Q: I am an MMA fighter and I want to get a hair transplant. How long do I have to be out of commission and which type of procedure should I have, FUE or FUT? — J.A., Columbus, OH
A: With any type of hair transplant it takes 10 days for the transplanted grafts to be permanently fixed in place. The difference between FUE and FUT is in the limitations of activity due to the donor area. With FUE one would need to abstain from MMA for the same 10 days it takes the recipient area to heal (the grappling component of Mixed Marshal Arts is the most stressful on the scalp). With FUT, however, one would need at least three months for the linear donor scar to heal before one could resume contact sports like MMA.
Q: How are specifications for recipient sites inputted into the ARTAS® robot?
A: At the outset of the procedure, the physician sits at a computer terminal that is connected to the ARTAS Robot and enters the specifications directly into the robot’s software. Variables programmed in this manner include: the number of recipient sites, density of sites, angle that the hair will extrude from the skin, depth of recipient sites, and the minimum distance away from existing hair follicles that a site can be created.
Q: Will Robotic FUE reduce the cost per graft for FUE hair transplants?
A: Robotic FUE may cost slightly more per graft than a typical manual FUE procedure due to the greater expense of this new technology. At Bernstein Medical, we use the ARTAS Robotic System for all Follicular Unit Extraction (FUE) procedures.
Q: How does the ARTAS System avoid damaging hair follicles in the balding area during recipient site creation?
A: The ARTAS robot’s optical guidance system enables it to accurately create recipient sites in areas of thinning hair without damaging existing hair follicles. During the recipient site creation process, the robot uses its advanced image-guided optical system to scan the surface of the skin, locate existing hair follicles in the recipient area, and then create recipient sites at a specified distance from these existing hairs.
The ARTAS robot carries out this process rapidly, accurately, and consistently according to the physician’s programmed specifications. Thanks to the microscopic precision of the image-guided technology, the robotic hair transplant system can avoid injury to follicles that can result when Follicular Unit Extraction (FUE) is performed using manual techniques.
Q: Why is using the robot to create recipient sites useful in a hair transplant?
A: The ARTAS® Robotic Hair Transplant system eliminates the inconsistencies inherent in creating large numbers of recipient sites by hand. The robot can create sites at a rate of up to 2,000 per hour. Although there is more set-up time compared to sites made manually, once the physician specifies the parameters such as punch depth, punch angle, and site direction, recipient site creation is precise and rapid.
One of the benefits of robotic site creation is that the distribution of grafts over a fixed area of the scalp can be exact. For example, if one wants to transplant 1,000 grafts evenly over 50cm2 of area, this can be done with great precision and with uniform site spacing. In addition, the physician can vary the densities in select regions of the scalp and the robot will adjust the densities in other areas so that the total number of sites remains the same.
Another benefit of the new technology is that the robot can be programmed to avoid existing hair and select which specific hair diameters to avoid. The robot is programmed to keep a specified distance from the existing hair to ensure that the resident follicles will not be damaged and that the distribution of new hair is even and natural. This computerized mechanism appears to be more accurate than what can be done by hand and, importantly, does not sacrifice speed in the process.
Q: How do recipient sites get made in Robotic FUE? And how does the robot know where to create the sites?
A: In performing recipient site creation, the ARTAS Robotic Hair Transplant system automates another part of the hair transplant process that is repetitive and prone to human error. In robotic site creation, the physician first designs the hair restoration and then specifies the angle of hair elevation, hair direction, site depth, average density, and total number of the recipient site incisions. The robot then creates the sites according to these specifications.
During site creation, the robot automatically uses its image-guided technology to avoid hairs of a certain diameter (specified by the doctor). The robot creates sites at a minimum distance from hairs of the specified diameter (the distance is also specified by the physician) and will do so randomly throughout the areas where the hair is finer or the scalp is bald. With this important feature, the new distribution of sites can be made to complement the distribution of existing hair. Observation of the ARTAS System suggests that it performs recipient site creation with greater precision and consistency than can be accomplished manually.
Q: What is the main difference between hair transplants using the robot versus other procedures?
A: There are two basic types of hair transplant procedures, Follicular Unit Transplantation (FUT or strip surgery) and Follicular Unit Extraction (FUE). In FUT, donor hair is harvested by removing a long thin strip from the back of the scalp. Individual follicular units are then obtained from this strip using stereo-microscopic dissection. In FUE, individual follicular units are harvested directly from the donor area using a sharp, round cutting instrument. The ARTAS Robotic System performs the follicular unit isolation step of an FUE procedure and can also create recipient sites according to specifications determined by the hair restoration surgeon. In performing each of these steps, the robot uses its image-guided technology to locate the next target and position the cutting instrument, and it does so with precision and speed that cannot be accomplished using manual FUE techniques or instruments.
Q: I have been reading about Robotic FUE and have seen some photos on your website of you operating the ARTAS robot using what looks like a remote control. What is that thing and how does it control the robot?
