Selection and Comparative Analysis of Different Surgical Approaches in Modern FUE Techniques

I. Course Introduction

This course aims to systematically review the principles, instruments, pros and cons, and application scenarios of various planting methods in FUE (Follicular Unit Extraction) hair transplant surgery. This will help clinical doctors more accurately select and combine different techniques to achieve optimal clinical outcomes. The content will cover the background of hair transplantation, a brief history, a comparison of follicular extraction methods, and will focus on analyzing the operational details and clinical considerations of the Sapphire Blade Punching and Planting Method, Micro-needle Implantation (Instantaneous Implantation), and Implanter Pen Method (Continuous Implantation).

II. Overview of Hair Transplant Technology and Market Background

1. Hair Loss Status and Trends:

• The annual growth rate of hair loss patients is as high as 15%-18%.
• The trend towards a younger demographic is evident: 60% of males show signs of hair loss before age 25; the rate of hair loss before age 30 is as high as 83.9%. In clinical practice, an increasing number of young people, such as university students, seek medical attention for severe hair loss.
• Globally, more than 220,000 patients undergo hair transplant surgery annually (early data, current figures are likely higher).

2. Main Types of Hair Loss:

• Androgenetic Alopecia (AGA), also known as seborrheic alopecia or hereditary hair loss, is the primary indication for hair transplant surgery.

III. Brief History of Hair Transplantation

1. 1800: Animal autologous hair transplantation experiments, pioneering explorations in hair transplantation.
2. 1933: Japanese dermatologist Dr. Okuda invented the punch graft technique using scalp composite tissue flaps, first applied clinically for alopecia treatment.
3. 1959: Dr. Norman Orentreich performed autologous hair transplantation using standard 4mm punches and proposed the famous “Donor Dominance Theory.” This theory explains that transplanted occipital dominant follicles retain their original non-shedding characteristics in the recipient area, forming the cornerstone of successful hair transplantation. It can be used to treat male pattern baldness, sparse eyebrows, sparse eyelashes, and body hair loss.
4. 1995: Dr. Rassman pioneered FUT (Follicular Unit Transplantation). The FU (Follicular Unit) became the basic unit for follicle separation and implantation. FUT technology was hailed as the “gold standard” in hair transplantation, marking the entry of hair transplantation into the era of refined follicular unit transplantation. Early follicle extraction involved obtaining larger hair tufts, whereas follicular units typically contain 1-3 hairs (most commonly 2 hairs/unit).
5. 2001: Dr. Rassman further proposed the FUE (Follicular Unit Extraction) theory. With the maturation of FUE technology, hair transplant surgery has gradually moved towards minimally invasive, no-scalpel procedures. Currently, most patients opt for FUE technology.

IV. Comparison of Follicular Extraction Methods: FUT vs. FUE

Feature	FUT (Follicular Unit Transplantation)	FUE (Follicular Unit Extraction)
Surgical Scar	A linear scar will remain in the occipital region, but if sutured meticulously, the scar can be well concealed.	Dot-like micro-scars; if extraction density is reasonable and punch diameter is small, marks are inconspicuous (formally termed “stealth scar hair transplantation”).
Follicle Collection Volume	Larger, can reach 4,000 follicular units or more.	Initially smaller (around 2,500 units), now with mature technology, can also reach 4,000-5,000+ follicular units.
Collection Sites	Mainly the dominant donor area in the occipital region.	Occipital dominant donor area, as well as submandibular beard hair, body hair, and other broader areas. Beard hair provides good scalp coverage and has a high survival rate.
Surgical Time	The surgeon’s strip extraction is fast (about 20 minutes), but subsequent dissection by technicians is time-consuming.	Initially considered time-consuming, but with advancements in technology and instruments (e.g., extraction devices with adjustable speed and direction), skilled surgeons can also complete it efficiently.
Indications	Traditionally suitable for large-area hair transplantation or scenarios requiring a reduction in the surgeon’s extraction time.	Initially suitable for small volume extractions, now widely used for large-area transplants as well, due to technological maturity.
Regional Preference	Still a common choice for Caucasians in Europe and America due to less visible scarring.	Preferred by Asians due to concerns about scarring.
Dissection Difficulty	Technicians need to first slice the scalp strip into thin sections and then finely dissect follicular units, a relatively complex process.	Technician’s operation is relatively simple; mature technicians can quickly and accurately dissect already extracted follicular units.

