Sequential Technique (DES)
Sequential Method: The Preferred Extraction Method By Dr. Koray in
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
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
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
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
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
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.