A: The ARTAS robot uses a dual operating system when performing follicular unit extraction. One station consists of a desktop computer adjacent to the robot. This station is used to establish the basic parameters of the transplant such as the spacing of grafts, the angle and depth of the harvest, which size follicular units will be targeted, and a host of other important variables.
The hand-held pendant is used by the operator situated next to the patient. The remote has more limited options – the main ones being depth adjustment and to immediately suspend the action of the robot. Many of the parameters are determined automatically by the robot’s computer to maximize the accuracy of the harvesting. The robot also makes real-time adjustments to these variables during the hair restoration procedure.
The physician sets the parameters at the computer monitor and, once the settings are determined, he/she sets the tensioner grid on the patient’s scalp. The tensioner determines where the grafts will be harvested. The grid is moved approximately every 130 harvests. The robot can be operated at the computer terminal and through a mobile pendant. The physician often alternates with a trained assistant between that station and using the pendant.
Besides the involvement in the operation of the robot, there are many other important physician-dependent steps to the hair transplant including the planning and design of the procedure, and recipient site creation. Other steps, such as the microscopic sorting and trimming of harvested follicular unit grafts and graft placement, are often performed by trained staff, but require the physician’s close supervision.
How Does the ARTAS System, or the Surgeon, Determine the Depth of the Incision, and Can it be Adjusted During Surgery?
Q: How does the ARTAS robot control the depth of the incision in Robotic FUE?
A: The ARTAS robotic system is equipped with advanced sensors that determine the precise depth of the sharp and blunt needles used both in the graft harvesting step and for recipient site creation. The robot automatically adjusts to the precise depth needed for the non-traumatic extraction of the grafts. The tip of the punching mechanism contains depth markings so that the physician can visually override the punch when he wants to fine-tune its action. While monitoring the procedure in real time, if it is observed that the punches are too superficial or too deep, punch depth can be modified using the robot’s computer system.
The physician can also use the ARTAS system to precisely control the depth of recipient sites. As with harvesting, the robot automatically adjusts the depth based on parameters set by the physician and the doctor can then make further adjustments, in real-time, during the procedure.
Q: Does Follicular Unit Extraction performed by a robot hurt more than regular FUE? — R.T., Greenwich, CT
A: As with manual FUE, robotic FUE hair transplantation is an outpatient procedure performed under long-acting local anesthesia – a combination of lidocaine and bupivacaine. After the initial injections, the patient does not experience any pain or discomfort.
Before starting local anesthesia, we give most patients oral valium and intra-muscular midazolam (a very fast acting sedative that is very relaxing). While some patients doze off at the beginning of the procedure, others prefer to watch TV, a film, or just chat.
Local anesthesia generally wears off after 4-5 hours, so for transplant sessions lasting longer than this, we will give more anesthesia before the first wears off. With Robotic FUE, there is no discomfort once the procedure is completed and the anesthesia wears off. This is in stark contrast to an FUT strip procedure which can be uncomfortable in the donor area for days to weeks.
We recommend waiting at least 10 days before playing any contact sport, like football, as transplanted grafts could be dislodged if vigorously rubbed.
Q: How many follicles can you transplant with robotic FUE compared to manual FUE?
A: We can extract the same number of follicles robotically as we can manually.
That said, the goal of any hair transplant procedure is not to transplant as many hair follicles as possible but rather to achieve the best possible cosmetic result given your degree of hair loss and the number of hair follicles available in your donor area.
Is it Possible To Have a Robotic FUE Hair Transplant on the Crown Area with African Hair at 26 Years of Age?
Q: I am 26 years old and have been suffering from hair loss for 8 years. I have been on Propecia (finasteride) and Rogaine (minoxidil) during those years. Unfortunately my hair loss has continued to progress aggressively. I am of half African and Caucasian descent, and my hair is curly. I understand that there are certain limitations on having hair transplants before you are 35, however I do not mind having another transplant in a few years, if necessary.
A: Although it is possible to have a hair transplant to the crown using robotic FUE in African American patients, given your young age and that you state your hair loss is progressing aggressively while on Propecia and Minoxidil, it is likely not a good decision to have surgery at this time.
The reason is that as your hair loss surrounding the crown expands over time, it may look unnatural to have hair transplanted solely to the crown region.
At your age, it is best to take Propecia (finasteride) and Rogaine (minoxidil), and if a transplant is indicated, to start at your frontal hairline and top of your scalp, the areas that will be most important cosmetically long-term.
Q: I’ve heard that your ARTAS hair transplant robot can now create the recipient site in a hair transplant procedure. Has it been done on humans or is it still in an experimental phase, and if so can you tell if it looks as natural as when the surgeon does it?
A: In February 2014 we introduced new technology that allows the ARTAS Robotic System to assist the surgeon in recipient site creation. We are now using the ARTAS robot to make recipient sites in select hair transplant procedures. If designed and programmed properly by the doctor, robotic assisted recipient site creation can produce a hair transplant result that is as natural as when the surgeon does it by hand.
Q: I heard FUE is a scarless surgery. Is this true using any of the current FUE methods (ARTAS® robot, Neograft, manual FUE)?