V. Basic Concepts of Follicle Implantation

Follicle implantation refers to the process of extracting healthy follicular units from the occipital region (or other donor areas) using microsurgical techniques, meticulously separating them, and then transplanting them to areas requiring hair, allowing them to regrow.

VI. Comparison of Different Planting Methods in FUE Hair Transplantation

Currently, common FUE implantation methods are mainly divided into three categories (naming may vary among institutions, but core techniques are similar):

1. Sapphire Blade Punching and Planting Method (Slit Grafting Method)
2. Micro-needle Implantation Method (Instantaneous Implantation / Stick-and-Place Method)
3. Implanter Pen Method (Continuous Implantation Method)

(A) Sapphire Blade Punching and Planting Method

1. Concept and Instruments:

• Operational Flow: The surgeon first uses a sapphire blade to create recipient sites (incisions) in the planting area, and then implanters or the surgeon use implantation forceps to insert the follicles into these sites. It involves two steps: site creation and implantation.
• Core Instruments:
  • Sapphire Blade: The blade tip is mainly composed of aluminum oxide (Al₂O₃, also known as sapphire). It possesses physical and biological advantages such as high hardness, thinness and sharpness, high density, no burrs, non-staining, non-metallic (does not rust), and good biocompatibility. The incisions created are extremely fine and neat, causing minimal tissue damage, low friction, less bleeding, fast recovery, small scars, and a natural appearance. Its disadvantage is high brittleness, making it prone to breakage, requiring special care during cleaning and operation.
  • Implantation Forceps: Commonly used are straight forceps and curved forceps (or angled forceps). Different operators have different preferences, often holding a straight forcep in one hand and a curved one in the other for coordinated operation. Early on, general microsurgical forceps were used, which were longer and caused fatigue; now, shorter blue-handled implantation forceps designed specifically for hair transplantation are available, making the operation more comfortable.

2. Advantages:

• Sharp and Smooth Blade Tip: Incisions are clean and facilitate healing and implantation.
• Good Biocompatibility: No metal residue, does not rust.
• Precise Incisions, Skin Not Easily Deformed: The sapphire blade is sharp, exerting minimal pressure on the skin, which prevents “pop-out” (dislodgement) of already implanted follicles. Suitable for high-density site creation.
• Fast Incision Speed: Skilled surgeons (e.g., 3-5 incisions per second) can significantly shorten the site creation time, improving surgical efficiency.
• Fixed Blade Length, Easy Depth Control: Incision depth is accurately controlled, ensuring high safety and preventing injury to deeper tissues (like the periosteum).
• Surgeon-Led Site Creation, Overall Control: The surgeon designs and executes site creation, allowing full control over the width of the planting area, hair direction, density transition, and other key factors, ensuring the surgical outcome aligns with the design concept. This is a core advantage for ensuring surgical quality.
• Wide Applicability: Suitable for various hair transplant institutions, especially for scar tissue (harder texture) transplantation, where its sharpness is advantageous.

3. Disadvantages:

• Higher Cost: Sapphire blades are expensive (early on, a single blade with handle could cost over a thousand RMB).
• Fragile Material, Prone to Damage: Easily broken, requires care during storage and use to avoid impact.
• Limited Incision Angle: Typically creates incisions perpendicular to the scalp surface, making it difficult to form complex curvatures.
• Increased Surgeon Labor Cost: Site creation is performed by the surgeon, which, compared to methods entirely performed by nurses, increases labor costs.
• Slits Heal Quickly, Potential for Missed Sites Intraoperatively: Site creation and implantation are separate steps. Early-made sites may close or become difficult to identify due to tissue elasticity and bleeding, leading to difficulty in finding sites and potentially missed sites.
• Multi-Step Process, Increased Surgical Stages: Site creation and implantation are two steps, making the overall workflow longer compared to integrated methods.

