Bernstein Medical physicians answer the most frequently asked questions on Robotic FUE hair transplant procedures and the ARTAS® System. For additional Q&A on robotic hair transplants visit Answers.

Robotic FUE FAQ

What is a Robotic Hair Transplant?

A robotic hair transplant is a type of hair restoration procedure where donor hair is removed directly from the back and sides of the scalp using robotic control. The specific type of hair transplant where robotic technology is used is called Follicular Unit Extraction (FUE). In FUE, a small round punch instrument separates individual follicular units (naturally occurring groups of 1-4 hairs) from the surrounding tissue so they can be extracted then implanted in the balding area. This process is very tedious and exacting, and when it is performed using manual instruments it often leads to significant damage or injury to the follicles.

Robotic technology allows the FUE procedure to be performed in a more precise and consistent way, ultimately maximizing the growth of the grafts. In a robotic FUE hair transplant, follicular units are extracted one at a time by the image-guided, computer-driven system called the ARTAS Robotic System, a technology developed by the company Restoration Robotics. At Bernstein Medical, all FUE procedures employ the speed and precision of the robotic system.


Robotic FUE FAQ

Is There an Ideal Patient for Robotic FUE?

The indications for Robotic FUE are similar to manual FUE. FUE can be performed on any patient who is a candidate for a hair transplant. In general, robotic follicular unit extraction is particularly suited to patients who wish to maintain a short hair style and who are very physically active and want to return to sports or rigorous activity as soon as possible. FUE is also the treatment of choice for patients with very tight scalps or who have an increased risk of donor scarring.

As with manual FUE transplants, the ideal robotic FUE patient is one with stiff, coarse hair that is more perpendicular to the scalp (rather than lying flat) and whose skin possesses a thick dermis. These features are particularly striking in patients of Asian descent. Clinically, the robotic system is widely used on various hair types such as coarse straight hair, curly hair, and wavy hair of different colors. Robotic FUE is also very useful in African-American patients who are at risk to a having thickened donor scar from an FUT-strip procedure.

To determine if you are a candidate for Robotic FUE, you must have a hair loss consultation with a board certified hair restoration physician.


Robotic FUE FAQ

How Does the ARTAS System Work?

The ARTAS System is composed of a robotic arm, dual-needle punch mechanism, video imaging system, and computer user interface. Its extraction technique consists of a double-punch arrangement with an inner (sharp) punch and outer (dull) punch. The inner punch has a cutting capability and is used to score the upper most part of the skin. The outer punch dissects the follicular units from the surrounding tissue, with the blunt edge helping to minimize injury to the grafts. This sharp/blunt technique, a modification of the original sharp FUE punch technique, has significantly reduced the incidence of follicular transection (damage to the grafts). The image-guided technology allows this step to be accomplished with microscopic precision.

The patient lies on a specially designed operating table that allows access of the robotic arm to the donor area of the scalp. A grid-like device called a tensioner is applied to the donor area of the patient’s scalp. The tensioner contains fiducials on its outer border which the robot “reads” for proper orientation; the robotic punch system isolates the grafts within the grid. The physician then advances the robotic arm into position to allow the robot to analyze the fiducials for proper orientation. There is a “pendant,” or remote, that the surgeon can use to advance the robotic arm while standing adjacent to the patient. The physician may then select various parameters in the computer algorithm, including the depth of the sharp and blunt punches (which can be measured with markings seen on the needle), the angle which the robot enters the scalp to perform the punch, and a variable distance between the follicular unit punches performed by the robot. The robot is then automated to isolate the follicular unit grafts within the grid utilizing these parameters.

Once the system has made incisions around a hundred or more follicular units, special forceps are used to extract the units from the scalp and place them in a special holding solution. This process is repeated until the prescribed number of follicular units to be transplanted has been extracted from the donor area. The follicular units are then implanted manually into recipient sites in the balding area and the transplant is complete.


Robotic FUE FAQ

How Long Does a Robotic Procedure Take?

