Q: How does the ARTAS System avoid damaging hair follicles in the balding area during recipient site creation? — R.K., Brooklyn, NY
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.
A 2014 study in the journal Dermatologic Surgery measured follicular unit transection (follicle damage) during the extraction step of a robotic follicular unit extraction (R-FUE) procedure. The study found that robotic transection rates, using the ARTAS Robotic System, compared favorably with non-robotic (manual) FUE transection rates. ((Avram MR, Watkins SA. “Robotic follicular unit extraction in hair transplantation.” Dermatol Surg. 2014 Dec;40(12):1319-27))
The researchers found the average rate of transection over many robotic procedures to be 6.6%. This rate compared favorably to an average manual transection rate of 6.14% reported in a 2006 study ((Harris JA. “New methodology and instrumentation for follicular unit extraction: lower follicle transection rates and expanded patient candidacy.” Dermatol Surg. 2006;32:56–612.)) and was significantly lower than an average transection rate of 17.3% reported in 2008 study using manual techniques. ((Onda M, Igawa HH, Inoue K, Tanino R. “Novel technique of follicular unit extraction hair transplantation with a powered punching device.” Dermatol Surg. 2008;34:1683–8.))
While the study’s robotic FUE transection rates compared favorably to two reported manual transection rates, the authors stressed that more well-designed studies comparing robotic to manual FUE are needed.
The authors noted that “The main advantages of robotic FUE compared with the standard ellipse are its minimally invasive nature and the lack of a linear scar.”
This paper was reviewed by Dr. Bernstein. ((Bernstein RM. “Commentary on Robotic Follicular Unit Extraction in Hair Transplantation.” Dermatol Surg. 2015;41:279.))
Dr. Bernstein Presenting ‘Follicular Unit Extraction: Then and Now’
Dr. Bernstein was honored to deliver the keynote address at the ARTAS International Users Forum in San Francisco, California. Dr. Bernstein’s presentation, “Follicular Unit Extraction: Then and Now,” was a review of the evolution of surgical hair restoration from Follicular Unit Transplantation (FUT) through Follicular Unit Extraction (FUE) to the cutting edge technique of Robotic-FUE.
The presentation described the steps that resulted in the use, and growth in popularity, of the state-of-the-art ARTAS Robotic System for FUE. Dr. Bernstein pointed out that with the introduction of each procedure — FUT, FUE, and Robotic-FUE — there was initially a rocky reception with physicians. In each instance, however, the surgeons’ concerns were overcome first by strong, patient interest and then by clinical studies that confirmed the procedures’ usefulness.
Dr. Bernstein discussed how FUE procedures progressed from the use of hand-held instruments to the computer-assisted, image-guided ARTAS Robot. One of the initial hurdles of FUE procedures using hand-held devices was a high rate of follicular unit transection (cutting of the follicles). Restoration Robotics, Inc., the company that developed the ARTAS system, used a “sharp/blunt” punch technique that was introduced by Jim Harris in his 2004 publication on the SAFE System for FUE. The sharp/blunt technique, that was validated in 2006 by Dr. Bernstein’s research publication, “New Instrumentation for Three-Step Follicular Unit Extraction,” reduced transection of follicles when compared to older instrumentation. Dr. Bernstein then detailed modifications to the system that he proposed in order to improve the ARTAS robot. These improvements include: a smaller tip for the sharp/blunt punch, selection of larger over smaller follicular units, tensioner placement, ‘feathering’ the ends of the tensioner, and pre-making recipient sites before extracting the follicular unit grafts.
Looking to the future, Dr. Bernstein mapped out the further evolution of the Robotic FUE procedure and the tasks it will be required to perform. In future procedures, the physician will not only guide the robot on extracting follicular units, but also in creating recipient sites and, further down the road, placing grafts into the recipient sites. Graft placement will represent the most significant challenge to the robotic system as this step is the most sensitive to patient to patient variability. Once this last step is accomplished, a fully automated hair transplant should be possible, eliminating much of the human error in the mechanical aspects of the hair restoration process.
