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NOVEMBER/DECEMBER
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Curly Hair FUE: My Approach Using Classication of
Follicle Curvature and Curl
Alba Reyes, MD, FISHRS I Santo Domingo, Dominican Republic I albareyes@albareyes.com
ABSTRACT
Specic knowledge of curved hair structures is necessary to be able to perform a successful surgery in
this specic group of patients. In this article, we present a brief description of the cosmetic categories of
curly shaped hairs and we establish a connection with the internal structure of this specic kind of hair. We
introduce a classication based on seven predominant types, and we specify based on punch tip type, punch
diameter, punch insertion angle, punch insertion depth, and punch centering, taking into consideration the
specic characteristics of ethnic skin.
In my experience the Hybrid punch is the most adequate instrument to perform this surgery in a step-by-
step approach. Because of the great variety of shapes and textures possible in a single patient, slow pace,
testing, and constant adjustment is the key to completing a successful hair transplant procedure.
Keywords: curly hairs, follicular unit excision (FUE), hair transplant, Reyes Classication of Follicle
Curvature and Curl
This article is open access and may not be copied, distributed, or modied without written permission from
the International Society of Hair Restoration Surgery.
Some patients of African descent tend to have a spiral or helical hair structure that is clinically referred
to as tightly coiled. Others have the appearance of very curly hair, but when the grafts are extracted, we
observe that the follicle structure is not so curved underneath the skin. There are a variety of curvatures,
conrming that the internal curvature is typically an extension of what we observe externally. Recogniz-
ing that there are several varieties of curl, we cannot always apply the label Afro-textured hair. It’s better
to understand the specic curl characteristics of each case to tailor our approach during follicular unit
excision (FUE) surgery.
In some patients with curly hair, FUE is easily performed by an experienced team using any type of
punch; however, some types of curly hair can pose a signicant challenge even for the most skilled sur-
geon. It is important to redene the terms Afro-type or curly or curly kinky hair, so we can understand
how some patients with extremely curly hair may show slight internal curvatures while others will pose a
great challenge to the surgeon due to very tight follicle curves, curling, and growing parallel to the scalp.
TYPES OF HAIR CURL
Curl of the hair is where there is a curve in one direction and then curve in the opposite direction.
The tufts of hair are intertwined, providing more volume. It is often thought that curly hair is intrinsi-
cally thicker, and the curlier it is, the greater the three-dimensional space it occupies. Hair curls can be
classied into ve distinct types (Figure 1).
1
This paper is dedicated to types 3, 4, and 5 as they are most
frequently seen in the author’s region because of the genetic typing that is more Afro than Caucasian.
Type 1 (Figure 1, 1) is a hair that takes 2-3 inches to form a curl; it looks like straight hair if shorter than
2 inches, hence the need to carefully examine it to not confuse it with Caucasian straight hairs.
Type 2 is a hair that needs 1-2 inches to form a curl, and I would characterize this type of hair as
wavy. Figure 1 2A and 2B show the different kinds of wavy my practice frequently identies.
Type 3 is shown in Figure 1, 3. This hair curl has a spiral pattern creating a “gentle capital E shape.”
This curl starts to form after 0.5-1 inches. This is the type of hair curl that most people have in mind
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when visualizing a curly hair: the curl being formed from a
half inch to one inch off the skin.
Type 4 has a frizzier and compact “corkscrew” shape (Fig-
ure 1, 4) These curls are formed from one-eighth of an inch
to half an inch off the skin and are known as curly/kinky. If
the hair is shaved short, you cannot tell it is curly hair.
Type 5 is hair that is so tightly curled that it does not
have sufcient length to express a curve. Its shape resem-
bles locks of hair in the form of a Z (Figure 1, 5). These
curls are formed less than 0.125 inches off the skin and the
curly shape is evident, even when shaved short. This is the
so-called kinky or Afro texture.
All of these types are curly: the difference among them is
the distance from the skin where the curl starts to form.
TYPES OF INTERNAL FOLLICLE CURL
The external curls of the hair are indeed extensions of
internal follicle curve.