The length of your hair transplant procedure will depend upon how many follicular unit grafts are transplanted. Small to medium size sessions (fewer than 2,000 grafts) generally take one day. Larger FUE sessions will be performed over two consecutive days.


Robotic FUE FAQ

How Does Recovery from a Robotic Hair Transplant Compare to FUT or FUE Procedures?

Recovering from a Follicular Unit Extraction hair transplant with the robot is the same as recovery with a manual FUE device. However, there is a significant difference between FUE and FUT procedures. Compared to FUT strip surgery, the donor area heals faster and with less discomfort after Robotic FUE. Also, with FUE there are no limitations on strenuous exercise after the procedure. After Robotic FUE you can resume your normal routine after one or two days.

While robotic and manual FUE procedures and FUT strip surgery will scar the donor area, the nature of the scaring is quite different: FUT leaves a linear scar, while FUE leaves many tiny white dots. Because of this, you will be able to wear your hair shorter after an FUE procedure than after FUT. Healing in the recipient area, where the grafts are placed, is the same in Robotic FUE, manual FUE, and FUT.


Robotic FUE FAQ

Does an ARTAS Robotic Hair Transplant Require Stitches?

As with all Follicular Unit Extraction (FUE) procedures, the ARTAS robotic system is a minimally invasive hair transplant technique that does not require stitches or surgical staples. Instead of the sutured donor incision of a strip FUT procedure, robotic FUE leaves tiny round incisions that heal with little white marks that are imperceptible even with sort hair.


Robotic FUE FAQ

Does the Robot Work with Dark, Blonde, Gray, Curly, White, or Ethnic Hair?

The ARTAS robot is able to perform on dark hair, blonde hair, gray hair, very curly hair, and ethnic hair. With ethnic hair we use a 1.0mm punch instead of a 0.9mm punch. People who have white hair need to dye their hair before the Robotic FUE procedure in order for the robot to best visualize the hair follicles.


Robotic FUE FAQ

How is Robotic FUE Different than Manual FUE? What Are the Advantages to Robotic Transplants?

Harvesting

In robotic FUE hair transplant procedures, individual follicular units are harvested directly from the donor area using a sharp inner needle and an outer dull punch. The inner needle creates a shallow scoring incision that pierces the epidermis. The outer dull rotating punch dilates the scoring incision, dissects deeper into the scalp and frees up the follicular unit graft from the surrounding tissue. The robotic system uses a sophisticated optical system and algorithms to automatically detect hair on the scalp, target multi-hair follicular units, calculate the appropriate angle of dissection and adjust the depth of dissections based on physician inputs. A suction system lifts the graft up above the scalp, facilitating manual forceps extraction of the grafts. The parameters that control the robotic dissection can be modified in-real time if adjustments are needed to these variables. The robotic FUE system has the advantage of both precision that does not fade over thousands of harvests and the ability for the physician to override the system when needed. The peer-reviewed literature states that transection rates of the robotic FUE technique are between 4.9%-6.6%.[1],[2]

Graft selection is the key to obtaining the most hair with the least amount of recipient wounding. In the robotic system, the physician programs the robot to select grafts based on the desired hair content and establishes the field from which those grafts are harvested. The visual field is converted to an enlarged digital image in which the physician can program the robot’s computer to select grafts from areas of higher density and avoid those of lower density in advance of the actual extraction. It can also increase the spacing of the harvests in areas of lower density and can feather the edges of the harvest for a more undetectable appearance. Although these manipulations can be done by hand, with the robotic system the physician can make these decisions in advance. In this way, the process is not affected by decreased visibility due to bleeding or the loss of orientation and/or concentration when the manual operator is focused on other factors such as punch angle and depth.

In manual FUE techniques, hand-held instrumentation can vary from sharp punches to dull instruments and these can be motorized to rotate into the skin or manually oscillated. The physician wears magnified lenses to directly visualize the hair on the scalp, manually aligns the cutting tip of the extraction instrument to be parallel to the hair follicles as it penetrates the skin and physically estimates the depth of the punch, or controls it with a mechanical stop. In the manual system, graft selection is achieved visually by the physician.