A: All hair transplant procedures, follicular unit transplantation (FUT) and follicular unit extraction (FUE), leave scars. FUT produces a linear scar at the back of the scalp that may be visible if you keep your hair short. FUE, on the other hand, leaves small dot scars at the back of the scalp that are not visible if you keep your hair short. These tiny scars will happen regardless of which FUE method is used, i.e., ARTAS robot, SAFE system, Neograft, or manual FUE. Some physicians who use the Neograft method advertise that there is no scarring involved when using the Neograft; however, this is not true: however, this is not true: there is some scarring associated with all FUE methods that increases with the total number of grafts harvested.
Q: I have read a bit about the ARTAS robot and how it uses an “image-guided” system, but what does that mean? And how is the robot’s imaging system different than a human surgeon viewing the grafts with the naked eye?
A: That is a great question and it gets to one of the key benefits of the robotic hair transplant system: its accuracy. When a surgeon is performing FUE using manual techniques, they must wear a headset that magnifies the scalp so they can see the follicular units more clearly than with the naked eye. The surgeon must visually and mentally process subtle nuances of the skin and follicular units for every one of the hundreds or thousands of units that are extracted. The ARTAS robot magnifies the surface of the skin in much the same way, but to a much greater extent. In addition, it is not subject to the limitations of the human eye, or human hand, and it is not subject to human error. The surgeon may not have exact hand-eye coordination. The surgeon may be concentrating on one aspect of the extraction, say following the angle of the hair, but might ignore another important aspect of the follicle, say its depth in the skin or its orientation. And, of course, the surgeon tires, both physically and mentally, from performing the hundreds or thousands of repetitive motions.
The robot’s image-guided system, on the other hand, does not experience these limitations. The robot magnifies the skin, detects each follicular unit and the nuances of the skin/hair characteristics, and then extracts that follicular unit with precision. When the imaging system detects changes to the skin, this new information is fed into the computer in real-time and the system adjusts automatically based on this feedback as it continues to harvest grafts. There is no distracting the robot, and the robot will not forget, or ignore, key variables in the extraction. The robot can extract thousands of follicular units without tiring from repetition or slowing down the extraction.
Based on my own practical experience using the robot, it is clear that the robot’s ability to estimate the position of the follicles under the skin and to extract it with precision is superior to manual techniques. Having used the ARTAS system for over three years, and having helped make improvements to the device since the first iteration, I have seen robotic technology substantially improve the outcome for my patients.
Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE?
A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually.
The goal of a hair transplant is not to simply transplant as many grafts as possible but to achieve the best possible cosmetic result given the number of hair follicles in your donor reserve. Remember, this is always a limited supply.
While there is no difference between robotic and manual FUE in terms of the number of follicular unit grafts that each can extract, robotic FUE does differ from manual FUE in several important ways.
First, there is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.
Second, while the robot is not necessarily faster than the human surgeon, the robot is much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.
Q: I understand that in robotic hair transplant, a robot performs the extraction part of the FUE procedure. What’s the outlook on the robot doing more of the hair transplant procedure?
A: Currently, the ARTAS® Robotic System is a technology for extracting grafts. This is the most difficult part of a follicular unit extraction procedure, but it is only one part.
There are two other major parts to the FUE procedure: one part is the creation of recipient sites (in our practice, we create the recipient sites first, so that once we harvest the grafts, we can immediately place them into the scalp), and the other part is graft placement.
Recipient site creation involves more than merely making holes in the recipient area.
It involves making decisions on hairline design, graft distribution, hair direction, recipient site size and depth. When done manually, the surgeon first designs the new hairline so that the hair transplant will look as natural as possible, particularly as the person ages. Next, the surgeon will demarcate the extent of the area to be transplanted and decide on the graft distribution (i.e., how much hair will be placed in each part of the scalp) and then prepare a “recipient site” on the part of the scalp that has lost hair. The surgeon will then manually create incisions in the recipient site into which the follicular units will be placed.
On February 8, 2014, Dr. Bernstein unveiled “recipient site” creation capabilities of the hair transplant robot. These new capabilities allow the doctor to import a hairline design and other markings that have been made on the patient’s scalp directly into the robot. The robot then maps the design onto a precise 3-D model of the patient’s head. The physician can then program the proper distribution, direction and depth of the future recipient sites and the robot then creates the sites according to the physician’s specifications.
Graft placement, the last step, is perhaps the most challenging to automate. Engineers are currently working to design and build the capacity to automate the placement of extracted follicular units into recipient site incisions. Done manually, it requires significant hand-eye coordination and a very slow learning curve. For the hair transplant robot, it will be a significant challenge with development taking several years or more.
Q: Does transplanted hair grow faster after a robotic FUE?
A: There is no difference in the rate of growth between manual FUE verses robotic FUE. However, with robotic FUE, the actual growth should be better due to less transection (damage to follicles during the harvest).
In general, one can expect transplanted hair to start to grow within two to five months with the transplanted hair taking on its final appearance after approximately one year.
Read more about Robotic Hair Transplant surgery.
Q: I’ve heard that robotic-assisted FUE is better than manual FUE, but what exactly is the main advantage of Robotic FUE?
