AKESO MSDF (Multi-Stage Deep Follicular Dissection FUE) is an advanced, multi-step follicular extraction method focusing on careful dissection of the surrounding tissue around each follicular unit.
Here’s a detailed breakdown of how the MSDF technique works, along with its advantages. MSDF is Multiphasic FUE graft extraction method so we will first describe the points in sequence
- What is traditional FUE punch and their systems
- What is MULTIPHASIC FUE DEVICE
- What is benefit of Multiphasic FUE over traditional FUE
- What is AKESO MSDF prerequisites
- How AKESO MSDF is different from traditional Multiphasic FUE devices
- Why AKESO MSDF is superior to other FUE methods and devices right now
WHAT IS TRADITONAL FUE SYSTEMS AND PUNCHES
Traditional FUE methods have different types of HAIR PUNCH, which use a mechanism.
SHARP PUNCH FUE SYSTEMS
Sharp punches cannot go deeper than that because they cut grafts due to graft curvature inside the deeper layers. For the deeper layer, grafts are pulled out with forceps so that the deeper layer can be avulsed during graft removal. The problem with this approach is that the graft root is always devoid of adjacent fat
If the sharp punch is used without a guard, then—traditionally, a low rpm motor is used, and tissue resistance is supposed to slow down the motor as depth increases.
If sharp punch fue is done without a guard, transactions may be 30 – 50 % in deeper layers. Unfortunately, most clinics prefer this approach because it is very fast. Punch sharpness provides unimaginable speed at the cost of more follicular damage. We do not advise the use of very sharp punches like Cole punches in FUE because we can never dissect deeper with these punches.
BLUNT PUNCH FUE SYSTEMS
BLUNT punches, flat punches, or hybrid or trumpet punches without guard – Tradition blunt punch methods require high rpm and cause more giant holes in donor skin as the punch cuts skin by avulsion force rather than cutting force
Blunt or flat punches are used at high RPM to cut superficial layers, and as punches go deep, they become slow due to friction and tissue resistance. Dull or flat punches give ragged edges and heat production.
They can go completely deeper but main problem is that if they are very flat then they are not able to penetrate the superficial hard layer of skin. When force is applied then skin tents and suddenly skin brakes and punch edge takes grafts deeper and buried. It cause risk of sabecous cyst. Sometimes 5 – 10 % grafts are buried so risk is very high for future sebaceous cyst in very flat punches .
HYBRID PUNCH SYSTEMS
HYRBID, TRMPHET, or FLARED punches have sharper outer edges but dull inside edges making them less likely to produce graft injury as the punch movement goes deeper.
Their blunt inner edge enables them to extract graft safely. Sharp outside edge reduces risk of buried graft.
They will create a bigger wound because the wound will be equal in diameter at the outer edge rather than the inner edge.
Hybrid punches deliver more tissue around the graft root because they can go deeper without cutting the graft.
They can go approximately 1 mm deeper than sharp punches without cutting graft but they cannot go more deeper than that because sharper outer edge cuts the grafts in extraction process or adjacent hair when we go deep.
Sugeons should always use hybrid punch system to remove grafts in traditional fue rotation motors.
In multiphasic FUE –
The use of rotation, oscillation, or a combination of rotation and oscillation (rotoscillation) instead of only rotation for FUE.
The upper layers are hard, so they require rotation to cut. Deeper layers are soft, and part of the hair graft inside the softer fat layer is very flexible and curly or splayed, so it can be damaged by rotation. Oscillation or vibration are soft forces that dissect deeper layers.