Recipient Site Creation

When recipient site creation is performed manually, the physician must estimate both the distribution and density of sites for a specific area. He must then control both the angle and depth as these sites are being made, as well as trying to avoid existing terminal hair.

In robotic site creation, the physician first uses a software program on a tablet computer to design the recipient site pattern on a 3D model of the actual patient. The software has the versatility to simulate the potential patient’s aesthetic outcome using different recipient site scenarios. Once the physician and patient agree on a plan, the treatment plan is transferred to the robotic system, which makes the actual recipient sites on the patient. The physician programs the system so that a specific number of grafts can be randomly distributed over a desired area, eliminating errors in placing too many grafts in one area and having inadequate numbers for another. The robotic system can also be more uniform in site depth and more precise in keeping sites parallel to one another compared to hand. Most importantly, when creating sites in areas of existing hair, the robot can be programmed to avoid pre-existing terminal hair by a pre-determined distance – a task that is extremely difficult to do by hand.

In sum, the robotic FUE system can perform both the separation of follicular unit grafts from the surrounding scalp and recipient site creation with precision and consistency, regardless of the number of grafts. Its image-guided system and sophisticated computer algorithms enable the physician to carry out these functions to his/her exact specifications, but can also be adjusted in real-time as clinical situation demands.


Robotic FUE FAQ

Does the ARTAS Robot Perform the Entire Procedure, or Does the Physician Also Perform Part of the Procedure?

There are four main steps to a Follicular Unit Extraction (FUE) procedure (in addition to the consultation, surgical planning and design). These are:

  1. Separation of follicular unit grafts from the surrounding scalp
  2. Extraction of the grafts from the scalp, trimming and sorting
  3. Recipient site creation
  4. Graft placement

The ARTAS robot, under the guidance of a hair transplant surgeon, can perform two of the four major steps in an FUE hair transplant: follicular unit separation (step 1) and recipient site creation (step 3).

After follicular unit grafts have been separated from the surrounding tissue by the robot, they are manually extracted using fine serrated forceps. The extracted grafts are then trimmed, counted, and sorted according to the number of hairs they contain (step 2). The robot is currently not able to perform these steps.

It is anticipated that within the next several years, the robotic system will be able to make recipient sites and simultaneously place grafts into these sites (steps 3 & 4), so that in the near future, three of the four main steps of FUE will be performed robotically.

In a Follicular Unit Extraction (FUE) procedure, the physician should be intimately involved with the entire hair transplant, whether manual or robotic. In robotic graft extraction, the physician inputs the surgical parameters into the robot’s software via a computer terminal or hand-held device. At the start of the procedure, he manually applies the tensioner (a rectangular picture frame-like device) to the patient’s scalp to orient the robot in the operative field and to create traction on the scalp. During the procedure, the physician adjusts certain parameters, such as punch depth and angle, using the hand-held pendant or the computer. The tensioner must also be advanced to new areas of the scalp as the harvest in each area has been completed.

In robotic site creation, the physician programs the total number of sites, density for specific areas, site angle, needle orientation (coronal or sagittal) and site depth. A fiducial is used to orient the robot to specific regions of the patient’s scalp. Once programmed, the site creation will proceed automatically, unless overridden by the physician

There are many other important physician-dependent steps in the Robotic FUE hair transplant, especially the recipient site planning and design of the procedure. 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.


Robotic FUE FAQ

Does Robotic FUE Eliminate Pain and Scarring?

As with manual FUE, robotic FUE hair transplantation is a minimally-invasive outpatient procedure performed under long-acting local anesthesia – usually a combination of lidocaine and bupivacaine. After the initial injections, the patient doesn’t experience any pain or discomfort. In contrast to an FUT-strip procedure which can be uncomfortable in the donor area for days to weeks following surgery, with robotic FUE, there is no discomfort once the procedure is completed and the anesthesia wears off.