A: Robotic FUE is a significant improvement over other FUE techniques for a number of reasons. The accuracy and ability of a robot to perform countless repetitive motions are key reasons why robotic techniques are an improvement over manual techniques.
In a manual procedure, the skill and speed of a physician are under constant stress, as he or she must follow the angle and depth of the hair precisely hundreds to thousands of times. This task is almost impossible for even the best surgeons to perform without risking harm to the integrity of the follicles. Entering the skin at the wrong angle risks transecting or cutting the follicles and may render them useless for transplantation. Making too shallow an incision can also damage follicles, as the important base of the follicle can become sheared off when it is subsequently extracted.
The robot is engineered to avoid these problems, and so the number of viable grafts that the robot extracts is increased. As a result, the likelihood of the success of the transplant is greater using the robotic system.
Q: I’ve heard it takes the artistry of the surgeon to create a natural looking hair transplant. How do you do this with a robot?
A: I currently create the recipient sites by hand using different size needles. They determine the angle, direction and distribution of the grafts, and these three variables determine the aesthetic aspects of the hair transplant.
However, I am working with Restoration Robotics to have the ARTAS System create recipient sites and we are currently beta-testing this technology. The robot can now make very precise recipient sites. The ability of the robot to mimic the art of the surgeon is in the works, and we expect it to be ready in the fall of 2014.
In this new robotic-assisted process, the surgeon designs the hairline and delineates the area to be transplanted directly on the patient’s scalp. The surgeon then photographs the patient’s scalp and feeds the photograph into the robot’s computer to create a digital 3-D image. The doctor, in order to have the robot mimic what he would do by hand, can then manipulate various parameters, such as hair angle, direction and density.
A: Currently the robot is only used for harvesting grafts from the donor area. In FUE, the doctor punches out hundreds to thousands of individual follicular units from the back and sides of the scalp by hand using a small round instrument called a punch.The punch has to be held at exactly the right angle, with just the right pressure applied, stopped at a precise depth and, during this time, rotated (or spun mechanically) without changing the alignment.
As one can imagine, this exhaustingly tedious process can best be done using the precision of a robotic device.
In FUT, the harvesting is done by a surgeon using a scalpel to make a long incision in the back of the scalp. It only takes a few minutes. The harvested strip is removed and then placed under dissecting microscopes where the individual follicular units are isolated. This dissection, thus far, can only be done by hand. There is no robotic technology available to do this.
Harvesting the donor hair, of course, is only one part of a hair transplant. The other steps, recipient site creation (making the holes that the grafts are placed into) and actually placing the grafts into those sites are similar in both FUE and FUT.
It is anticipated that robotic site creation will be available in the fall of 2014 and robotic graft placement, the third and final step, about two years after that. At that time, the robot will be able to perform the entire FUE procedure and the last two parts of the FUT procedure.
Of course, the robot doesn’t do the surgery alone. The physician must input all the information regarding the design and planning of the procedure and closely monitor each step of the robotic process. Unlike automating industrial production, the human scalp has great variability, so there is no one formula that will be appropriate for every patient. Physician skill and involvement is just as important in robotic hair transplantation as it is with every other type of surgical hair restoration procedure.
Q: At one time, I was told my donor area was not sufficient for an FUT hair transplant procedure. Does this also mean I’m not qualified for a FUE procedure either?
A: Great question. You are not giving me quite enough information to answer your question specifically, so I will answer in more general terms. If your donor hair supply was not good enough to do FUT (i.e. you have too little donor hair and too much bald area to cover) then most likely you will not be a candidate for FUE either, since both procedures require, and use up, donor hair. That said, if don’t need that much donor hair, but the nature of your donor area is such that a linear FUT scar might be visible then FUE might be useful.
An example would be the case in which a person has limited hair loss in the front of his scalp, has relatively low donor density, and wants to keep his hair on the short sides. In this case, FUT would not be appropriate as you might see the line scar, but we might be able to harvest enough hair through FUE to make the procedure cosmetically worthwhile. Remember, with low density neither procedure will yield that much hair to be used in the recipient area.
Another example is an Asian whose hair emerges perpendicular from the scalp so that a line incision is difficult to hide, i.e. the hair will not lie naturally over it. A third example is where the patient’s scalp is very tight. In this case, the donor density might be adequate, but it would just be hard to access it using a strip FUT procedure. In this case, FUE would also be appropriate.
From these situations, one can see that the decision to perform FUE vs FUT, or even a hair transplant at all, can be quite nuanced and requires a careful evaluation by a hair restoration surgeon with expertise in both procedures.
Q: Is it true that hair transplants can now be done totally by a robot?
A: The ARTAS Robotic System, developed by Restoration Robotics, is the most advanced technology for extracting grafts (the first and most difficult step in a Follicular Unit Extraction procedure), but it cannot yet do the entire hair transplant procedure, nor can it work without the supervision of the hair restoration surgeon.
