon as I cut a few hundred recipient sites, I begin to harvest once again from Box 2. As soon as my assistant has removed all the grafts from Box 8, I will return to this Box 8 to cut more grafts, while my assistant removes grafts from Box 2. As soon as my assistants finish placing the grafts on the top, I will make more recipient sites so that the procedure moves along as quickly as possible.
Once the grafts have been cut and removed entirely from Box 8, the left side of the scalp is open for a surgery tech to place grafts on the left side of the hairline or anywhere on the left side of the scalp.
Hair line preparation is different than other regions of the scalp where larger full size follicular groups are placed. On the hairline, I generally place predominately smaller grafts containing only one hair. Behind several rows of single hair grafts I place two hair grafts in at least two rows. Behind this I place several rows of three hair grafts. The number of one and two hair grafts depends on the caliber of the hair and the contrast between the hair and the skin. The larger caliber hair or when the contrast between the scalp and the skin is greater, I will place more single hair grafts.

Graft Processing

By the time if begin preparation of the single hair grafts, I will generally begin harvesting from the central boxes of the donor area. This allows at least two surgery assistants to place grafts following preparation of the recipient area while I harvest from the central boxes. This allows for the most number of hairs to have contact with the scalp at any given time.

Harvesting Speed

There are many ways to harvest grafts in the performance of FUE. The chief differences are in a manual approach and a mechanical approach. The fastest way to harvest grafts is to use the Programmable Cole Isolation Device. All other mechanical extraction methods are no faster than my manual method of extraction. Transection rates are slightly lower with my manual method in many instances, but the transection rate can be quite low with the PCID. Other forms of extraction tend to have significantly higher transection rates.

In a mission to make the highest quality hair transplant surgeries available to even more individuals, Dr. Cole is enthusiastic about training other surgeons in his proprietary Cole Isolation Technique.  Licensed doctors not only have access to his guidance and training, but also to the full Cole Instruments line, including otherwise exclusive tools and devices. 

The Counting Incision Device(C-ID) allows the physician to accurately maintain the incision count during recipient site preparation.

In this video demonstration of the CID, you can see just how easy and effective our popular automated incision counting device is.  You can see how quickly and simply a pre-cut blade or needle of your choosing can be loaded and secured into this device.  Customized blades and needles are available from Cole Instruments and you can easily control the depth of the incision with each CID.  Be sure to observe the ergonomic handle design, making site preparation as comfortable and easy as possible for the surgeon.  The digital count display is entirely accurate and so easy to read.   

This is a video demonstration of the CID - Counting Incision Device

The Cole Isolation Technique is being refined with the incorporation of Dr. Cole's newest motorized instrument called PCID (Programmable Power Cole Isolation Device). This equipment makes the extraction process faster, using smaller punches, than ever before.

This video demonstration shows Dr. Cole’s exciting PCID in action.  The Programmable Cole Isolation Device makes the extraction process faster, while using smaller punches, than ever before.  In addition to traditional scalp hair, this video shows the extraction of beard hair.  You can see firsthand just how easily and safely the PCID allows for even the, traditionally challenging and painstaking, extraction of body hair. 

This is a video demonstration of the PCID - Programmable Power Cole Isolation Device.