Dr. Bernstein performing Robotic Hair Transplant using ARTAS SystemDr. Bernstein performing Robotic Hair Transplant using ARTAS System

Robotic hair transplantation is a significant advance in the technology of the Follicular Unit Extraction (FUE) procedure. In Robotic FUE, the ARTAS® System automates the harvesting of follicular unit grafts, enabling the FUE to be performed with unparalleled precision. The advantages of FUE over traditional hair transplants are having no linear scar in the donor area and having no post-operative limitations on physical activity.

The ARTAS robot’s advanced optical guidance system locates and extracts follicular units according to specifications programmed by the physician. It carries out this process hundreds to thousands of times per session with speed and accuracy that is impossible to duplicate with the human hand. The robot can also create recipient sites for the placement of follicular unit grafts according to an aesthetic plan designed by the physician.

Bernstein Medical is a Center of Clinical Excellence for ARTAS Robotic Procedures
Bernstein Medical is a Center of Clinical Excellence for ARTAS Robotic Procedures

Bernstein Medical’s Robotic Hair Transplant CenterSM of New York is among the first facilities in the world to utilize the ARTAS Robotic System to perform FUE, a procedure pioneered by Dr. Bernstein. Our practice is a beta-test site for this innovative hair transplant technology. Dr. Bernstein is a medical advisor to Restoration Robotics, the company that manufactures the ARTAS robot.

In addition to enhancing the core technology, Bernstein Medical has introduced new applications of the robotic system including recipient site creation, follicular unit graft selection, and computerized imaging (ARTAS Hair Studio™). Every FUE procedure at Bernstein Medical is performed using the ARTAS Robotic System.

Robotic FUE Advantages

FUE, which was first described and popularized by Drs. Rassman and Bernstein in 2002,1 requires surgeons to extract hundreds to thousands of follicular units in a single session. Using hand-held instruments, this is a labor-intensive process that subjects the patient to significant human variability and error.2

In manual FUE procedures, the doctor visually selects the follicular units to be extracted, estimates the angle the hairs grow out of the scalp, centers the extraction tool over the unit, incises the skin at a specific angle and depth, and then manually removes the follicular unit graft from surrounding tissue. The smallest deviation with a hand-held instrument can “transect” (damage) the follicular unit rendering it of little value in the transplant. The ARTAS Robotic System helps to minimize transection caused by human error and thus improves the quality of the hair restoration procedure.

More about
Robotic FUE Hair Transplants

The ARTAS robot also minimizes human error in the creation of recipient sites – tiny holes created in the balding area of the scalp where grafts are placed. There are several parameters in the creation of recipient sites that affect the aesthetic outcome of the transplant. Some of these include: angle of hair elevation, hair direction, site depth, average density or spacing, and total number of recipient site incisions. The physician uses the ARTAS system to program these parameters and the robot executes the plan with greater precision, speed, and consistency than can be accomplished manually. Read more about robotic recipient site creation.

The robot’s software allows the physician to specify which size follicular units to harvest and thus enables the doctor to select those containing the most hair. This has many benefits, but most important are to minimize donor wounding and make the process more efficient. Read more about robotic graft selection.

Potential advantages of robotic procedures over manual FUE

  • Increased accuracy of graft harvesting
  • Increased survival of harvested follicular units
  • Reduced harvesting time
  • Computerized selection of follicular units to maximize hair and minimize wounding
  • Easier extraction of grafts from the sides of the scalp
  • Easier extraction of grafts in patients from different racial backgrounds or with atypical hair characteristics
  • Increased speed and accuracy in creating recipient sites

Video Animation of a Robotic 2-Step Follicular Unit Dissection




Robotic 2-Step Follicular Unit Dissection


Robotic Hair Transplants at Bernstein Medical

The FUE robot used at Bernstein Medical, called the ARTAS Robotic 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. Wolfeld performing Robotic FUE Hair Transplant at Bernstein MedicalDr. Wolfeld performing Robotic Hair Transplant at Bernstein Medical

Dr. Bernstein’s contributions and expertise have made the ARTAS FUE 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.

ARTAS Robot harvesting follicular units from the back of a patient’s scalpARTAS FUE Robot harvesting follicular units
from the back of a patient’s scalp

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.3,4 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.

The ARTAS Robotic System for FUE

ARTAS Robot's Imaging SystemThe ARTAS Robot’s Imaging 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.

Animation Overview of the ARTAS Robotic System




Overview: The ARTAS Robotic System


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 Robotic Follicular Unit Extraction 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.

Robotic hair transplant procedures at the 2012 ISHRS “Coffee with the Experts”

Dr. Bernstein answers questions on Robotic FUE Hair Transplants


Video: Dr. Bernstein With “First Of Its Kind” Robotic Hair Transplant System



References:
  1. 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. []
  2. Bernstein RM, Rassman WR. Anderson KW. Follicular Unit Extraction Megasessions: Evolution of a technique. Hair Transplant Forum International 2004; 14(3): 97-99. []
  3. 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. []
  4. Bernstein RM. Integrating Robotic FUE into a Hair Transplant Practice. Hair Transplant Forum Intl. 2012; 22(6): 228-229. []

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