All Follicular Unit Extraction procedures produce donor scarring, but in contrast to the linear scar of an FUT-strip, FUE procedures leave fine, white dots easily covered by hair. Scarring from robotic FUE is comparable to scarring from manual FUE for similar size punches. Scarring can be minimized with robotic FUE by programming the robot to select only the larger follicular units so that there will be more hair, on average, obtained per harvest.


Robotic FUE FAQ

Can I See a Preview of How My Hair Will Look After My Robotic Hair Transplant?

ARTAS Hair Studio is a computer program that allows physicians to help patients see his/her personalized hair restoration outcome through a visualization of the planned results. The software creates a 3-D digitized model of the person’s head which can be used to demonstrate how the results will appear. The physician can even show the patient anticipated results using different numbers or densities of grafts. The software also aids the physician in explaining important details of the transplant design. As a result, the patient is more engaged in the process and can better understand the rationale behind the surgeon’s recommended plan.


Robotic FUE FAQ

Are There More Risks Using a Robot or With a Physician Using a Handheld Instrument?

If the physician controls the robotic procedure, there should be no more risk than if the physician performed the entire procedure manually. The ARTAS system is a 510K cleared medical device that was engineered to include multiple safety features including automatic optical control, force sensors, and E-stops. The tensioner, a frame-like device that is applied to the patient’s scalp, is secured with silicone straps that limit head motion during the procedure. If there is any head movement while the robot is functioning, built in motion sensors automatically pause the action of the robotic arm. The robot can also be paused at any time using the stop buttons located on the pendant and at the computer user interface.

Another safety feature of the robot is the system of sensors that determine the depth of punches used in harvesting and the needles in recipient site creation. If a sensor registers forces beyond safety threshold levels or increasing forces during dissection, an automatic stop is triggered and the device retracted away from the scalp.


Robotic FUE FAQ

What are the Qualifications of the ARTAS Technicians You Use?

We do not use ARTAS technicians at Bernstein Medical. The staff members that assist Dr. Bernstein or Dr. Wolfeld during the robotic FUE procedure are our regular full-time staff of nurses and medical assistants who are fully trained and certified in the ARTAS procedure. Because we also perform FUT, our staff is also expert in stereo-microscopic follicular unit dissection, an essential part of trimming, counting and sorting the robotically-harvested grafts.


Robotic FUE FAQ

How Does the ARTAS System Compare to Neograft?

The Neograft machine for Follicular Unit Extraction (FUE) uses a single sharp punch to isolate grafts and a suction mechanism to extract grafts from the scalp. Both the sharp punch and suction are felt by many doctors to risk injury to the follicles due to the tendency to cut follicles and separate the follicles from their vital support tissue. Also, the Neograft uses a hand-held instrument that must be manually guided by the physician in order to extract the grafts. If the physician imperfectly aligns the sharp punch with a follicular unit or if the incision is too shallow, there is a significant risk of damaging the graft. The ARTAS robot‘s two-step sharp/blunt dissection technique and image-guided robotic system offers precision and control that is impossible to replicate using a hand-held FUE device like the Neograft.


Robotic FUE FAQ

Is the ARTAS System Safe for FUE Hair Transplant Surgery?

The ARTAS FUE robot has multiple safety features that are only available in a robotic system. The tensioner, or grid, that is applied to the patient’s scalp is secured with silicone straps that limit head motion during the procedure. If there is any head movement while the robot is functioning, built in motion sensors automatically pause the action of the robotic arm. The robot can also be paused at any time using the stop buttons located on the pendant and at the user interface.

Another important safety feature of the robot is the system of advanced sensors that determine the precise depth of the sharp and blunt needles used in the punching mechanism. These needles each have a built-in skin pressure sensor that can trigger an automatic on/off switch. If a sensor registers pressure greater than 10 newtons, an automatic stop is triggered and the punch mechanism is retracted.


References:
  1. Shin JW et. al. Characteristics of robotically harvested hair follicles in Koreans. JAAD 2015; (72)1:146–150. []
  2. Avram M, Watkins S. Robotic follicular unit extraction in hair transplantation. Dermatol Surg 2014; 40:1319–1327 []

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