I've noticed that some docs use ~.7 (e.g.) custom blades, whereas others utilize .9-1+ (e.g.)custom blades. Is it logical to follow the intuition of "the smaller the better"?

Doctor skill always reigns paramount when discussing something like this, or loupes/scopes, but assuming doctors of "equal" ability, is there any reason why smaller blades/incisions is not optimal? And, are there actual attributes for using the larger blades like I referenced (other than, perhaps, it is easier for a doc...which isn't to say that is the worst thing in the world)?

thanatopsis,

In my opinion, the surrounding tissue on each follicular unit should be trimmed as much as possible while preserving the integrity of the follicular unit. Some of the surrounding tissue needs to be preserved however, elite physicians who regularly use ultra refined follicular unit "skinny" grafts have proven to get high growth yield and a greater ability to dense pack.

The number of hairs per follicular unit also plays a significant role in the size of the blad needed. Surgeons who regularly make .7mm incisions do so for single hairs. In many cases, even surgeons using ultra refined methods will use up to 1.1mm or 1.2mm for the larger 3 and 4 haired follicular units. I'd have to see it to believe it if a surgeon tells me they can fit a 3 or 4 haired follicular unit into a .7mm incision.

It's highly important for grafts to fit perfectly into recipient incisions. The fit should be "snug", but not forced. A forced fit often results in "popping", and as a result, cobblestoning. That's why not only the size, but the depth of the incision is vital.

Larger incisions create a greater risk for scalp trauma and eliminates close graft proximity (dense packing).

Hair charateristics will also play a role in the size of the graft, and thus, the size of the incision.

Custom cut blades in my opinion are ideal because you can cut the blade to meet the needs of the patient.

Best wishes,

Bill (Falc)

Ahh, makes sense; thx for the pointed answer!

Thana you knew the answer .
You just want to get this months trophy for the new topic starter.

Great answer on Falc's part. .7mm is for singles whereas larger grafts will need larger incisions.

PGP, either I plead myself ignorant or I cop to tinkering with the the monthly HTN elections...not good either way!

Good thread guys, right on. Sometimes it's best to use a larger blade to accommodate families to create density, like the forelock area or behind the hair line. Other times it's best to not use a blade, and use a solid core needle instead like when working to increase density in a diffuse thinner with a lot of remaining hairs.

quote:

PGP, either I plead myself ignorant or I cop to tinkering with the the monthly HTN elections...not good either way!

quote:

Thana you knew the answer .
You just want to get this months trophy for the new topic starter.

Honestly, I thought it was a great question! I think I'll add this thread to the frequently asked questions section.

Best wishes,

Bill (Falc)

Thanatopsis_awry:

The answer to your question is that sometimes smaller blades are more optimal, and sometimes not. It depends on many factors. What is more important then the size of the blade is how the Follicular Unit fits in the incision. The graft should fit snugly, but not too tight to cause compression. Also, the incision size should be such that the FU grafts can be planted into the skin with as little trauma as possible. The texture and thickness of ones skin and the size of the graft determine what size blade should be used to make the incisions. Some patients have tough, non-forgiving skin that does not have much stretch to it. In these patients I would usually cut my blades a bit larger. Some patients have follicular units which splay at the bottom. I find they get squashed a bit if the incision size is too small and I have to use larger incisions for this type of FU. A person who has thin blond hair will have much smaller FU's then a person who has thick, black hair. Persons with very curly or kinky hair will have a curve to the FU and will need larger incisions. Also, a FU with 4 hairs will be larger then a one hair FU and will need a larger incision to fit properly.

At Shapiro Medical Group we cut our blades and they usually range in size .6mm to 1.2 mm. On average we use a .7 or .8 mm blade when we are making incisions for the one hair FU in the hairline. For the 2 hair FU we usually use .8 to 1.0 cm. For 3 and 4 hair FU we usually use .9 to 1.2cm blades.

What I do is estimate what size blade I will need for a 1,2,3, and 4 hair FU. Then I make about 10 incisions and place some FU's into the incision. Sometimes the fit is perfect. Sometimes I need increase or decrease the width of my blade. I would say that in half my patients I use a .7mm blade for my one hair FU's. The other times I use a .8 and sometimes even a .9mm blade. Very rarely I have used a .6mm blade for one hair FU's.

The smaller blades are great. We can make incisions closer together when we want to do dense packing. In patients with existing hair in the area of the transplant, the smaller the blade the easier it is to get between the existing hairs. Also, the smaller the blade, the less trauma there is with each incision. But also the smaller the blade, the more chance it will be difficult to place the FU without any trauma.