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.
With subsequent FUT procedures we remove the first scar, so the patient only has one scar (albeit long). With subsequent FUE sessions we are adding additional scars, so over the long-term the cumulative scarring over large areas can present its own problems of visibility.
The main advantage of FUE is to have the option of wearing your hair very short (but not shaved). FUE is also appropriate for patients who are at risk for a widened donor scar (i.e., very athletic and muscular or with thin, tight scalps, etc.).
In my experience, Robotic Hair Transplantation is superior to other FUE methods in that it is much more accurate and more consistent. It enables the doctor to extract grafts with less damage than with hand-held instruments or other automated devices.
We are pleased to announce that robotic FUE is now available at Bernstein Medical – Center for Hair Restoration. This is a major advance in FUE technology.
The ARTAS system for hair restoration allows us to more effectively isolate follicular unit grafts from the donor area of the scalp without causing damage to individual follicles, a problem that has been a limitation of manual FUE techniques. Many other important parts of the FUE procedure will still be performed by the physician and team, including actual removal of the follicular units from the scalp, recipient site creation, and graft placement. The aesthetic elements that give a hair transplant a natural-looking result will still be in the hands of the physician. Read more about the benefits of robotic hair transplantation.
We are proud of the cutting-edge work we do in our state-of-the-art medical facility and are excited as we take FUE hair transplantation to the next level.
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, called transection, inherent in manual techniques.
Dr. Bernstein is quoted extensively in an article on robotic hair transplantation in the online magazine American Health & Beauty.
ARTAS Robotic FUE Imaging System Click for larger version
In “ARTAS: A Faster and More Accurate Hair Transplant Using Robotics?” Dr. Bernstein explains the benefits of robotic FUE over traditional FUE hair transplant procedures. He describes how the new robotic device overcomes some important limitations of FUE when performed manually. To better understand the role of the new instrument, Dr. Bernstein simplifies the FUE procedure into four basic steps and discusses where the image-guided robotic system fits into this process.
Dr. Bernstein explains how the new technology enables the robotic device to preserve follicular units and minimize damage to grafts though its image-guided system.
“ARTAS allows us to do the FUE procedure with much less damage to the graft which means much healthier grafts. Grafted follicles extracted by ARTAS are not cut, which has been a problem with FUE, but the grafted follicular units are actually chunkier with more protective tissue around them, resulting in a better graft survival with the robotic FUE vs. doing FUE manually,” says Dr. Bernstein.
Follicular Unit Grafts Removed by ARTAS Robotic System Click for larger version
In addition to extracting grafts that have a higher chance of surviving the extraction and transplantation process, the article discusses the increased speed and accuracy of the automated procedure, as well as the safety mechanisms built into the robotic unit.
Always with an eye towards the future of hair transplantation, Dr. Bernstein predicts what he sees as an inevitable rise in the use of robotics in the field:
“I imagine that within a relatively short time, everybody will be offering the robot-assisted device when considering FUE procedures, because it’s just a better way of doing it: more accurate, quicker extraction and healthier grafts.”
The ARTAS System, developed by the California-based Restoration Robotics, Inc., will be available for FUE hair transplant procedures at Bernstein Medical – Center for Hair Restoration in November 2011.
Robotics in FUE hair transplant surgery is a topic that is attracting increasing attention in the world of hair restoration. As we have discussed, the ARTAS robotic system for hair restoration is the newest technology in this ever-evolving field.
Before & 9 Months After FUE with ARTAS Robotic System Click image for larger version
This new system, developed by Restoration Robotics, Inc., is more than just a new tool for performing Follicular Unit Extraction. Rather, it is a complex system that uses the latest in mechanical and software technology to automate FUE surgery. The robot not only allows doctors to perform this typically labor and skill intensive procedure, but it provides a variety of benefits to their patients. Among these benefits are increased accuracy in follicular unit graft harvesting, reduced harvesting time, and increased graft survival.