(B) Micro-needle Implantation (Instantaneous Implantation)

1. Concept and Instruments:

• Operational Flow: Uses specialized implantation needles or medical syringe needles to implant the follicle simultaneously with site creation, i.e., “instantaneous implantation” or “stick-and-place.” Site creation and implantation are completed in one step.
• Core Instruments:
  • Implantation Needle/Micro-needle: Mostly fine stainless steel needles or disposable syringe needles. Common diameters include 1.2mm, 1.0mm, 0.8mm, 0.6mm, and even 0.45mm (No. 4.5 needle).
  • Common Syringe Needle Specifications (colors correspond to different specs, may vary slightly by manufacturer):
    • Pink: 0.9mm (standard model, commonly used)
    • Yellow: 0.9mm x 38mm (preferred by some teams, longer length may increase operational efficiency)
    • Purple (No. 5 needle): 0.81mm (suitable for eyebrow transplantation or single fine follicles in the front rows of the hairline)
    • Orange (No. 6 needle): 0.63mm (suitable for fine, soft hairs at eyebrow edges or other very fine areas)
  • Implantation Forceps: Assist in guiding the follicle into the needle or site.

2. Advantages:

• Stick-and-Place, Unlikely to Miss Sites: Implantation occurs immediately after site creation, avoiding the problem of finding sites and missed sites. Particularly suitable for加密 (densification) planting.
• Can Be Performed by Multiple Nurses/Implanters Simultaneously: 1-3 nurses can operate at the same time, distributing the workload, shortening surgical time for large-area transplants, and reducing surgeon labor costs.
• Low Cost, Needles Can Be Frequently Replaced: Syringe needles are inexpensive (a few cents each), allowing frequent replacement to maintain sharpness.
• Precise Point-Like Incisions from Needle Tip: The needle tip creates a point-like incision, which is precise and causes relatively less damage to native hair, beneficial for densification.
• Elastic Metallic Material, Provides Dilating Effect: The needle exerts some pressure on the scalp, creating a temporary dilation. After the follicle is implanted, the scalp retracts, securing the follicle more firmly.
• Needle Can Be Bent Intraoperatively to Create Curvature: Suitable for eyelash transplantation or body hair transplantation requiring specific curvatures, allowing simulation of natural hair growth patterns.

3. Disadvantages:

• High Technical and Experiential Demands on Nurses/Implanters, Consistency Difficult to Control: Site creation and implantation are performed by nurses. Differences in experience, philosophy, and technique among operators can lead to inconsistencies in implantation density, direction, and depth, deviating from the surgeon’s design and affecting the final outcome. For beginners or inexperienced teams, surgical quality is difficult to guarantee.
• Micro-needles Wear Out and Dull Easily, High Consumption: Needles dull quickly and require frequent replacement.
• Needle Body is Thin and Long, Depth and Stability Hard to Control: Scalp elasticity varies across different areas, potentially leading to inconsistent incision depths.
• Relatively Small Incision Diameter, High Demands on Follicle Dissection: Micro-needles create circular sites, which are smaller than the slits made by sapphire blades, requiring technicians to dissect finer grafts, potentially increasing technician workload and trimming of follicles.
• Higher Requirements for Transplanting Fine, Soft Hairs in Special Areas: Requires even sharper needles and more precise size control; too large can lead to dislodgement, too small can damage the follicle.

(C) Implanter Pen Method (Continuous Implantation)

1. Concept and Instruments:

• Operational Flow: Assistants (nurses) load dissected follicles into the needle of an implanter pen. The operator then inserts the implanter pen into the scalp and activates a mechanism to complete site creation and implantation. This allows for continuous implantation.
• Core Instruments:
  • Implanter Pen: A pen-shaped device with a replaceable grooved or hollow needle at the tip and a plunger mechanism at the back. Available in various sizes to accommodate follicles of different thicknesses.

2. Advantages:

• Relatively Simple and Easy to Learn: Beginner-friendly, easy to master.
• Site Creation and Implantation in One Step, Unlikely to Miss Sites, Precise Placement: Similar to micro-needles, but follicles are pre-loaded into the pen.
• Straight Implantation Channel, Protects Follicles: Follicles are protected within the pen’s core during implantation, reducing the risk of bending or damage.
• Suitable for Fine, Soft Hair Transplantation: Smaller diameter implanter pens can be selected.

