Sequential Technique (DES)


Sequential Method: The Preferred Extraction Method By Dr. Koray in
FUE Surgery

The patient is in a sitting position and the surgeon is either
standing or in a sitting

position. The surgeon holds the punch and forceps in both hands at
the same time. The

non-dominant hand penetrates by punch under the control of the
pointing dominant

hand. The first penetration is perpendicular to the skins surface in
order to obtain a

clean circular cut by an axial pushing force with a semi circular
rotation. After passing

through the epidermis, the position of the punch is adjusted
according to the follicle

direction. The dominant forceps hand one graft at the time of rapid

accomplishes sequential harvesting. This is to provide an
opportunity to control the

transection and graft quality each time, also adapt the punch size
or angle to the

changing diameters and directions.

Why is the patient in a sitting position?

Since the original single follicles for leading frontline are
pre-dominantly located in

the temporal zones, the sitting position utilizes smaller punch
sizes. The punch

direction can be adapted according to the angle of the follicle.
This allows both the

patient and physician with better comfort than the other positions.
It is evident that the

follicles are sometimes at different angles. The sitting position
enables the physician

to adapt and better pin-point the graft more quickly.

In a sitting position, the physician can access long hair donor
photos during the

extraction to effectuate a better harvesting plan while another
physician can

simultaneously perform extraction opposite sides.

Why is the first penetration perpendicular to the skins surface?

Attempts are being made by all to minimize punch diameters without
damaging graft

quality thats creating smaller scars on the donor area. If
penetrations occur at the

perpendicular angle to skin surface, the smallest perfect circuit
cut is obtained within

the boundaries of the punch size used. Angle changes incurve an
elliptical scar.

According to penetration angle you will get a bigger scar than a
circle. This is not

exactly an elliptical shape, but to make calculations easier we can
accept it as an

ellipse. If we use the known formula: with 60 degree angle, we will
get a 1.15 times

larger scar. With a 45 degree angle, 1.4. with a 30 degree angle we
will have a scar 2

times larger. In fact, because of the increase of the wound length,
we will have

bigger scars than an elliptical shape. Consequently a right angle
will minimize the

patients scarring.

Why sequential extraction?

Because every follicle has a different direction to the determined
by the actual

location of the donor area. Additionally, the follicle becomes
closer to the skin surface

in a vertical direction from top to downwards. If a transection rate
or graft quality is

properly controlled then the best method to accomplish this is to
check each and every

graft after each penetration. Once a transection has been
established, the penetration

angle of the punch can be adapted easily.

Article by
Istanbul Hair Restoration Surgeon