An article in the September/October 2011 issue of the journal Aesthetic Trends & Technologies adds detail to our knowledge of the benefits of the ARTAS System. The article, titled, “How Technology is Changing the Hair Restoration Industry,” first gives a basic overview of the system and why it was developed. It then goes on to describe how a specially-designed device, called a skin tensioner, along with an image-guided system, tracks each follicular unit on the patient’s scalp and allows for the precise control of graft extraction.
From the article:
The technology determines the location, angle, and direction of each individual hair follicle; and via complex algorithms and computer programming, it is able to determine almost instantaneously the proper approach to harvest each follicular unit. The image-guided robotic arm begins harvesting the hair follicles in random patterns, according to the harvest spacing set by the physician. These random patterns make the procedure virtually undetectable after the wounds have healed.
The accuracy and performance of the image-guided robotic system is notable and contributes significantly to the improved outcome of the FUE procedure. As Miguel Canales, M.D., Medical Director for Restoration Robotics, says in the article, the transection rate, or rate at which follicular units are damaged in the extraction process, is consistently less with robotic controlled FUE compared to that performed manually.
This kind of consistency yields a benefit not only to seasoned hair restoration surgeons, but to physicians of all skill levels. James Harris, M.D., a hair restoration physician based in Colorado, says that a novice physician, who might only be able extract 50-70 grafts in one hour using the traditional manual technique, extract 600-700 an hour. For a procedure of 1,500 grafts, the physical demand on both the physician and the patient is substantially reduced with the ARTAS System versus the standard manual graft excision techniques in FUE surgery.
Before & 7 Days After FUE with ARTAS Robotic System Click image for larger version
The developers of the ARTAS System were also conscientious of the safety of the FUE patient. An array of sensors monitors patient movement and causes the system to respond to the force of the punch used in graft excision or to any instances where the system’s casing touches the patient. If the force exerted is too strong, or if the casing touches the patient, the system automatically backs away from the patient, allowing the physician to make sure that all is well before the surgery proceeds. According to the article, there were no safety-related “adverse events” in trials with over 350 patients.
From the efficiency of the ARTAS System in extracting follicular unit grafts, to the quality of the grafts, to patient safety, the benefits are many for the physician. The patient will receive a high quality hair transplant with a less intensive time commitment, less local anesthesia needed to numb the area, improved hair growth rates, and a better overall FUE hair transplant experience.
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: 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? — C.C., Hell’s Kitchen, N.Y.
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.
There are a few other terms used as well.
Shredding occurs when the follicular unit is not totally separated from the surrounding tissue and pulls apart upon extraction. Shredding can also occur when the follicular unit was partially damaged in the first step.
Transection is like topping, but here the mid or lower portion of the hairs in the unit are cut.
Buried grafts occur when the graft is pushed into the sub-cutaneous space rather than extracted. Buried grafts can usually be removed, but if not removed completely, may turn form small cysts.
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. — E.Z., Long Island, N.Y.
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.
In our practice, we also place every extracted graft under the microscope. This serves a number of purposes:
It gives me immediate feedback on transection rates, so that I can adjust my technique in real-time (using a stereo-microscope is much better than visual inspection for this purpose)
It enables us to trim away excess tissue and hair fragments (we use the same judgment as we do with strip harvesting, so that a “viable looking” fragment would be left attached
It allows us to accurately count the number of hairs in each follicular unit graft, as it is particularly important to have pure 1-hair grafts for the frontal hairline. This also allows us to better anticipate the end cosmetic result.
It allows us to dissect larger follicular units into smaller ones for specific cosmetic purposes, i.e. eyebrows, hairlines, temples etc.
One of the ironies of FUE is that it is more efficient to extract the larger FUEs, since this gives us a greater hairs/hole ratio, but this often leaves us with an inadequate number of 1-hair units, which must be obtained though traditional stereo-microscopic dissection of the larger extracted grafts.
Other causes of folliculitis (manifested by pimples and redness) can result from placing the grafts too deep in the recipient site (where they may get buried) and secondary infection. A mild, transient folliculitis is often seen after a hair transplant without any precipitation factors.