Currently, the ARTAS System assists the surgeon in performing the first part of an FUE hair transplant (i.e., the extraction phase) with greater precision and consistency than can be done by hand. Engineers and researchers are currently developing the ARTAS to do the remainder of the procedure as well, i.e., making recipient sites in parts of the scalp that have lost hair and then implanting the harvested grafts into these sites.
The next step, recipient site creation, will be available in the latter half of 2014. Dr. Bernstein is already testing a beta version of this new technology. We anticipate that within two years, under the supervision of the surgeon, the ARTAS robot will be performing most of the FUE hair transplant procedure.
Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise.
A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.
Q: I’ve noticed from the chatter on blogs, that it is not uncommon for men to go through multiple FUE procedures over 10+ year time-frame. It seems to be that after the initial FUE procedure to address moderate hair loss, the patient continues their natural balding to where they must undergo another FUE procedure in order to get back to their desired look. I’m almost 33 and while I take Propecia, my hair loss has been very gradual since I was about 26. I still have what many would consider a full head of hair, although very thin and with noticeable loss at my temples and crown. I’d always thought that a hair transplant would be a “1 and done” procedure, and now I’m concerned that if I do an FUE procedure now to replace what’s been already lost, I’ll just have to revisit a subsequent FUE down the line. Are ongoing FUEs simply part of the hair maintenance that a patient needs to accept about hair restoration process?
Q: If I have no linear scar and I can exercise right away, why would you ever recommend FUT instead of FUE?
A: I advise FUT because the grafts are of better quality (less transaction and more support tissue surrounding the follicle) and because more hair can be obtained from the mid-portion of the permanent zone –- which is where the hair is the best quality and most permanent. For the majority of patients a linear scar buried in the donor hair is not an issue. Each patient has to weigh the pros and cons of each procedure when making a decision.
A: I think that both procedures are excellent, which is why I do them both. My recommendations are determined by the individual patient. His or her age, desire to wear hair cut very short, athletic activities, donor density and miniaturization, extent of hair loss, and potential future balding are all important aspects in the decision process.
Q: Is the recovery time a lot longer with FUT compared to FUE?
A: Cosmetically, the recovery for FUT is actually shorter, since the back and sides do not need to be shaved and the longer hair can completely cover the donor incision immediately after the Follicular Unit Transplant procedure. In large Follicular Unit Extraction procedures, the entire back and sides of the scalp need to be clipped very close to the scalp. It can take up to 2 or 3 weeks for the hair to grow long enough to completely camouflage the harvested area. Once the healing is complete and any redness has subsided, the hair can be cut shorter.
Q: I am an African-American man with tight curly hair. Will the FUE robot be able to work on curly hair?
A: Yes, the ARTAS robot for FUE can be adapted for African-American hair when performing follicular unit extraction. We use a punch that is 0.1mm wider in diameter than the instrument used for Caucasians. It allows us to incorporate the slightly larger volume of tissue that results from the curved hair and enables us to accomplish the hair transplant with less in jury to follicles than if a smaller instrument were used.
A: The ARTAS Robot performs follicular unit extraction just as well with blond hair as dark hair, but not white hair. It is simple to just to dye the white donor hair prior to the procedure. This donor hair will be clipped very short the morning of surgery removed anyway, so it will not present too much of a cosmetic issue.
A: The recipient area in both procedures is visible for up to 10 days. The donor area in FUT is generally not visible immediately after the procedure. In FUE, the donor area must be shaved, so that will be visible for up to two weeks (the time it takes for the hair to grow in).
A doctor’s comment regarding the paper “Pre-making recipient sites to increase graft survival in manual and robotic FUE procedures.”
Q: While I was lying awake last night your approach of making sites the day before implantation came to mind. It takes guts to have spearheaded that! I am not aware that that precedent has been set in hair transplant surgery. I would have been timid about infection; it’s a lot like closing a wound with a foreign body in it the next day. As with most things, I am a little slow to jump on board something new so I’m glad you’ve paved the way. Do you have any hesitance about this or do you have enough experience that you no longer hesitate? I would be concerned that variations of the local flora might make a difference and that, accordingly, a large sample size would be necessary to get comfortable. Glad for all of us that you are still blazing trails.
A: Thanks for your kind words. No hesitancy whatsoever. We find no increased risk. Think of it as if you did a hair transplant and ran out of grafts. The remaining sites don’t get infected, they just close up. In the process, all those chemotactic factors involved in the healing process move toward the wounds, so if a graft is placed into them, they would be less likely to get infected than a graft placed into a fresh (non-primed) wound, not more. It is like applying the surgical dressing Duoderm to a wound that helps it auto-sterilize. Putting the speculative science aside, we have not seen one single issue with it. Give it a try with an FUE or FUT procedure. Make the sites, have the patient takes his normal shower that night and you will be pleasantly surprised how little bleeding there is the next day and how easy it is to place the grafts.
Q: What are the chances of the donor scarring being visible long-term in FUT compared to FUE?
A: Both FUT and FUE produce donor scarring; FUT, in the form of a line and FUE in the shape of small, round dots. With FUT hair transplantation, the line is placed in the mid-portion of the permanent zone, whereas in FUE the dots are scattered all over the donor area.
