67 Newer Systems and Methods for Follicular Unit Excision
Summary
Keywords: 4D FUE Mamba WAW FUE system hybrid punch touch activation punch vibration FUE motor touch screen controls latest technology new FUE devices
Key Points
•The 4D follicular unit excision (FUE) device uses preprogramed rotational movement that starts when the graft touches the skin. The punch advances by a mechanical piston movement rather than by hand force, reducing repetitive trauma injury and decreasing operator error.
•The WAW device uses a flat punch with a cutting edge 90 degrees to the flat anterior-facing surface of the punch. A key characteristic of the system is the ability to use short arc oscillation whose speed can be varied manually with a sensitive foot pedal during the punch process.
•The Mamba system uses gentle suction as well as a programmable multiphasic motor that allows for preprogramming different punch modes (such as rotation, oscillation, vibration, and Mamba modes) during different parts of the punch process. The Mamba system uses three innovative punch designs.
•The UGraft system provides inline irrigation through the punch. This irrigation can lubricate the grafts to decrease friction and transection, flush out grafts stuck in the handpiece, and keep the surgical field clean of blood.
67.1 The “4D” Follicular Unit Excision System
The 4D follicular unit excision (FUE) system was conceived by Dr. T.K. Shiao.1 A traditional FUE punch is a rotating tube with a cutting end that creates circular wound as it enters the scalp. Typically, the physician operator manually advances the punch, to encompass and separate a graft from its surrounding tissue. Out of concern over repetitive stress injury that may result from harvesting, thousands of grafts during FUE hair transplant procedures, Dr. Shiao started a project in 2011 to build a handpiece that would automate the punch movement process.
A breakthrough came in 2013 when he discovered Arduino, a prototyping microcontroller that made processor-controlled devices easier to build. In 2013, the author also acquired his first 3D printer. With these tools, he was able to create a handpiece that introduced multiple preprogrammable controls over the depth, timing, and movement of the punch (Fig. 67.1).
Fig. 67.1 Picture of the first 3D printed handpiece.
67.1.1 Properties of the 4D FUE System
•Touch activation: The punches only rotate upon “activation” of the cutting process, which occurs when the punch touches the scalp (touch activation).
•Piston mechanism for punch advancement: The punch advances with automatic pistonlike action rather than axial force from the operator. This piston action is unique to the 4D handpiece. All other devices require the axial force created by the operator.
•Preset programmability: After a preset time delay from touch activation, the punch spins at a preset rotation speed and advances in a piston action to a preset depth before it stops and withdraws to its resting position. Furthermore, the operator can set parameters so that the punch rotates at a higher speed for the initial part of its advancement, then automatically reduces to a lower rotation per minute (RPM) for the deeper penetration. Higher speed is desirable to cut the harder surface of the epidermis, but undesirable in the softer dermal and fat layers of the skin. The functions that can be preset and programed on a touchscreen (Fig. 67.2) are listed in Table 67 1.
Table 67.1 Functions that can be preset and programmed with the 4D follicular unit excision system
•Touch activation |
•Time lapse between the punch touching the scalp (touch activation) and when it starts rotating |
•Initial punch speed rotation (faster to get past epidermis) |
•Insertion depth at the initial punch speed rotation |
•Secondary slow punch speed rotation |
•Total depth of insertion |
•Speed of punch advancement |
Dr. Shiao stated that the result from his first procedure using this device stunned not only himself but also his nurses. They had never seen so few transected follicular units from him before, His excision rate also increased. The device made it easier to line up the punch with the hair. He was able to use his nondominant hand and novices who tried it were able to punch grafts with acceptable transection rate from the first attempt.
67.2 Mamba Follicular Unit Excision System
67.2.1 Overview
The Mamba device was created by Trivellini (Fig. 67.3a). The name came from Dr. Trivellini’s son who said that his very fast and short punch movement reminded him of the black mamba snake. The system has many unique characteristics, but the most distinguishing characteristic is its ability to provide programmable multiphasic modes of dissection during the punch process. This and other characteristics, such as unique punch designs, the use of “gentle” suction, a useful touch screen, long hair modes, etc., have made it an important new device in hair transplant surgery.2 The Mamba employs several innovative punch designs such as the flared, edgeout, and long hair described in Chapter 54, Punch Designs.
