Is a punch size of 1.0 mm considered too large for FUE these days?

Question

One surgeon I met says he always uses 0.75-0.8 punches and anything beyond that is too large and unnecessary. The other surgeon says he uses 1.0 punches and his intention is to mostly remove 2-4 hair containing follicles for better density . From what I read these days on the internet, it seems like most HT surgeons now use 0.8-0.9 punches but a minority still use 1.0, which I understand also to be the current ARTAS's typical punch size? I have relatively coarse hair. Who should I go with?

Amir Yazdan, MD · Answer

The size of punch used differs from surgeon to surgeon. While it is personal preference, it is the common understanding among most certified and experienced hair transplant surgeons that the larger the punch size the higher the risk of scarring. I prefer to only use a 0.7mm punch to extract grafts. This greatly reduces the risk of scarring. Using this small of a punch, I am still able to extract follicles that contain 2-4 hairs. What I often see with doctors that prefer to use a larger punch, is that they prefer it for its ease, as there is a lack of experience and skill present. Additionally, the robots and devices that are utilized by some doctors to conduct hair transplant surgeries use these larger punch sizes. This is because a machine cannot be as precise as hand held extraction. The great thing about FUE is that there is minimal risk for scarring. Using a 1.0mm punch and larger negates the best thing about this type of surgery.Also, based on my experience there are VERY few doctors using 0.8mm punch and smaller.  Usually they never show the patients, they label the punches A & B during surgery so patient doesn't know the size, and they have no way of measuring the punch.  Take a caliper measuring device to your consultation and ask the doctor to measure his punch size (can be purchased on amazon for $15).  I can bet most doctors 0.8mm punch turns into a 1.2-1.3mm punch very quickly.  I make my own punches by hand and sharpen them with a laser.  I know exactly and accurately the outside and inside diameter of my punches and Im happy to measure them for patients so they can see.

Anil R. Shah, MD · Answer

Hello,Let’s clarify all of the information on the ARTAS robot.  Summary is that the ARTAS is the best tool to harvest hair grafts on the market.
The original ARTAS was slow and took as long as 1 hour to harvest 50 grafts!!  The original iPhone had a 2 megapixel camera and 4gb storage.Since then, the ARTAS is on its 9th version- called the 9x.  With this version, up to 1500 grafts can be harvested in 1 hour!!  The iPhone X has a 12 megapixel camera and a processing chip faster than a high end Macbook pro did in 2007.The point here is that not all robots are the same- it is a piece of technology that has been updated and improved over time just as your iphone has.  Not all robots are 9x (latest version) and their features will be quite different!!In my experience with FUE, the quality of the graft and the graft yield was low.  I believe most handheld FUE are probably in the 60% quality range rather than the 90% being reported.  With the ARTAS, our graft yield has been high 90s which is a huge difference.The ARTAS can actually make sites which is important in patients seeking higher density.  When the ARTAS makes sites it can avoid other hairs preventing 1 type of shock loss.The ARTAS as described is one important tool in the hair making decision.  In my practice, every patient receives regenerative technique (PRP or growth factors), because it makes the results so much better.  In some cases, miniaturized hairs can actually become terminal.  The quality of the hair is also better in our experience (using quantitative software with trichoscope, our data)Best Dr. Anil Shah

Jae Pak, MD · Answer

You should pick a doctor you trust over the size of their punch. It's how they use the punch, not the size of the punch that matters.Smaller diameter punch size logically leads to higher transection rate.  There has to be a balance between the size of the punch and the practicality of its performance.  The is no absolute rule or size in a highly variable surgery.

Michael Vories, MD · Answer

Except in cases of very curly hair (African-American), a 1.0 mm punch is much too large for extraction. Keep in mind a 1.0 mm punch is roughly double the size of a 0.8 mm punch.  This can lead to noticeable scarring of the donor area, which negates the purpose of FUE procedures.  To date robotic devices have not advanced to the point of using these smaller punches.

William Woessner, MD · Answer

It is the opinion of a few FUE clinics that a 1.0mm IS too large. At our clinic we hoover between a 0.8mm and a 0.9mm. We have never used a 1.0mm. The 0.9mm encompasses 99.9% of the follicles we extract and this includes the curliest or kinkiness follicular groups. We believe the use of the blunt punch adds to the low transection rate we have as well. The link below goes to our FUE page along with our actual FUE tool.

Sean Behnam, MD · Answer

1.0 is large but not unheard of, especially if you have unusually coarse/curly hair. I doubt it would affect the final result of your recipient area, but it would make the scarring in your donor area a little more pronounced. If scarring isn't a main concern you have and the doctor gets good results with hair types similar to yours, I wouldn't worry.

Matt Tahsini, MD · Answer

Thank you for the question. Most clinics use anywhere from .8mm to 1 mm, which are standard. The punch size varies patient to patient, and hair /skin texture is what should determine what size punch is the best for the patient and their outcome according to the quality of the donor region.

Sahar Nadimi, MD · Answer

In general, a small punch size will result in a smaller FUE scar. Likewise, larger punch will lead to a larger scar. Using a larger punch, however, will decrease the likelihood of hair follicle transection. For most individuals with straight hair, a smaller punch is possible. For individuals with very curly hair, however, one often needs to use a larger punch to decrease the chance of follicle transection. Bottom line: It depends on the patient's scalp and hair characteristics to determine which punch size will produce the best quality hair follicles with the smallest possible scar. I recommend following up with an hair surgeon experienced with FUE.

William Rassman, MD (retired) · Answer

The key is to use a punch size that gets out the largest follicular units with the most hairs that is intact and minimally strips off the distal fat. A good surgeon knows how to titter this and adjusts his punch size accordingly. Small unch size to minimize scar at the expense of the quality of the grafts misses the point. 
FYI:  I am  the modern day inventor of the FUE procedure, doing these FUE procedures longer than anyone in the US, dating back to 1995. I published the first article on FUE in 2002 and then the rest is history. I am also the patent holder inventor of two core technologies of the hair transplant robot, receiving two patents in the technology which eventually became commercialized.  I invented the robot because too many doctors failed to perform FUE successfully with the manual technique, which is somewhat the case today. I hold now 17 US patents on various hair technologies and publish in medical journals and medical textbooks extensively

Is a punch size of 1.0 mm considered too large for FUE these days?

Answers (9)

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