If a patient becomes extensively bald (i.e. the donor fringe becomes very narrow), the line of FUT will generally still remain hidden, whereas the dots of FUE will be seen above the fringe of hair. In the less likely scenario of the donor hair actually thinning significantly, both the line (of FUT) and the dots (of FUE) may become visible.
Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ
A: FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).
In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.
Q: Can the ARTAS Robot FUE hair transplant be performed on blonds? I heard it only works on dark-haired individuals? — T.W., Jersey City, NJ
A: Correct, robotic FUE doesn’t work well on light-blond or white hair -– but it is easy to dye the hair prior to surgery, and this will solve the problem. We generally advise patients to dye their hair two to three days prior to the procedure so that any residue of the dying still on the scalp can be washed off.
Q: I wanted to find out about the difference between what Dr. Bernstein does with his robotic system versus NeoGraft. — G.M., Newark, NJ
A: The ARTAS robotic system, used at Bernstein Medical, has robotic control, video imaging and uses a blunt dissection technique. This allows for very precise extraction of follicular units from the donor area with minimal transection. The Neograft machine for FUE is a manually operated machine which uses sharp edge dissection. Because it relies on manual controls rather than robotics, it is less accurate and the cutting tip causes more graft injury. The precision of the robot allows the grafts to be harvested with less trauma and will thus result in better growth. In my opinion, these differences are very significant.
Q: Is robotic FUE more expensive than traditional Follicular Unit Extraction? — K.M., Wayne, NJ
A: In our practice, we charge the same per graft for both procedures. However, there is a slightly higher minimum fee for robotic FUE procedures. See our Hair Transplant Costs & Consultation Fees page.
Q: Does the robot do the whole operation or does the doctor do any of it? — B.W., Brooklyn, NY
A: The ARTAS robot only performs a small part of the FUE procedure, although it is an important one. The robot performs the first step, the isolation of follicular units.
Read more details about how the doctor uses the robotic FUE system.
Q: Is Robotic FUE faster than traditional FUE hair transplants? — F.W., Hoboken, NJ
A: Yes. Although, the speed of removal per graft is about the same, the actual procedure time is shortened when using the robotic device. The ARTAS robotic FUE system has a longer set-up time, but this is more than offset by the fact that the robot doesn’t “tire” during longer procedures.
Q: How many different kinds of robotic devices are there? — T.R., Boca Raton, FL
A: There is only one, the robot called the ARTAS System for FUE, made by Restoration Robotics. The Neograft machine, occasionally confused with a robotic device, is actually a hand-held instrument that is not robotically controlled and lacks image-based tracking. It is, therefore, not capable of eliminating the operator error and variability of hand operated devices and does not decrease the damage to follicles inherent in manual techniques.
Q: Does Robotic FUE leave any scars? — T.B, White Plains, NY
A: Robotic FUE leaves the same tiny, white scars in the donor area produced by manual Follicular Unit Extraction.
Q: What is the main difference between NeoGraft and the ARTAS™ robotic system? — H.T., Staten Island, NY
A: The Neograft device is basically a powered FUE tool. It is still done by hand and therefore risks operator induced errors and damage to hair follicles. The ARTAS System, made by Restoration Robotics, uses electronic image-based tracking capabilities to map the individual follicular units. It does so to determine the optimal approach for automated graft harvesting. The robotic harvesting device produces consistently high quality grafts and low dissection rates.
Q: With the ARTAS™ robotic system, by Restoration Robotics, what part of the FUE hair transplant procedure can actually be done by the robot? — A.M., Los Angeles, CA
A: The ARTAS System is a computer guided method of harvesting follicular units in the donor area during FUE. The initial phase of FUE, where the follicles are selected, scored and separated from the surrounding scalp is done by the ARTAS System. All other phases of the procedure including; actual follicular unit graft removal from the scalp, hairline design, recipient site creation and placement of the grafts into the balding scalp are done by the surgical team.
In the near future, improvements in the ARTAS System should allow it to be able to actually extract the separated grafts from the scalp. Eventually, the engineers hope to be able to increase the capability of the system so that it can create recipient sites and implant the extracted grafts into them.
Q: How does the ARTAS™ robotic hair transplant system actually work? — J.N., Fort Lee, NJ
A: The ARTAS System for Follicular Unit Extraction (FUE) combines several features including an interactive, image-guided robotic arm, special imaging technologies, small skin punches of two different sizes, and a computer monitor. After the system is positioned over the patient’s donor area of the scalp, ARTAS is capable of identifying and isolating follicular units from the surrounding scalp.
After the robotic arm is aligned with the follicular unit, a sharp 1-mm punch is used to cut through the upper part of the skin (the epidermis and upper dermis).
Immediately following this, a duller, 1.3mm punch is used to separate the deeper part of the follicular unit from the remainder of the dermis and subcutaneous fat. Once separated by the robot, the follicular units are manually removed from the scalp and stored until they are implanted into the patient’s recipient area.