Multiphasic FUE devices
Note – MULTIPHASIC DEVICES NEED SPECIFIC PUNCHES. THEY CANNOT BE USED WITH TRADITIONAL SHARP PUNCHES beyond a particular depth. DEVICE ALONE IS NOT USEFUL WITHOUT SPECIFIC PUNCH OR EXPERT SURGEON. THEY MAY DO MORE HARM IN HANDS OF INEXPERIENCED STAFF THAN GOOD. THEY SHOULD BE ALWAYS HANDLED BY SURGEON WHO HAS GOOD COMMAND ON FUE EXTARCTION PROCESS. Few surgeons market multiphasic devices, but instead of using them, they give them to assistants or nursing staff. A 9 lakh rupee ( 10000 US dollar) device is bought to attract patients in the name of new technology, but it is 90 % times an advertising gimmick as they hand over to nursing staff. They try to prove that good results are due to the device rather than the surgeon’s expertise.
The COLE PCID device, the Trivellini device, WAW devices, etc. produced devices to combine different motor movements.
All devices available in market like trivellini and waw device can use rotation, oscillation, and vibration based on timers rather than depth of punch insertion. They work on the hypothesis that rotation damages the inner layers, but oscillation causes less damage. In these devices you can set rotation movement time and oscillation movement time and repeat cycles.
In these Multiphasic devices, the surgeon has to set an approximate time when he expects to cross the upper layers. This means he has to set a time in the machine and make sure that the rotation phase duration is just enough to cross the upper layer. If he remains superficial during that time, then the skin and graft will buckle, and the graft can be buried or damaged. If he is too fast, then rotation may reach deeper layers, where the graft can be cut.
AKESO MSDF VS TRADITIONAL MULTIPHASIC FUE DEVICE
AKESO MSDF also works on the same principle as multiphasic devices, but the difference is that the surgeon decides for each graft depth and has to use a foot paddle to stop rotation at the correct depth. Although MSDF does not require oscillation in the second phase, oscillation can be used in harder tissues. In MSDF, the surgeon can decide at what level of depth he wants to stop rotation by pressing the foot pedal of the MSDF machine.
The only disadvantage of MSDF is that it is much more tiring for the surgeon, as he has to concentrate more and press the foot pedal in fractions of seconds. If the surgeon wants to extract 1500 grafts in one hour, then he has to press the foot pedal 1500 times in MSDF. In normal FUE or Multiphasic devices, we can set timers so they are less tiring.
Prerequisites of performing AKESO MSDF Technique
- AKESO MSDF MOTOR—D AKHILESH JANGID made the MSDF motor through independent research. This motor can switch rotation to oscillation or vibration in just 100 milliseconds by pressing a foot switch. We had tried automation by timers in initial phase, but timer is not perfect solution. So right now, it is manual switching. New methodologies are being tested like pressure sensors to reduce surgeon fatigue but currently they are in experimental phase.
- AKESO MSDF PUNCH is a circular blunt punch with sharp teeth in some places. As the edges of sharp teeth are beyond the blunt edge, sharp teeth cut the tissue when the punch rotates. When the punch is stopped or vibrates or mildly oscillates, sharp teeth are not able to cut the tissue. When hair or any hard tissue comes in front of sharp teeth in vibration or low arc oscillation phase – Punch displaces the hair rather than cutting it, and the hair goes to a blunt edge so it gets protected even if we go into deeper layers. You can also easily go to the depth of 5 mm without cutting the graft.
- Expert Surgeon—The Surgeon has a big role in AKESO MSDF, as only the surgeon can decide when to stop rotation. If the surgeon stops rotations prematurely, the skin may be tented, and the graft may be buried. If surgeon is late to stop it – graft may be cut.
- Magnification – Besides tactile feed, the surgeon should be able to see the depth of punch along with hair angle premises. So, it should be done using surgical loupes of 4X – 6X or a microscope. Surgeons using Optivisior, specs, naked eye, or 2 X magnification cannot learn or perform it. The best is to do it with a Microscope (MAGP PROCESS)
Stages of MSDF Technique:
Initial Superficial Dissection (2 – 3.5 mm depth – varies from patient to patient ):
The first stage involves the punch rotating or oscillating to make a superficial circular incision around the follicular unit, typically up to a depth of 2 -3.5 mm. This initial phase cuts the upper part of the graft ( epidermis, dermis, sebaceous gland and arrector pili muscle. This allows the surgeon to limit the sharp cutting motion to the superficial skin layers and prevent trauma to deep layers or cutting of hair follicles due to their curvature.