Fig. 67.3 (a) Picture of current Mamba device and screen controls. (b) Picture of current Mamba handpiece connected to suction. If desired, punch can be adjusted in length in the handpiece to adjust length.
67.2.2 Properties of the Mamba FUE System
•“Gentle” suction: Although the Mamba uses suction, it is not in the same category as other “suction-assisted” devices (such as SmartFraft or Neograft) because the Mamba suction is much gentler and not intended to remove the grafts from the skin and transport them to a holding canister. See Chapter 65, for a discussion on true suction-assisted machines. Rather, the gentle suction of the Mamba is only intended to stabilize initial engagement, as well as pull the epidermis slightly into the punch lumen to assist with initial scoring of the skin. It also plays a role in touch activation (Smart React) as will be described below (Fig. 67.3b).
•Touch activation (Smart React): The punch process can be initiated either manually by depressing a foot pedal or automatically (Smart React) when the punch is placed in contact with the skin, creating a vacuum seal and negative pressure. Once the negative pressure reaches a threshold, it triggers, the preprogrammed punch process. The latency between touching the skin and starting the punch process can be adjusted by the operator.
•Programmable multiphasic modes of dissection: The skin density changes as one moves from the epidermis to the less dense dermis and, finally, to subcutaneous fat. In addition, skin and hair vary from patient to patient. Having the ability to select and change the mode of dissection at different points during the punch process offers the greatest ability to address all circumstances . The Mamba device allows switching between various modes of dissection at different points in the punch process. One can use rotation, oscillation, vibration (fast short-arc oscillation), and/or proprietary Mamba (asynchronous roto-oscillation) modes. Mamba mode creates vibration. One can fully adjust the speed of rotation and the arc and frequency of oscillation. The fast short-arc osculation creates a gentler vibration, while the Mamba mode creates a stronger, shakylike vibration that is felt to loosen the graft from surrounding tissue and make extraction easier. Three separate modes can be preprogrammed to occur sequentially and last different length of times during the punch process. A touch screen is used for preprogramming and presenting feedback data such as number of attempts, procedure time, etc. For example, one may program a short burst of fast rotation to get through the epidermis, followed by slower oscillation to more gently cut through the dermis, and ending with a brief Mamba mode to loosen the graft, making extraction easier. Many variations are possible and one of the benefits of these devices has been learning that has occurred by physicians sharing their combinations of experience in different patients (Fig. 67.3a and Table 67‑2).
•Punches: The Mamba device will fit most punches, but the company has developed a few punches specifically for their machine. These are the flair, edge-out, and ring punches. The properties and differences in these punches are discussed in Chapter 54, Punch Designs, and will not be repeated here except to say they fall in the category of hybrid punches with more laterally directed cutting edges plus modifications of the angle and width of the internal bevel.
• Punches are available in 0.70-, 0.80-, 0.90-, and 1.0-mm true external cutting diameters. The Mamba device has the ability to adjust the punch length in the handle to control depth control.
•Long hair follicular unit excision: The Trivellini device has been modified to create a long hair punch to allow for long hair FUE harvesting. The punch tip is made up of a blunt section (~70% of the surface) and a sharp section (~30% of the surface; Fig. 67.4a). The blunt section contains four micro-openings of 0.25 μm, which will catch and drag the hair away (and protect it) from the sharp section of the punch. The gentle suction provided by the machine may assist with the hair finding its way into these micro-openings. With hair safely guided into the blunt channels, the punch can be advanced to excise the follicle. Only oscillation can be used for long hair FUE to prevent the hair from winding around the punch. The Trivellini device possesses a novel alignment function that returns the punch to a preset rest orientation degree (e.g., the sharp edge always returns to 0 degrees) allowing the surgeon to know which side of the punch to use to gather the hair shaft (Fig. 67.4b; see Video 67.1a for demonstration of Trivelllini device; and Video 67.1b for suggested settings for beginners.
Related posts:
The Patient with Minimal Hair Loss: Planning and Decision-Making
Hair Anatomy and Histology for the Hair Transplant Surgeon
Plugged in: How to Ensure That Your Practice Thrives (and Survives) in Today’s DigitalWorld
Transplanting into Areas of Cicatricial Alopecia
Special Considerations for Postoperative Care in Follicular Unit Excision
Hairline and Recipient Area Repair of Poor Previous Transplantation
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