2
Below the skin are curved forms that
range from a J shape to a C shape (Figure 2). In my experi-
ence, I have even observed extreme curved forms so closed
that I refer to them as “O” shape. Closed C to open C shapes
are found in patients with type 5 or Afro hair. There are
many varieties in type 4 curly/kinky patients; they range from
open C to J shapes to proximal bend, albeit very soft. Type
3 has very light curvature or a proximal bend shape. I have
not studied the specics of Types 1 and 2 because in general
there is less variety in shape with these hair structures.
There is a direct relationship between the appearance of
these various types of hair and the degree of complexity
that will confront the surgeon during the surgery. The more
closed the shape of the follicle curve, the more difcult the
excision, because the follicles are positioned almost paral-
lel to the skin surface. The perception is that these follicles
are larger, but this is not always the case: sometimes it’s
because the curves themselves are very small.
In my team’s approach to FUE surgery, the hybrid punch is
always our rst option, and the most used punch diameters
are between 0.95-1.05mm (sometimes 1.10mm). The hybrid
punch is preferable because the cutting edge is farther away
from the follicle. The Devroye Serrated Tornado Punch,
Trivellini Edge Out punch, Umar Intelligent punch, and Zero
T punch by Cole are all effective; however, I prefer the ser-
rated Tornado punch because most patients have the type of
skin that is more rm and tough compared to other types of
skin, and the serrated tip performs better in this situation.
3-5
The donor area is shaved proceeding from the superior
part of the donor area to the inferior, so that the shave is
not too aggressive (when the hair is shaved from the bottom
upward there is more risk the hair will be cut too short). I
prefer to leave the hairs at a length of 1-1.5mm in the donor
area because this length provides a good indication of the
direction and angle of the excisions.
Through carefully observing a large number of cases, I
have created the Reyes Classication of Follicle Curvature
and Curl, which has seven predominant types. Of course
there are outlier shapes, but these seven main categories
apply to the majority of cases. I will describe each type and
how I modify my FUE technique for each type.
Reyes Type 1 (Figure 3)
When the graft follicles are
curved and long, in most cases
it is not necessary to per-
form an arc movement during
excision. I prefer to enter the
punch perpendicular to the skin.
These follicles have a length
of 4-5mm, and can be cut to a
depth of 3-3.5mm. By not using
the arc movement, the proce-
dure will be more efcient and
go faster. These types of grafts,
if the skin is favorable, allow me
to use 0.9-1mm punches.
Reyes Type 2 (Figure 4)
In this kind of graft, the follicles are long, but at the
ends, the follicles are splayed. Therefore, I insert the punch
perpendicular to the skin up to a depth of 2.5-3mm. These
follicles have a total length of 4-5mm, and when the skin
is favorable, the 1mm punch can be used. But if the sub-
1
2A 2B 3 4 5
FIGURE 1. Imagen curl types 1-5
FIGURE 2. Different types of follicles
FIGURE 3. Reyes type 1
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cutaneous tissue is rm, I prefer to use a larger punch of at
least 1.05mm. Since the skin is so rm, I adjust the diameter
of the punch as this facilitates a deeper dissection and less
traumatic extraction.
Reyes Type 3 (Figure 5)
In this type of graft, the follicles have a more pronounced
curve compared to types 1 and 2. Thus, I place the punch at
an angle of around 85 degrees, and penetrate to a depth of
2.5mm and from there penetrate in an arc movement, imitating
the curvature of the follicle, until reaching a depth of 3-3.5mm.
With these types of grafts, it is quite common to nd
intertwined hairs. Therefore, as you can observe in these
rst three gures, the punches are off-center, more towards
the border of the superior edge of the punch, in relation to
the grafts to be extracted.
Reyes Types 4 and 5 (Figures 6 and 7)
These grafts are shaped like an upside-down umbrella;
they are small and have a length of 3-3.5mm. On occasion,
hairs may be intertwined. The difference between type 4
and type 5 is that the level of splay in type 4 is larger. In
these cases, the best punch to use will have at least 1mm
diameter. I perforate in a perpendicular direction to a depth
of at least 2-2.5mm. Going deeper would easily increase the
percentage of transected grafts.
Reyes Type 6 and 7 (Figures 8 and 9)
These types of grafts are short because of the closed curve
shape. They are small, measure approximately 2.5-3mm,
and you can see different varieties of splay.
