FUE technique: manual harvesting, robots, micromotors, PCID, WAW, U-Graft etc
In the past, Hairforlife and the forum community have been critical and controversial on the topic of FUE hair transplantation and removal methods, including micromotors, so-called motorised punches/hollow needles, FUE removal devices and automated systems with robots.
In the course of the development process of the hair transplant industry, I would like to say a few sentences about this:
Robotic hair transplantation and the ARTAS® system
According to ISHRS1 , the ARTAS® system is the most machine-operated FUE device. It is a fully robotic follicular unit harvesting system for hair transplantation. It was developed by Restoration Robotics, Inc, a company that develops robotic systems for use in surgery. The system has been in development for several years and has received 510K clearance from the US Food and Drug Administration (FDA) for follicular unit harvesting in brown- and black-haired men diagnosed with androgenetic alopecia. The system is operated under the supervision of a physician using a computer-assisted, image-guided robotic arm equipped with Powered SafeScribe® small punches for incision and an air suction unit for removal of individual FUs. As ISHRS also writes, according to the ARTAS® company, one thousand FUs can be removed per hour.1
An important key point seems to be the know-how, experience and judgement of the doctor who operates and adjusts the robot. The robot itself does not talk and therefore cannot give recommendations to an inexperienced person about dimensions, angles and distances to be programmed. In the end, any tool can only be as good as the hand that operates it.
Dr. Barusco and criticism of the marketing and sales system of robots to inexperienced doctors regarding hair surgery
According to Dr. Barusco2 from Florida, USA, the disadvantages of new systems/instruments/technologies are rarely discussed in public and 1. large-scale marketing campaigns give many consumers the impression that a doctor who does not have this new instrument/device is no longer up to date with the latest science, or 2. even worse, that some patients are even given the impression that doctors who have these new instruments/devices are automatically experts and achieve good results.2
In this respect, I remember some conversations with hair surgeons who openly admit to acquiring new systems/devices in principle and that these are no longer in use, but are still available in the practice. They deliberately buy new equipment for “marketing reasons”, either to be able to advertise it or, conversely, as mentioned by Dr. Barusco, not to leave the impression that they are no longer up to date.
Dr. Barusco is of the opinion that behind all such devices there must always be a competent doctor and, together with the doctor, also a competent team, otherwise no robot or other vacuum-assisted device will help. According to him, this is exactly the problem and he criticises that the robots all over the world are often sold to those doctors who have not had any training in hair transplantation.2
Dr. Barusco further mentions on his website2 that in recent years he has had a sharp increase in patients asking to correct the bad result, mostly achieved by robots and/or by unqualified persons under insufficient or no supervision of a qualified doctor. According to Dr Barusco, some of the patients did not even know the name of the doctor, but at least knew that one must have had a surgery with a certain robotic “procedure” or by a new FUE “procedure”.
Finally, Dr Barusco also says that robots are just machines and if the person in charge of controlling them does not have know-how and experience in hair surgery and who does not know the basic rules, the results could be bad. For example, according to him, the robot may not be able to see certain hairs well (the best case for the robot, he says, is dark, straight hair versus light skin, high scalp-hair contrast) and the hair surgeon would ideally have to switch to manual extraction, but what if the hair surgeon has no know-how in this regard, cautions Dr. Barusco2
Manual FUE harvesting vs motorised/automated/electric harvesting
While manual FUE extraction is still the benchmark for some renowned hair surgeons, others are switching to motorised/automated/electric extraction and it is likely that others will follow suit if there are opportunities to treat more patients with less effort in less time and thus convert more at the end of the day.
Arguments/arguments for manual harvesting: Optimal adjustment to individual skin structures, different depths of the grafts, less transection/damage/trauma to the grafts
The argumentation of doctors with manual extraction is that when using electronic tools (micromotors/robots) during the procedure, structural differences/changes in the individual skin layers in hardness, thickness, etc., which can also vary from area to area, are not optimally detected, and that the risk of transection/damage to the grafts/follicles is higher, especially when a micromotor with heat generation is used. The argumentation from the point of view of a hair surgeon with manual extraction is that with manual extraction it is much easier to deal with the individual skin structures (thin/thick/hard/soft) and possibly different depths of the grafts, that there is much more “feeling” and thus less transection, and that manual extraction is gentler overall and causes less trauma to the grafts.
Some FUE micromotors originally made for dental surgery and not for own hair transplantation
It should be noted, however, that some of the micromotor devices currently on the market were originally produced for other areas, such as dental surgery, and are therefore less suitable for hair transplantation and the extraction of hair follicles and therefore the risk of causing great damage to the donor is simply much greater than with manual extraction, especially with little know-how, little experience and too fast and careless procedure (see also Hair Transplant Turkey Istanbul)!
