Q: As a medical advisor and an end-user of the ARTAS Robotic System, do you see any impact of your involvement with Restoration Robotics? — J.V. ~ Miami, F.L.
A:Restoration Robotics has been very responsive to the needs of its physicians and to their patients. Because I work closely with Restoration Roboticsin the development of new improvement and advances they are often introduced first in our practice.
Dr. Bernstein is credited with introducing the “follicular unit” to surgical hair restoration, the innovation that allowed for a “completely natural-looking hair transplant” to be achieved. The commentary on Dr. Bernstein’s contributions to the field of hair transplantation are outlined in an historical review of dermatologic surgery that appeared in the Journal of the American Academy of Dermatology.
Dr. Bernstein is noted as being responsible for moving the field of hair restoration surgery away from large graft “plugs” and mini-micrografts to follicular units:
The 2 advances, the application of the stereomicroscope to follicular dissection and the use of follicular units as the basic element of hair transplantation, arose from a background in dermatology. They moved the field of hair restoration surgery from plugs and mini-micrografting, where this basic anatomical feature of the hair follicle was ignored, to follicular unit transplantation, where the follicular unit became sacrosanct. These 2 ideas, when put to clinical use, allowed the once elusive goal of a completely natural-looking hair transplant to finally be achieved.
Dr. Bernstein’s pioneering of the Follicular Unit Transplant (FUT) procedure still resonates, almost two decades later, as the follicular unit continues to be the anatomical structure that is transplanted in hair transplant surgeries worldwide.
The article then describes how Dr. Bernstein, along with his colleague Dr. Rassman, laid the foundation for the next major developments in hair restoration; first with his description of the Follicular Unit Extraction (FUE) technique and more recently with innovation in robotic hair restoration technology.
With the publication of the article, “Follicular unit extraction,” in 2002, the follicular unit extraction procedure gained popular appeal and was rapidly adopted by doctors worldwide. The authors cautioned on the limitations of this harvesting technique and the risk of follicular damage. Dermatologists Berman, Zering, and Bernstein, along with their colleagues in other specialties, continue to work on the problem of harvesting in follicular unit extraction, with the application of robotic technology showing particular promise.”
Taken together, these passages underscore how Dr. Bernstein’s research and medical publications have fundamentally transformed the field of hair restoration to the benefit of patients and physicians alike. While many other very talented physicians have had a substantial impact on hair restoration procedures ever since the hair transplant concept was first proposed by Dr. Norman Orentreich in the 1950s, Dr. Bernstein has contributed the key innovations that have made modern, natural-looking hair transplant surgery a medical and aesthetic possibility.
The article is titled, “Current status of surgery in dermatology.” The Journal of the American Academy of Dermatology is the official journal of The American Academy of Dermatology (AAD), the largest, most influential and most representative dermatology group in the United States.
Reference
C. William Hanke, Ronald L. Moy, Randall K. Roenigk, Henry H. Roenigk Jr., James M. Spencer, Emily P. Tierney, Cynthia L. Bartus, Robert M. Bernstein, Marc D. Brown, Mariano Busso, Alastair Carruthers, Jean Carruthers, Omar A. Ibrahimi, Arielle N.B. Kauvar, Kathryn M. Kent, Nils Krueger, Marina Landau, Aimee L. Leonard, Stephen H. Mandy, Thomas E. Rohrer, Neil S. Sadick, Luitgard G. Wiest, Current status of surgery in dermatology, Journal of the American Academy of Dermatology, Volume 69, Issue 6, December 2013, Pages 972-1001, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2013.04.067.
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.
The innovations Dr. Bernstein has described through his medical publications are now a part of history. In the Millennium Paper of the journal Dermatologic Surgery, a comprehensive history of the field of dermatologic surgery cites Dr. Bernstein as being one of the three physicians who played a leading role in hair transplantation in the 1980′s and 1990′s.
“Millennium Paper: A History of Dermatologic Surgery in the United States,” draws on research and papers authored over the past 100 years to develop a timeline of the most important advances. The article appears in the January 2000 issue of Dermatologic Surgery (Volume 26, Issue 1).
Dr. Bernstein’s 1995 publication ‘Follicular Transplantation’ was the first to describe the use of naturally-occurring follicular units as the basis for surgical hair restoration. This paper and others have secured Dr. Bernstein’s place in the “long and distinguished history” of cutaneous surgery.
Reference
Millennium Paper: A History of Dermatologic Surgery in the United States. Dermatologic Surgery 2000; 26(1): 5-11.
Dr. Bernstein is credited with introducing the “follicular unit” to surgical hair restoration, the innovation that allowed for a “completely natural-looking hair transplant” to be achieved. The commentary on Dr. Bernstein’s contributions to the field of 
The innovations Dr. Bernstein has described through his medical publications are now a part of history. In the Millennium Paper of the journal Dermatologic Surgery, a comprehensive history of the field of dermatologic surgery cites Dr. Bernstein as being one of the three physicians who played a leading role in hair transplantation in the 1980′s and 1990′s.
