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A “Double Guns” FUE Method for Difficult Graft Extraction
Yes, and it is often necessary. Standard FUE protocols can fail when follicles are irregularly angled, deeply seated, or embedded in fibrotic tissue. The Sequential Technique provides a real-time, adaptive solution, allowing the surgeon to assess and adjust the depth and angle of extraction on a graft-by-graft basis to maximize yield in difficult zones.
The Sequential FUE Technique (originally the “Double-Gun Technique”) is developed to manage difficult extractions during FUE. Using two hands simultaneously—one to score the graft with a punch and the other to extract it with forceps—it allows for immediate visual feedback and adjustment, minimizing transection in challenging cases. This innovation was formally recognized and named by the ISHRS FUE Committee.
In 2008 we developed a meticulous technique using both hands to extract grafts simultaneously, a reminiscent of its namesake.
Positioning: The surgeon holds a motorized punch in one hand and fine curved forceps in the other.
Sequential Action: The surgeon scores a single graft with the punch, then immediately extracts it with the forceps in the other hand.
Immediate Feedback: The extracted graft is instantly inspected. If transection occurs, the depth and angle are adjusted for the very next graft, allowing for continuous, precise calibration.
The ISHRS FUE Committee’s subsequent formal recognition and naming our technique as the “Sequential FUE Technique” validates its clinical utility, and in 2019 formally acknowledged our team as the original developers of this Sequential Follicular Unit Extraction approach.
It was later published in Hair Transplant 360 FUE, Drs. Sam Lam & Ken Williams. page 27, First Edition 2016
It addresses the primary intra-operative challenge of FUE: unpredictable graft transection during difficult extractions. In standard FUE, multiple grafts are scored (punched) before extraction.
If the depth or angle is incorrect for a particular follicle, multiple grafts can be transected before the error is noticed. Our sequential method eliminates this blind spot.
The procedure is a meticulous, two-handed process reminiscent of its namesake.
Positioning: The surgeon holds a motorized punch in one hand and fine curved forceps in the other.
Sequential Action: The surgeon scores a single graft with the punch, then immediately extracts it with the forceps in the other hand.
Immediate Feedback: The extracted graft is instantly inspected. If transection occurs, the depth and angle are adjusted for the very next graft, allowing for continuous, precise calibration.
Its benefits are most apparent in complex surgical scenarios.
Maximizes Yield in Difficult Areas: Drastically reduces transection rates in zones with irregular follicle direction or scarring.
Real-Time Surgical Calibration: Provides instant visual feedback, turning each extraction into a learning point for the next.
Preservation of Donor Integrity: By preventing buried or transected grafts, it prevents waste and protects the long-term health of the donor area.
This is a specialized tool within a broader surgical arsenal, not used for every graft.
Primary Use: Managing challenging extractions in areas of high follicular density, irregular angles, or where previous surgery has caused fibrosis.
Standard Protocol: For routine, straightforward extractions, we employ our standard FUE-HD protocol for efficiency.
Strategic Hybrid Approach: This demonstrates our clinic’s philosophy: mastering multiple techniques allows for adaptive, patient-specific surgery to safeguard every possible graft.
Images & Information shown are for reference only
Information on this website is provided for general educational purposes only and does not constitute personalized medical advice. It is not intended to promote our service or imply superiority over another.
Individual results in hair restoration vary significantly and no outcome can be guaranteed. The before-and-after images shown represent possible results — not promises. We recommend seeking independent medical advice to discuss your options … Read More
Pre-Consultation Review
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Our practice adheres to guidelines established by leading international organizations in Hair Restoration.
International Society of Hair Restoration Surgery is the leading global medical association that establishes international practice standards and patient safety protocols.
The American Board of Hair restoration Surgery represents the highest standard. To maintain rigorous certification requirements the physician must demonstrate surgical expertise.
Worls FUE InstituteI serves as the premier educational body focused exclusively on Follicular Unit Extraction methodology. The institute ensures consistent application of safe FUE.