Unsuitable FUE micromotors are often used in cheap clinics or by inexperienced doctors
But it should be mentioned that especially those doctors/providers (cheap discounters) carry out the removal with cheap micromotors (mostly not developed for FUE ), but who are often still inexperienced with hair transplantation and/or lack the necessary basic knowledge (for example, how many grafts may be removed from an area at most without causing apparent removal areas with football field and window optic patterns), but also do not yet have sufficient experience and know-how to adjust the micromotor to the individual situation of the patient as far as possible.
FUE micromotor and experience/know how of the doctor
Therefore, the tenor among hair surgeons is that an experienced hair surgeon (who has mastered FUE for years and has sufficient experience with manual extraction) can most likely operate a micromotor and adjust it to the individual situation of the patient better than an inexperienced hair surgeon, regardless of the manufacturer, and thus most likely also achieve appealing results with a micromotor. The following applies (not as is often published on the Internet): Even when using a micromotor, the doctor’s experience/know how with transplanting one’s own hair is very important!
Development process/continuous development of FUE: Automated systems/electrical aids/micromotors for FUE removal developed by experienced hair surgeons, developed exclusively for FUE procedures!
In the development process of FUE and perfect removal, 3 devices with 2 different approaches are gaining more and more customers, which, however, can hardly be compared with the conventional micromotors/electrical aids and have been designed exclusively for FUE procedures and also by experienced hair surgeons.
The PCID by Coleinstruments: sharp FUE removal approach
Dr. John Peter Cole, USA, is known as a pioneer in FUE (Follicular Unit Extraction) and has been a leader in the development of state-of-the-art precision medical instruments for years. Coleinstruments now introduces a revolutionary device that can be used for the extraction of follicular units (grafts) in the FUE method.
The key feature is that the device works with a motorised drive. In the past, Hairforlife and the forum community have been very critical of the use of micromotors. The fact that Dr. Cole, of all people, now offers and recommends such a device for use in FUE operations has prompted Hairforlife to take a closer look at its use, range of functions and components. Interested readers can find a comprehensive overview table of previous, often enough controversial, micromotors in comparison to the PCID at4 or see the following PDF provided by Coleinstruments.com.
In the medical device sector, there are currently numerous models on the market for use in FUE surgery. Unfortunately, almost all of these devices were originally produced to be used in dental surgery (another exception is the WAW system/trumpet punch by Dr. Devroye presented below) or to cut through much harder material than skin, e.g. wood, bone or teeth. Human skin, however, has a very different texture than these significantly harder materials. Only the PCID was made for the sole purpose of extracting hair follicles from the skin.
The features of the PCID
The PCID offers many optional settings, including rotation, oscillation and roto-oscillation (rotation combined with oscillation). The respective parameters for the PCID can be preset exactly. Therefore, it is very important to know the exact settings and make sure that they correspond to the selected punch. A preset that is set too high can damage both skin and hair follicles if the punch is very sharp. A setting that is too low, on the other hand, can damage the skin too much and destroy hair follicles with a slightly duller punch.
Patients’ individual skin and hair conditions
Every patient has different skin and hair structures. Therefore, it is necessary that the settings for the punch correspond to the patient’s personal skin type. Currently, the PCID is the only device on the market where the settings can be matched so precisely and accurately with the diverse characteristics of a patient type. There are patients with a large number of multiple grafts, others with only singular units. There are also patients who have thicker hair and others who have thinner hair. The root sheath often turns out differently, the fatty tissue around the roots, but also the length of the hair follicles is different in each type of patient. The skin condition of the patients is just as different (thick, oily, thin, dry, leathery skin, etc.). Any punch that is only used with a certain setting for all patients will not be able to take this diversity into account. The consequences are greater skin injuries, increased trauma to the hair follicles, increased bleeding, transection and other accompanying symptoms, all of which often take place in a microcosm that is hardly perceptible to the patient. However, all these factors contribute significantly to the success of a hair transplant. Previous micromotors have therefore not been able to guarantee success across the board due to only limited adjustment possibilities, because individual characteristics could not be sufficiently appreciated.
The PCID is currently the only device on the market that appreciates the diversity and complexity of different patient characteristics. The individual parameters are entered by the doctor via a central unit, a computer-controlled brain. The input is very simple via a touch screen, which allows optional features almost without limits. The end device, the punch, reacts to the control by the computer and communicates with it continuously during the treatment. In this way, extreme precision and fine work can be ensured.