3. Disadvantages:

• Requires Multiple Nurses for Loading, Increasing Labor Costs: Nurses loading follicles into implanter pens is time-consuming and labor-intensive.
• If Implantation is Done by Nurses, Design and Operational Experience May Be Lacking.
• High Instrument Cost, Tips Dull Easily, High Consumption: The implanter pen itself and replaceable tips are more expensive than syringe needles. Tips dull easily, and frequent replacement during large-area transplants increases costs. Some believe implanter pen tips significantly lose sharpness after one use and should not be reused for multiple surgeries.
• Tips Cannot Be Bent, Difficult to Create Curvature: Fails to meet the needs for special angle implantation.
• High Demands on Follicle Dissection, Increasing Dissection Costs: Due to the fine nature and inherent thickness of the implanter pen tip, more meticulous follicle dissection is required.

VII. Intraoperative Auxiliary Instruments and Materials

1. Follicle Extraction Punch: Punches with side holes are recommended. If a graft blocks the punch opening during extraction, the side hole allows easy removal with a needle tip, preventing extraction difficulties due to negative pressure siphoning.
2. Retractable Sapphire Blade: The blade tip can be retracted into the handle, protecting the tip during sterilization and preventing puncture of packaging.
3. Silicone Ring Holder (Follicle Placement Tray):
   • Trays with central dividers: Allow for separate placement of single, double, and multiple follicular units, facilitating quantity tracking and enabling implanters to pick grafts as needed (e.g., single fine, soft follicles for the front rows of the hairline, double or multiple follicles for posterior areas to increase density and coverage).
   • Maintaining a low-temperature, moist environment for follicles is crucial.
4. Low-Temperature Plasma Sterilization: Some special precision instruments (like punches, sapphire blades) require this specific sterilization method.

VIII. Clinical Application Strategies and Summary of Different Planting Methods

1. Combined Use, Leveraging Strengths and Mitigating Weaknesses is the Core Strategy:

• Hair Transplantation: Primarily recommend Sapphire Blade Punching and Planting (e.g., for 70-80% of the graft volume), leveraging its high-quality site creation and surgeon’s full control over direction and density. Subsequently, Micro-needle Implantation can be used for densification and detail adjustment (for the remaining 20-30%), utilizing its instantaneous implantation, unlikelihood of missed sites, and suitability for densification.
• Eyebrow and Eyelash Transplantation: Micro-needle Implantation is more advantageous due to its bendable needle and precise point-like site creation. For eyelashes, although suture needle guidance was used earlier, micro-needle implantation has shown better results in recent years; the key is to master the implantation direction and curvature.
• Beginners or Institutions in Early Stages: The Implanter Pen Method can be an introductory choice due to its ease of learning and follicle protection.

2. Summary of Application Scenarios for Sapphire Blade Punching and Planting Method:

• High-density transplantation (low scalp resistance, easy to increase density).
• Scar tissue transplantation (high sharpness effectively incises hardened tissue, minimal mechanical damage).
• Pursuit of rapid healing, reduced trauma, and increased efficiency.

3. Summary of Application Scenarios for Micro-needle Implantation (Instantaneous Implantation):

• Private institutions with scarce surgeon resources or those wishing to delegate tasks to experienced implanters (nurses).
• Hair densification, effectively preventing missed sites.
• Fine transplantation for small areas with high morphological requirements, such as eyebrows and eyelashes.
• Training senior, mature nurse implantation teams.
• Marketing and promotion (the “micro-needle” concept is easily accepted by patients, perceived as less traumatic).

4. Summary of Application Scenarios for Implanter Pen Method:

• Beginners or for training new personnel.
• Hair transplant teams with ample staff, unconcerned about labor consumption for loading.
• Institutions in early stages, seeking easy-to-master techniques.
• Small-area densification (for large areas, costs are high, and tip consumption is significant).
• Transplantation of fine, soft hairs (utilizing its guiding and protective effects).
• Not suitable for technically demanding special areas (e.g., eyelashes, severe scars, high-density densification).

5. Flexibility of Final Choice:

• The choice and combination of implantation methods should be flexible, based on the patient’s specific condition (area of hair loss, hair quality, recipient site, scalp elasticity, etc.), the surgeon’s technical proficiency, personal preferences, and the institution’s operational model.
• Mastering multiple methods allows for individualized and optimized treatment plans tailored to each patient.