The punch should not be smaller than 1.05mm, and the
perforation needs to be in a nearly vertical angle of around
85 degrees. I will perform an arc movement to a depth of
1-1.5mm and never go beyond the maximum depth of 2mm.
In general, the skin of these patients is more adherent at the
subcutaneous level.
FIGURE 4. Reyes type 2 FIGURE 5. Reyes type 3
FIGURE 6. Reyes type 4 FIGURE 7. Reyes type 5
FIGURE 8. Reyes type 6 FIGURE 9. Reyes type 7
In my practice, we always perform a test at the beginning
of and throughout the surgery and, if needed, adjust the
size and type of punch as well as the depth and speed of
movement.
For type 6 and type 7 grafts shown in Figures 8 and 9, we
like to use the arc movement approach because of variations
in the shapes and curves that can sometimes be observed
in one single patient. We use the WAW or the Trivellini
machine with the serrated trumpet punch and controlled
movement.
The nature of the skin is fundamental because it provides
an impression of the quality of the graft. The ideal skin for
extraction is neither too rm nor very exible. In tight skin
with very rm subcutaneous tissue, we prefer to use minimal
tumescence and always use a new punch. In such cases, it
is also more difcult to perform an arc movement.
With skin that has more laxity, this can result in some loss
of precision during the punch penetration because of the
instability of the skin. This will cause a higher percentage of
transection. In such cases, we use supercial tumescence and
stretch the skin with our ngers or elevate the skin in between
our ngers creating a small belly to achieve better precision.
Although we are all familiar with the standard techniques
during extraction, I would like to add that with the most
extremely curved grafts I prefer to make a more vertical
movement during my manual extraction as this facilitates the
optimal detachment of the graft from the donor area.
The hybrid punch is the punch of choice in this patient
population.
6
The use of tumescence should be conservative,
depending on the skin type. Tests need to be performed
throughout the excision process because the curvatures vary
not only from one region to another in the donor area but
also from one follicular unit to another.
7
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Knowledge of the structure of curved hair is necessary to
establish an extraction strategy. Do not hesitate to increase
the diameter of the punch, since many times the curved
structure of the shaft must be fully incorporated within the
perimeter of the punch.
In my practice, we always perform a physical exam and
investigate for keloid history with these types of patients.
I perform a test before surgery when we are going to
extract from areas outside the scalp, such as the beard area.
I strongly recommend testing always when your patient has
a specic type of hair that you are not very familiar with. I
want to specically investigate the level of scarring and the
risk of hypertrophic scars.
Do not consider the above concepts as a guarantee to
eliminate all transections. These patients typically have a
higher percent of transection than occurs with straight folli-
cles, especially in cases of closed curvatures and skin with
high resistance or hardness.
CONCLUSION
There is a great variety of shapes and structures associ-
ated with the scalp of curly-haired patients. The outcome
of surgery will depend on recognizing which variations are
present and then adapting techniques during surgery accord-
ing to the variations. The specic aspects of the techniques
used by the surgeon will also impact transection rate and
graft quality.
References
1. Samson R. Hair-Proling Aspect: Get to Know Your Hair. The
Men’s Hair Book. United States: Createspace Independent
Publishing Platform, 2013; pp. 26-31.
2. True R. What FUE techniques are used for patients of African
ancestry? Hair Transplant Forum Int’l. 2017; 27(3):116.
3. Trivellini R, Gupta A. The Edge Out Punch, an advancement that
reduces transections in follicular unit excision hair transplant. J
Cosmet Dermatol. 2020; 5:1-7.
4. Umar S. Patent US8,876,847-B2. 2014:11. United States.
5. Cole JP. Tool of the trade: the zero + punch. Presentation during
2020 Conference “Global Hair Loss Summit.” Virtual Summit,
December 4-6, 2020. https://globalhairloss2020.org/day2.012-
video. Accessed.
6. Devroye J, et al. Sharp and hybrid punches: a detailed comparison
of different quality control markers. Hair Transplant Forum Int’l.
2020; 30(1):1-6.
7. Reyes AV. African Hair FUE Tips. Virtual Presentation during
American Board Webinar on Afro Hair FUE, May 22, 2021. https://
lamanagementco.sharele.com/d-004b1f8740814470
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