Precise depth control of the follicular units and sophisticated micro-technology with the sharpest blades help the doctor to successfully extract healthy hair follicles without tiring him. This is a not insignificant factor, as the stereotypical working process of hair surgeons can often force them to pay less attention during the course of a treatment. With the PCID, this circumstance can be eliminated.
The importance of the sharpness of the individual cutting edges of a sophisticated punch was determined in a comparative study. The result of the analysis can be read here5.
Turning speeds / tension arc
The PCID also allows the turning speed to be precisely adjusted. This possibility does not currently exist with any other FUE punch. The PCID allows a maximum rotation speed of up to 4000 RMP. A minimum success can be measured at currently about 1250 RMP. Depending on the situation, the treating physician can determine the speed, but also the tension arc when alternating between rotation and oscillation. As soon as the fine blades threaten to become just a little duller, a constantly constant rotation speed inevitably leads to a measurably increased longitudinal force, which puts more strain on both skin and hair and possibly destroys them. However, this side effect can be compensated for by increasing the rotation speed. What has not been possible with other motorised devices so far, the PCID now succeeds in many ways.
The PCID allows the use of a variety of different punches. However, the PCID only achieves its optimum benefit with the extremely sharp cutting edges from Cole Instruments.
As a result of the increased removal, the hair surgery can also be completed much faster and the patient can go home sooner. Almost all of the devices from Coleinstruments meet the highest standards and are the result of very intensive research work by Dr. John P. Cole himself. It has become a special concern of Dr. Cole to pass on his knowledge and skills to other doctors in order to guarantee the highest technological standard in hair transplantation worldwide.
See below some pictures showing Andreas Krämer from Hairforlife during an FUE operation by Dr. John Cole with the PCID device:
Hybrid Trumpet Punch/WAV FUE System Dr. Devroye/U-Graft Dr. Umar: Blunt FUE extraction approach
In the development process of new devices that decisively shape the extraction process for own hair transplantation according to the FUE method, the PCID produced by Coleinstruments had recently emerged alongside manual extraction methods.
After this basically linear further development of electronic punches for the removal of hair follicles, a new approach has become more and more prevalent in FUE. This does not concern the basic methodology but rather the technical functioning of the extraction needle. In the meantime, at least two renowned hair specialists have already successfully adopted this new technical approach after a long process of discovery. Dr. Sanusi Umar (USA), who is already successfully performing surgeries with the ultrasound-operated U-Graft from his own development6 , and Dr. Jean Devroye (Belgium) with his Hybrid Trumpet Punch7 from the latest production give this development a new impulse. Both have decided on a similar redesign of their punching technique to ensure safe and injury-free removal of hair follicles.
For this reason, Hairforlife would like to briefly discuss the new technique and procedure in this article. For the presentation, the Hybrid Trumpet Punch produced by Dr. Devroye and its mode of action will be described in more detail below:
FUE hair transplantation and the initial situation: Transection – extraction difficulties in African-American patients
Due to the often difficult position of hair follicles in the subcutaneous tissue in African-American patients, in the past even renowned and successful doctors could often only achieve limited success with black patients during FUE hair transplantation. Because of the desire to avoid the linear long scar of FUT surgery, these patients had less chance of success with the modern FUE method than others. The frizzy hair structure of African-American patients usually meant that the follicles were never fully captured by the FUE punch and transected last, because the particular location of the hair papilla was not suitable for the punching technique. In most cases, the hair follicles could not be removed with their entire root from the donor area of the patient, which jeopardised the success of the entire FUE operation.
However, transection is also a problem in many other ethnic groups, especially in Europe, if the doctor does not succeed in extracting the hair follicles unharmed. This may sometimes be due to the patient, the technical equipment of the clinic as well as the lack of experience of the hair surgeon himself. For this reason, the primary goal of FUE has always been to achieve a low transection rate. However, this could never be fully guaranteed.
The realisation: skin and tissue structures – sharp or blunt punches
The new technical development is based on the realisation that the greatest resistance for the hollow needle or punch during extraction is always on the outer surface of the skin. Therefore, the development of medical extraction devices has always been more and more clearly a race for particularly sharp and at the same time extremely thin punch attachments. The micro-technology of the extraction needles for FUE own hair transplants has recently taken on a highly developed degree of sharpness, the aim of which is to penetrate the skin both quickly and without force, if possible without major injury.
However, as a consequence, there is also a risk of transection and injury to a hair follicle if the sharp blade of the punch penetrates too deeply into the skin, causing premature separation or splitting of the hair root as a result of its location or depth.