Q: What does the ARTAS™ robotic system for Follicular Unit Extraction (FUE) actually do? — E.J., Plainsboro, NJ
A: ARTAS is a computer assisted system, made by a company called Restoration Robotics, that utilizes image-guided robotics to increase the quality of the hair follicles harvested during FUE. It aids in the initial part of the FUE procedure where follicular units are separated from the surrounding tissue. The system is operated under direct physician supervision.
Q: When was ARTAS robot for FUE approved for use in hair transplantation? — J.B., Jersey City, NJ
A: Restoration Robotics’ ARTAS System for robotic follicular unit harvesting, received 510K clearance by the Food and Drug Administration (FDA) on April 14, 2011. The indication is for “harvesting hair follicles from the scalp in men diagnosed with androgenetic alopecia (male pattern hair loss) with black or brown straight hair.”
Q: What is Restoration Robotics? — L.N., East Brunswick, NJ
A: Restoration Robotics is a medical device company, based in Mountain View, California, that has developed a computerized instrument to assist in the graft extraction phase of follicular unit extraction (FUE) hair transplant procedures. Their patented device, called “ARTAS,” is an image-guided system for FUE. Their website is: www.restorationrobotics.com.
Q: I have read your page on robotics in hair restoration and am interested in learning more. Are there any updates in the development of the system you mentioned? — W.T., London, UK
A: Restoration Robotics, Inc. — based in Mountain View, CA — has spent the last few years developing and testing a robotic hair transplant device for follicular unit extraction (FUE). The ARTAS™ robot system has recently received 510(k) approval from the Food and Drug Administration, meaning that the company may now begin marketing the system for use in hair restoration clinics.
Q: I recently saw an episode of the Rachel Ray Show where her guest, Dr. Anthony Youn, said that the Neograft machine for Follicular Unit Extraction is painless and uses a vacuum rather than surgery to remove the grafts. Can this be true?
A: Follicular Unit Extraction (FUE) using the Neograft machine is not painless and, while it does not produce a linear scar, it is surgery and there is significant scarring in the form of thousands of tiny holes that heal with round white marks.
Q: I have had a hair transplant done in the hairline of 1,000 or so FUE grafts. However, as the hair sheds, under natural light the recipient skin seems bumpy with incisions and holes that are noticeable. Do these tend to go away with time once they have healed?
A: If a follicular unit transplant is performed properly (using either extraction or a strip) there should be no bumps or surface irregularities. When the hair restoration is totally healed, the recipient area should be appear as normal looking skin.
Q: I wanted you to determine if I would be a candidate for FUE (to camouflage a scar). After reading through your vastly informative website, I had become aware that the Fox test is necessary to determine patient viability for FUE. When I mentioned the test, I believe I heard you say it was unnecessary. Unfortunately, I can’t help but think there was miscommunication between us, as your letter states that I should schedule a Fox test if I am considering FUE. Please confirm if a Fox test is, in fact, necessary.
A: I perform FOX tests on all patients when I am considering a FUE hair transplant. I do not routinely perform FOX tests before repairs (or on eyebrow transplants) where the number of grafts is relatively small.
The purpose of FUE is to identify those patients in whom FUE is inefficient — i.e. there is a greater than average risk of damage during the harvest. If this is the case, I would not perform the hair transplant since even slight inefficiencies create a significant problem when thousands of grafts are transplanted.
Q: I recently had a follicular unit extraction procedure of 320 grafts to fix an old strip scar. The donor area where the FUE’s were taken looks very diffuse – worse than the original scar ever was, it looks horrible. My doctor said this was just shock loss. Have you seen that happen where the donor area gets all diffuse from shock? If not, have you seen it where the FUE’s are taken in an illogical pattern resulting in new scarring that is noticeable?
A: You can have shedding in the donor area from an FUE procedure, although it is not common. In FUE, the hair must be taken from the permanent zone and if there is too much wastage in the extraction process, too large an area may be needed to obtain the hair. This can leave a thin look even without shock loss (shedding).
What Are Differences Between Follicular Unit Transplantation, Follicular Unit Extraction, and Ultra-refined FUHT?
Q: What is the difference between the following ways of doing hair transplants: Follicular Unit Transplantation (FUT), Ultra-refined FUHT, and Follicular Unit Extraction (FUE)?
In brief, with FUT, follicular units are obtained from the microscopic dissection of a donor strip that has been removed from the back of the scalp. In FUE, the doctor attempts to remove intact follicular units directly from the scalp via a small round instrument called a punch.
Ultra Refined FUHT (Follicular Unit Hair Transplantation) is term that Pat Hennessey uses on his Hair Transplant Network. It refers to using very tiny recipient sites, carefully dissected follicular unit grafts, and large hair transplant sessions in FUHT procedures.
Q: I am considering having an FUE procedure and have heard the phrases topping, capping, and tethering as part of the procedure. What do all these terms mean?
A: These are all terms that refer to the types of injury that can occur to grafts during a follicular unit extraction procedure.
In FUE, a sharp instrument (or sharp instrument followed by a blunt one) is used to separate follicular units from the surrounding donor tissue. Forceps are then used to remove the follicular units from the scalp.
