In discussing the use of technologically sophisticated surgical instruments, the discussion should be in the context of the skill and experience of physicians who use the instruments. No matter how sophisticated the instruments, the outcome of a surgical procedure is likely to be better for physicians who are skilled and experienced in performing the procedure. Sophisticated instrumentation may improve operative time and efficiency, but cannot replace skill and experience.
The Manual Punch
The manual punch—a circular hollow scalpel with a diameter of 0.7 to 1.0 millimeter—is the original FUE instrument.
The punch is placed over the visible portion of a follicular unit’s hairs, and pressed downward with manual rotation to incise the skin around the FU and free it from surrounding tissue. The FU is then extracted by traction with forceps. If the procedure is successful, an anatomically complete FU is made available for transplantation. The unanticipated complication of transection can damage one or more follicles in the FU in the process or incising or extracting.
A FUE session to obtain enough FUs for transplantation can require several hours of close and careful work by the physician hair restoration specialist. A FUE session using manual instruments may harvest fewer than half of the follicles obtained by strip harvesting.
Improvements have been made in the manual punch over the years—e.g., reducing the punch diameter to reduce the size of the circular scar and thus lessening potential for visible postoperative scarring.
Technological Evolution in FUE Instruments
Technology-minded inventors—frequently physician hair restoration specialists—turned to technology to improve the FUE procedure by improving FUE instruments. The aim of such improvements is always to give the physician hair restoration specialist an instrument that makes the procedure faster, less physically demanding, and safer in terms of decreasing potential for FU transection.
Efforts to improve FUE instruments began with changes in manual instruments, went on to mechanize portions of the procedure, and most recently introduced a robotic FUE system.
Another variation on the manual FUE instrument is the RotoCore device, which automatically rotates the sharp FUE punch as it incises skin around the FU. This relieves the physician of the necessity to physically rotate the punch to make the circular incision around the FU. The device also allows the physician to pre-set the punch to cut to a selected depth.
Cole Isolation Technique
The Cole Isolation Technique (CIT), also called Follicular Isolation Technique (FIT), requires the use of instruments designed especially for this technique. The rationale for CIT is to selectively isolate and extract intact a single FU at a time, along with elements of its micro-environment. Proponents of CIT can cite data showing that the technique can improve physician efficiency, and in skilled hands can equal strip harvesting in numbers of FUs harvested per session. Proponents of CIT differentiate the technique from FUE on the basis of rationale and technique.
The SAFE System
A three-step manual process called The SAFE System is meant to reduce potential for transection. It uses a sharp circular punch to incise skin around the FU, then a blunt circular punch to loosen the FU from surrounding tissue, a step that is meant to lessen potential for sharp transection. The third step is extraction.
The Feller Instrument
The Feller FUE instrument combines the essential FUE procedures into a single instrument—i.e., isolation, incision, extraction. The use of a single instrument is designed to help physician hair restoration specialists work faster and more efficiently.