Robotic Hair Transplantation
Overview of Robotic Hair Transplant Procedures
Robotic hair transplant surgery is a logical advance in the technology of Follicular Unit Extraction (FUE), a procedure first described and popularized by Drs. Rassman and Bernstein in 2002.1 The potential advantages of Robotic FUE (R-FUE) over traditional FUE procedures include:
ARTAS Robot for FUE
at Bernstein Medical
- Increased accuracy of harvesting grafts to minimize damage to follicles
- Ability to use FUE in a wider variety of patients
- Reduced harvesting time
- Increased graft survival
Follicular Unit Extraction is a harvesting procedure where hair is removed directly from the donor region of the scalp as individual, naturally-occurring groups of 1-4 hairs. The technique consists of two main steps: 1) Separation of the follicular units from the surrounding skin, and 2) Extraction (removal) of the follicular units from the scalp.
Step one, the separation of the follicular units from the surrounding donor tissue, is a highly repetitive and labor intensive process that requires great precision. This step requires the centering of the punch over the follicular unit and the alignment of the dissecting instrument with the follicles to prevent damage. This step, which must be repeated manually hundreds to thousands of times in a typical FUE procedure, subjects the patient to significant human variability and error.2
The problem associated with the initial step of separating follicular units from the surrounding tissue has been a major challenge for FUE practitioners.1 A significant advance towards minimizing trauma to follicular units in this first step was to divide it into two parts; sharp, followed by blunt dissection. This additional step reduces the chance of injury to the lower part of the follicles during dissection.3,4,5 The current robotic system is based on this concept.
Robotic Hair Transplants at Bernstein Medical
The FUE robot used at Bernstein Medical, called the ARTAS™ System, was developed by Restoration Robotics, Inc. for specific use in Follicular Unit Extraction. Bernstein Medical is the first hair restoration center on the East Coast and one of the first worldwide to use this new technology in clinical practice. Bernstein Medical – Center for Hair Restoration serves as a beta-site to study new product features and enhancements in the ARTAS hair transplant system. Dr. Bernstein is a medical consultant to Restoration Robotics, is involved in the research and development of the ARTAS system, and has a financial interest in the company.
Dr. Bernstein’s contributions and expertise have made the ARTAS robot more user friendly, improved the harvesting technique and made it a more compelling procedure for patients. We are the first to offer our patients smaller customized punch sizes and computerized follicular unit graft selection. These techniques enhance FUE hair transplants based on the hair characteristics of each individual patient.
As a beta-site for this new technology, we have participated in developing many of the nuanced modifications that continually improve the technique. The initial version of the robot required many intra-operative adjustments, such as changes to depth, angulation, and the speed of punch rotation. The current system needs less human intervention and is simpler to operate, but significant experience is still critical to achieving the best results.
The FUE robot is more versatile in its ability to harvest grafts from patients with different hair characteristics and from different parts of the scalp compared to hand-held systems. Although there is still variability in the ease of extraction among patients of different racial backgrounds, in our experience, the differences are less when compared to a manual device. Also, with the ARTAS system it seems easier to extract grafts from the sides of the scalp where the hair lies flatter on the skin.
Bernstein Medical offers patients the option of different punch sizes. We have found that a 0.9mm punch (the standard is 1.0mm) shortens healing time, decreases donor scarring and increases the number of follicular units that can safely be harvested in a specific area. It also creates grafts that require less trimming. Some patients, especially African-Americans, have less transection with the larger punch, so it is important to be able to customize the technique to the particular person.
The ARTAS Robot at Bernstein Medical is programmed to skip over 1-hair follicular units. The advantage of this should be obvious. By avoiding the 1’s the robot is able to harvest more hair with fewer incisions and thus less donor scarring. Because the Bernstein Medical team is expert at stereo-microscopic dissection, we can generate the 1-hair grafts needed for the hairline by dissecting some of the larger follicular units.
Another important modification of the FUE technique introduced at Bernstein Medical is pre-making recipient sites.6,7 This is done either prior to extraction in a one-day procedure or at the beginning of the first day in a two-day procedure. With this change, as soon as the grafts are harvested, they can be placed immediately into the recipient scalp. Not only does this minimize the time that grafts are outside the body, but; by allowing the healing process to begin in the recipient area; it minimizes popping, increases visibility when placing (due to less bleeding), and may create a better environment in which the newly transplanted grafts can grow.
ARTAS Robotic System
The ARTAS FUE robot is an image-guided system composed of a robotic arm, dual-needle punch mechanism, video imaging system, and a user interface. Its extraction technique consists of a double-punch arrangement with an inner (sharp) punch and outer (dull) punch. The inner punch has cutting capabilities to score the upper most part of the skin and the outer punch has a blunt edge used for dissection of the follicular units from the surrounding tissue that minimizes injury to the grafts. The image-guided system allows this step to be accomplished with great precision. The patient lies on a specially designed operating table that allows access of the robotic arm to the donor area of the scalp.
New Developments in Robotic Technology
Bernstein Medical is beta testing the ARTAS System for use in recipient site creation. Dr. Bernstein introduced this new technology at the Restoration Robotics user meeting in California on February 8, 2014. The capability should be available for general use by the fall of 2014.
For this application, the doctor draws the hairline and makes other markings directly on patient’s scalp to delineate the surgical plan. Next, multiple photos are taken and fed into computer which converts the images into a 3-D model of the actual patient that can be manipulated and saved. During the procedure, the physician specifies the angle, direction, density, and randomness of the recipient site incisions. When the robot creates the recipient sites, according to the parameter set by the doctor, it is able to avoid pre-existing hairs. The robot can make up to 1,500 recipient sites per hour.
A main benefit of the robot creating recipient sites is that it is a necessary step for the automated implantation of grafts. It is anticipated that this final phase of the robotic hair transplant procedure, the robotic insertion of follicular unit grafts into recipient sites, is about two years away.
Video: Dr. Bernstein With “First Of Its Kind” Robotic Hair Transplant System
- Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7. [↩]
- Bernstein RM, Rassman WR. Anderson KW. Follicular Unit Extraction Megasessions: Evolution of a technique. Hair Transplant Forum International 2004; 14(3): 97-99. [↩]
- Harris JA. The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction (FUE). Hair Transplant Forum Intl. 2004; 14(5): 157, 163-4. [↩]
- Rassman WR, Harris J, Bernstein RM. Follicular Unit Extraction. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 17. Elsevier Saunders, 2006: 133-137. [↩]
- Bernstein RM, Rassman WR. New Instrumentation for Three-Step Follicular Unit Extraction. Hair Transplant Forum International 2006; 16(1): 229, 237-9. [↩]
- Bernstein RM, Rassman WR. Pre-making recipient sites to increase graft survival in manual and robot FUE procedures. Hair Transplant Forum Intl. 2012; 22(4): 128-130. [↩]
- Bernstein RM. Integrating Robotic FUE into a Hair Transplant Practice. Hair Transplant Forum Intl. 2012; 22(6): 228-229. [↩]