Topping occurs in the first step when the doctor accidentally cuts off the top of the graft so that the remainder of the graft cannot be removed.
Capping occurs when the doctor grabs a graft with forceps and the top of the graft (the epidermis and upper dermis) pulls off, leaving the rest of the graft behind.
Tethering occurs when the bottom of the graft is still attached to the deeper tissues after the first step causing the follicular unit to pull apart during extraction.
Q: I had a hair transplant of over 600 grafts using Follicular Unit Extraction (FUE) to my frontal hairline and the frontal part of my scalp. The procedure was done less than a year ago by another doctor. Since then I have had persistent pimples and redness in the area that the grafts were placed. Also, the surface of the skin in the area is irregular.
A: One of the causes of having pimples and redness following Follicular Unit Extraction may be buried hair fragments and there are significantly more hair fragments generated with the two-step FUE technique than with the three-step method.
In the three-step procedure, we use blunt dissection which minimizes transection (cutting of hair follicles) and thus reduces the incidence of hair fragments. See the Three-Step FUE page at the Bernstein Medical – Center for Hair Restoration website.
Q: I am trying to have my donor scar repaired after a 1000 graft hair transplant. I was told the FUE’s placed into the scar would conceal it enough to shave my head? I would like to shave my head completely bald with a razor.
A: In general, after a scar correction with follicular unit extraction you can clip your hair very short, but not shave your head. If you shaved your hair completely bald, you would generally see a vague outline of the linear scar as well as the small scars from FUE.
A: In general, FUT will give you more hair since, in FUT, the best hair from the mid-portion of the permanent zone of the scalp (also called the “sweet spot”) can be utilized in the hair transplant.
With FUE, since only the hair follicles are extracted and not the surrounding bald skin, if too much hair is removed, the donor area will begin to look thin as hair is removed. This will limit the amount of hair that can be harvested.
Although in FUE additional areas of the scalp can be utilized to some degree, this will generally not compensate for the inability to access all of the hair in the mid-permanent zone and the total amount available for the hair restoration will be less.
Q: Is it possible to do a hair transplant using follicular unit extraction without shaving the donor area?
A: In follicular unit extraction, the area that is extracted is clipped to about 1-mm in length. However, if the session is not too large, then the clipped area can be long and thin so that the patient’s existing hair will cover it. The person’s hair should be left long for the procedure.
A: The first paper on Follicular Unit Hair Transplantation was published by Dr. Bernstein and Rassman in 1995 in the International Journal of Aesthetic and Restorative Surgery. The title of the paper used the abbreviated name Follicular Transplantation. The longer name “Follicular Unit Transplantation” was formalized by Bernstein et. al. in the paper “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” This paper appeared in Dermatologic Surgery in 1998.
Follicular Unit Extraction derived its name from Rassman and Bernstein’s publication “Follicular Unit Extraction: Minimally invasive surgery for hair transplantation” that appeared in Dermatologic Surgery in 2002.
Q: Can you shave your scalp after a hair transplant with FUE without noticing scarring in the donor area?
A: Although there is no line scar in follicular unit extraction, there are tiny round ones. You can clip your hair very short after FUE, however, shaving your head will make the very fine white scarring visible.
Q: What is Follicular Unit Transplantation and how is it different from Follicular Unit Extraction?
A: Follicular Unit Hair Transplantation, called FUT for short, is a procedure where hair is transplanted in the naturally occurring groups of one to four hair follicles. These individual groups of hair, or units, are dissected from a single donor strip using a stereo-microscope. The area where the donor strip was removed is sutured closed, generally leaving a thin, fine, line scar.
In Follicular Unit Extraction, or FUE, the individual units are removed directly from the back or sides of the scalp through a small round instrument called a punch. There is no linear scar. There is, however, scarring from the removal of each follicle. Although the scars of FUE are tiny and round, the total amount of scarring is actually more than in FUT.
In addition, since in FUE the bald skin around each follicular unit is not removed, the total amount of hair that can be removed in FUE is substantially less than in FUT. This is because if one were to remove all the hair in an area, it would be bald. In FUT, the intervening bald tissue is removed along with the follicles in the strip.
Q: Is it possible to use the strip technique with the extraction technique together? If so, would that hide the scar enough for me to wear my hair really short?
A: The combination of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) used the way you are suggesting does make sense and is actually how I originally envisioned the two procedures to work together.
The camouflage of the donor scar will probably never be necessary, but if it is desired, it should be postponed until after the last FUT procedure. FUE will make it possible for most people to wear their hair very short.
Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction?
A:It is possible to use beard hair for a hair transplant, but there are three main differences between harvesting from the donor area and harvesting from the beard that should be taken into account. These are: 1) scarring 2) ease of extraction and 3) hair quality. Let’s explore these differences in turn.
Q: If someone doesn’t have enough donor hair, do you ever perform a hair transplant using FUE, using donor hair from outside the permanent hair zone?
A: No. If hair was taken from outside the permanent zone as the surrounding hair continued to bald, the scars from FUE, although small, would become visible.
In addition, the transplanted hair would not be permanent, and over time would eventually fall out.