So as you see, ONE SIZE DOES NOT FIT ALL.

I hope this answers your question

Dr. Paul

The answers above by Falceros and Dr. Paul Shapiro are excellent and I agree with everything they have said.
I just wanted to add that a very important factor in blade size (or needle size) selection is the COARSENESS of the hair (the hair shaft diameter). Very fine 1-hair FU's can be placed into 0.6mm blade incisions, whereas coarse ones require a 0.8mm one. Same goes for 2-hair and 3-hair FU's. The blade width is significantly larger for these grafts when the hair is coarse.
And one more factor that is significant. Some patients have FU structures in which the hairs are very straight, parallel to each other, and situated "tightly" together. Other patients have what we term "teepee-ing" of the grafts, with the hairs curving off from each other in various directions. This affects what size blade is chosen also.
Mike Beehner, M.D.

Extremely informative!

It's great to see some of our quality doctors also offer their input on this important topic.

Thanks Dr. Shapiro and Dr. Beehner for your contributions.

Best wishes,

Bill (Falc)

Great responses by Drs Shapiro and Beehner, and Falceros.

Blade size is the one area that most men can agree that bigger is not always better.

The issues Falceros brings up about snuggness/popping are right on. You want the smallest slit to gently accomadate the graft such that when placing the next door neighbor graft, the first guy doesn't pop out.

The one thing not mentioned above though is bleeding. The smaller the hole, the less the bleeding. And it is not a 1:1 ratio either. For example a 0.7mm slit bleeds well more than half as little as a 1.4mm slit--I would guess it is 3 or 4 times less. Now its not blood loss that is the problem, rather it is visualization of the area, AND localized swelling of the transplant area. With smaller slits, the entire surgical field stays cleaner, and less swolen, letting placement occur efficiently and speedily.

Dr. Lindsey McLean VA

Great points,

We need to have more of these discussions on this forum where the hair transplant surgeons can share their experiences.

I don't use custom blades in my practice. I either use 20 gauge needles for frontal hair line or 18 gauge needles for the grafts with more than one hair behind the hairline.

I believe solid wire needles have the smallest risk for transecting existing hair, so I use them especially when I am transplanting in a previously transplanted area or when I have to go between remaining native hair.

Since Dr. Mohebi mentioned needles and this thread is about the size of the instruments creating recipient sites, I thought I'd offer a conversion chart from gauges to diameter in inches and MM.

Conversion of Needle Gauges to Diameter

Gauge Size - Inch Equivalent - mm Equivalent

13 - 0.095 - 2.413
14 - 0.083 - 2.108
15 - 0.072 - 1.829
16 - 0.065 - 1.651
17 - 0.058 - 1.473
18 - 0.049 - 1.245
19 - 0.042 - 1.067
20 - 0.035 - 0.889
21 - 0.032 - 0.813
22 - 0.028 - 0.711
23 - 0.025 - 0.635
24 - 0.022 - 0.559
25 - 0.020 - 0.508
26 - 0.018 - 0.457
27 - 0.016 - 0.406

Best wishes,

I generally agree with what was discussed above.

However, many patients that I see have a HUGE concern that they will look pluggy. We do alot of singles just to avoid that. We do doubles and some triples, but rarely anything bigger.

Using a gardening analogy, follicular units are alot like dandilions or clovers. You see them in clumps and in 1s 2s and 3s. I rarely see a group of 4 buttercups for example. Same with hair. When I take the strip, I don't see a group of 4 very often.

So unlike most manly things, with hairline blades, smaller is better. We custom make our blades AFTER seeing the size of the grafts.

Lastly its counter-intuitive. It is actually easier to place into smaller slits packed closely together. There is less bleeding and less popping. As I place alot of our grafts, I say that with first hand knowledge on placement.

Dr. Lindsey McLean VA

It is nice to have options, occasionally I employ cut to size blades especially in the patients with advance stage hair loss and little remaining hair. As I stated previously, the solid core needles, are very useful in creating sites between existing hairs, since the only part that can cut the follicle is the point, once pass this sharp point the needle shaft is blunt and will not transect the hair. When carefully introduced between hair follicles the needle wedges between the follicle creating the site without damaging the adjoining follicles. Dr. Mohebi, I too employ solid core 21g, 20g, 19g and 18g needles a lot, what a great value they are too. Dr. Lindsey, while the size is getting most of the attention, it is not all that matters. As a matter of fact, equally important is how deep. Dr. Arnold designed his Minde blades with this in mind. It is pivotal that the depth be controlled to prevent injury to the microvasculature, which lies below the follicles. When not using Minde blades I use my finger to minimize the depth of the incisions.

Smaller = Better