The new technological approach taken by both the Hybrid Trumpet Punch and others such as UGraft by Dr. Umar is based on the realisation that initially only the external skin resistance itself needs to be overcome, while the subcutaneous subcutaneous tissue is soft and elastic. It therefore had to become the aim of a new technique to remove the hair follicles in their entirety unharmed, taking into account the structural conditions of the soft subcutaneous tissue.
The method: dissection of hair follicles vs. cutting extraction
The Hybrid Trumpet Punch starts exactly where the transection originates in most cases. Since the subcutaneous tissue does not require sharp cutting processes to penetrate to the papilla, the Hybrid Trumpet Punch has a new type of construction. Instead of an increasingly sharp cutting edge (the cutting edge of a punch, which is produced in different variations and shapes), the Trumpet Punch has an essentially blunt tip. However, the eponymous shape is also decisive for the successful use of the punch.
The Hybrid Trumpet Punch has a trumpet-shaped opening that most closely matches the follicle shape in its natural position. This allows the hair follicle to be completely captured and absorbed by the punch.
The technique: Hybrid-driven rotation with a low angle of inclination
Due to the trumpet-shaped design of the punch and its low sharpness, a higher pressure is required by the hair surgeon to cut through the epidermis. The hybrid drive therefore supports the treating physician via a foot pedal, which is intended to replace the manual turning movement with an electronic one (simulation of manual extraction). At the same time, the hybrid drive allows more force even at slow speed and offers more accuracy. The exact adjustment possibility of the Hybrid Trumpet Punch by Dr. Devroy can be specially regulated via software.
The best solution for extraction is probably a low rotation with a low angle of inclination, which starts at about 60 degrees. At the same time, the new tool has an external angle of 90 degrees, which allows the punch to easily penetrate the surface of the skin. After the punch has penetrated the subcutaneous tissue, the blunt punch with its trumpet-shaped tip is used to separate the hair follicles from the soft tissue environment without causing injury. The tissue is not incised as with conventional punches, but rather dissected so that the grafts in the soft tissue cannot be destroyed. Because of the blunt and outward shaped tip, the punch basically moves away from the hair root instead of cutting it. While sharp punches penetrate tissue like soft butter, the Hybrid Trumpet Punch allows the follicle to slide into the inner punch lumen. Due to the trumpet-shaped structure of the punch, the follicle can therefore be “sucked in” almost unharmed and separated from the remaining tissue. The subsequent extraction of the hair follicle with one or two tweezers by the doctor follows the usual routine of an FUE hair transplant.
The goal: Injury-free extraction – Higher extraction density – Preservation of natural hair root components
The manufacturers of this technique have made it their business to use the advantages of the FUT method (strip extraction) for the minimally invasive FUE technique. The more available skin tissue (“connective tissue”) around the hair follicle ensures that the hair follicles are more protected during strip removal.
With the trumpet-shaped removal version of the Hybrid Trumpet Punch, the individual hair follicle can be removed from the tissue environment while retaining all its natural components. As a result, more tissue remains around the hair follicle while minimising the transection rate. With the Hybrid Trumpet Punch, the rotational movement is only applied to the epidermal tissue. This avoids traumatisation or extensive destruction of the hair follicles in the immediate surrounding area.
According to the current state of development, cutting through the tissue with the highest developed degree of sharpness (sharp punch approach) no longer sets the absolute standard. Rather, this approach aims to retain and extract the complete structure of a hair follicle. The shape of the precision punch gives it a striking opening, which could have a promising future in hair surgery. With little assistance from hybrid drive, ultrasound, etc., the removal process is accelerated without the otherwise dreaded consequences of electronic punches. Therefore, this type of development can also be attractive for doctors who have so far only extracted manually and even have great experience with this, such as low transection rates in patients in whom the extraction has so far been extremely difficult and in whom, despite great know-how and years of FUE experience, this has resulted in higher transection and thus only a higher proportion of single hair grafts could be obtained and this has thus lowered the graft/hair count. In addition, less fatigue due to the elimination of manual rotation and higher extraction volume in a shorter time (time saving = more grafts can be transplanted per day).
Furthermore, the more connective tissue around the grafts/follicles probably also benefits doctors who are less experienced with FUE, or hair transplant clinics where certain surgical steps (such as graft order, grafts, graft insertion, etc.) are basically delegated to assistants.) are delegated to assistants (which is common practice, even with renowned hair surgeons/clinics), which can reduce the risk of damaging the grafts/follicles due to technical errors (also errors due to overtiredness/inexperience).
Another issue that needs to be monitored just as closely, however, is how it relates to scarring in the donor, due to the new blunt trumpet-shaped punch approach as opposed to the sharp punch approach.
Hairforlife will certainly continue to monitor the development of FUE!
Andreas Krämer Hairforlife/Expert Editorial Team