Deep Blunt Dissection (2-5 mm depth—varies from patient to patient):
After the initial cut, The Dynamic motor braking mechanism is applied, which stops the punch’s rotation. Then, the punch can be used in oscillation or vibration mode. Vibration mode is preferable. If deeper tissue is tough, we can use oscillation mode.
RIGHT NOW, THE HIGH EXPERT SURGEON NEEDS to stop rotation at the right time by using the foot switch. The surgeon’s first role is to ensure that he can feel resistance release and stop the punch at the right depth. If inexperienced surgeons stop punching at a lesser depth, then the graft can be buried. If the punch is allowed to rotate for more depth, then the chances of follicle transection are high. So if the surgeon is doing 3000 grafts, he has to decide 3000 times in a fraction of a second and press the foot switch to start braking.
Braking takes less than 0.1 seconds because it is affected by electronic forces rather than mechanical braking. After braking, low-frequency vibration ( or oscillation if the deeper layer is harder than usual) is applied. The next phase involves applying a blunt dissection force. The goal is to advance deeper into the tissue surrounding the follicle, up to 4-5 mm, with vibration or low-arc speed oscillation.
No motor or electronic device is currently available to perform this type of follicular dissection. Existing advanced motor setups work on timer switches rather than surgeon decisions. Unfortunately, it is impossible to set a timer repeatedly for every few grafts or change location in your donor area.
Dr Akhilesh Jangid has made his own MSDF device to make this mechanism possible
We have tried timers and sensors instead of a foot switch mechanism to reduce surgeon fatigue, but no mechanism has matched the result of manual decision-making and switching for every graft until now.
Graft Removal and Preservation:
Once the follicular unit is separated from its surrounding tissue, the graft can be carefully removed or plucked using forceps.
This step involves gently pulling the follicle out to avoid stripping or damaging the root. The additional preserved fat and stem cells ensure the graft is bulkier and healthier.
Advantage: The deep blunt dissection removes grafts that contain more surrounding tissue, including protective fat and stem cells, which can increase the chances of graft survival and overall transplant success.
Key Benefits of MSDF Technique:
REDUCED GRAFT DAMAGE – Graft transection rates are low even when we work in deeper layers of skin
Enhanced Graft Quality: By carefully dissecting around the follicle in multiple stages, MSDF ensures that each graft retains more fat and stem cells, which leads to more robust and healthier grafts. These grafts are less likely to be damaged during extraction, improving their chances of survival when transplanted.
Reduction in Mechanical and Heat Damage: MSDF avoids this by stopping the punch after the superficial dissection and relying on blunt forces for deeper extraction. This minimizes heat generation and minimizes tissue damage. Because the motor stops repeatedly, the heat produced during rotation also dissipates.
Improved Outcomes with Small Punches: MSDF ensures the grafts are still bulky and healthy even when using smaller diameter punches, reducing the risk of “stripping” or damaging the f follicles during extraction. This is a significant advantage in achieving natural-looking, dense hair transplants.
Increased long-term results: The enhanced preservation of the surrounding tissue, fat, and stem cells, coupled with the precision of the technique, leads to higher graft survival rates and more life. This is particularly beneficial for patients looking for high-density, natural results from their hair transplant.
How MSDF Differs from Traditional FUE:
Standard FUE often involves a one-step sharp punch dissection, which can risk transecting follicles and damaging surrounding tissues.
MSDF, in contrast, allows for a controlled, stepwise dissection that better preserves graft quality and minimizes damage. It is an ideal technique for achieving high-density, natural results with fewer complications.
The MSDF technique is time-intensive and can increase surgeon fatigue due to the careful control required at each stage. However, the long-term benefits of healthier, more robust grafts make it a premium option for patients seeking high-quality hair transplants.