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?
Dr. Bernstein Operating the ARTAS FUE 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.
Dr. Bernstein Presenting at ARTAS User Group Meeting 2015
Dr. Robert M. Bernstein introduced a new capability of the ARTAS robotic system, “Follicular Unit Graft Selection,” at the ARTAS User Group Meeting on February 7th, 2015 in Newport Coast, CA. He presented the new technology and the preliminary results of a bilateral pilot study of the technique conducted at Bernstein Medical.
In robotic graft selection, the hair restoration surgeon programs the ARTAS robot to harvest follicular units based on the number of hairs in each unit. The robot first selects and then isolates larger follicular units of 2-hairs or more. If too few 1-hair units are extracted, the surgeon can program a second pass at extracting only the smallest grafts. As an alternative, the larger units can be divided into smaller ones using stereo-microscopic dissection. The goal is to both minimize wounding and harvest an adequate distribution of varying size follicular units to satisfy the surgeon’s, and ultimately the patient’s, aesthetic hair restoration needs. The new robotic graft selection system enables the robot to intelligently and efficiently harvest follicular units.
Results of the bilateral pilot study showed that the robot’s new graft selection capability was superior to random graft selection, the robot’s default setting, in the amount of hairs extracted per harvest attempt. Dr. Bernstein described how he was able to generate more transplantable grafts with fewer attempts at harvesting. By splitting larger follicular units into smaller grafts under stereo-microscopic dissection, he was able to produce additional grafts for use in the transplant without causing further wounding.
When the new computerized graft selection capability is coupled with dissection of larger units, the result is a substantial improvement over randomized graft selection. Read more about Robotic Graft Selection and the pilot study.
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.
Restoration Robotics, the company that developed the ARTAS® Robotic Hair Transplant system, has published a white paper case study on how Dr. Bernstein utilizes the robotic system’s tools to minimize scarring after Robotic FUE.
The paper describes how a Bernstein Medical patient — a 45 year old man with Norwood Class 5A male pattern baldness — had 2,540 follicular units harvested with the ARTAS robot, generating a total of 2,768 grafts. Some of the tools and techniques that Dr. Bernstein employed include:
Small 19g dissecting needle — the small needle leaves a smaller wound that heals more rapidly than previous needles.
Software programmed to avoid 1-hair follicular units — the extraction of follicular units with more than one hair maximizes the number of hair follicles per graft and reduces the number of donor wounds that need to be made.
Minimum distance between harvest sites — by increasing the distance between harvested follicular units (from 1.7mm to 2.0mm), Dr. Bernstein enabled “feathering” between harvested and non-harvested zones. This blending of harvest zones into non-harvested zones makes the harvested area less noticeable.
In the third month after his Robotic FUE hair transplant surgery, the patient’s donor area was reviewed for scarring with hair shaved at four different lengths.
See images of the patient’s donor area below:
Before Robotic Hair Transplant
Day 2 Following ARTAS Procedure
3mo Post-op: Shaved with #2 Clipper
3mo Post-op: Shaved with #1 Clipper
3mo Post-op: Shaved with Peanut Clippers
3mo Post-op: Shaved with Peanut Clippers (Close Up)
3mo Post-op: Shaved to the Skin
3mo Post-op: Shaved to the Skin (Close Up)
The case study illustrated that the ARTAS Robotic Hair Transplant system’s suite of tools can minimize the detectability of scars after an FUE hair transplant.
Michael B. Wolfeld, M.D., a board certified plastic surgeon in New York City, presented advances in robotic hair transplant procedures to the 88th annual Plastic Surgery “The Meeting,” the largest international conference on plastic surgery. Dr. Wolfeld presented topics such as robotic harvesting of follicular unit grafts and robotic recipient site creation using the ARTAS® Robotic Hair Transplant system at the conference that was held in Chicago, Illinois from October 10-14th, 2014.
Dr. Wolfeld Performing Robotic Hair Transplant at Bernstein Medical
Chicago, Illinois — Dr. Michael B. Wolfeld, a board certified plastic surgeon, presented recent advances and best practices in robotic hair transplant procedures to an audience of over one hundred plastic surgeons in their annual Plastic Surgery “The Meeting,” the largest international conference in the field. The 88th annual conference was held in Chicago, Illinois from October 10-14, 2014.
Dr. Wolfeld discussed the ARTAS® Robotic Hair Transplant system’s capabilities, such as follicular unit isolation during the graft harvest stage and the recently developed ability to create recipient sites. He also discussed ARTAS Hair Studio™, a new software suite that allows physician and patient to collaborate on a hair restoration treatment plan and then upload that plan into the robot for implementation. Together, these advances represent the state-of-the-art in surgical hair restoration and the integration of the two most critical phases of a hair transplant, the design and planning phase and the performance of the surgical procedure.
Featured in Dr. Wolfeld’s presentation was the new capability of the ARTAS robot to create recipient sites, small incisions in the patient’s scalp into which grafts of naturally-occurring groups of 1-4 hairs, called follicular units, are inserted. Dr. Wolfeld outlined how the robot performs this phase of the procedure with greater precision and consistency than a surgeon using manual instrumentation. His presentation showed how the physician can specify characteristics of recipient sites including the direction, angle, and depth of the incisions; the total number and density in the scalp of the incisions; and the diameter of existing hairs that the robot should use its image-guided technology to avoid. The distribution and style of recipient sites that the robot creates can be made to complement the distribution and growth of existing hairs. As a result of these innovations, the transplant results will appear more natural.
Dr. Wolfeld described how ARTAS Hair Studio, software that was developed by Restoration Robotics, Inc. to interface with the ARTAS Robotic Hair Transplant system, will allow the physician to create a three-dimensional model of the patient’s head and then design and manipulate a hair restoration plan that factors in the patient’s actual hair loss pattern. The physician can then digitally add hair to the 3-D model so patients can have a preview of how the hair transplant should look. This interactive tool will foster a collaborative environment in which the patient will feel more personally involved in their hair restoration experience. It will also help the patient align their expectations with a realistic outcome that takes into account the limited number of grafts that can be extracted from the back and sides of their scalp, or what is known as the donor area.
Dr. Wolfeld explained some of the best practices in procedures performed at Bernstein Medical and detailed two case studies of patients who had robotic hair transplants at the state-of-the-art Bernstein Medical facility in New York City. One of the best practices he described is a modification of the sequence of the Follicular Unit Extraction (FUE) procedure. By “pre-making” recipient sites, or creating recipient sites before follicular unit grafts are harvested, the physician, Dr. Wolfeld explained, can shorten the time the grafts are outside of the scalp, thereby increasing the chance that grafts will survive the transplant. The case studies included one patient who had a transplant with 1500 follicular unit grafts over the course of one day and one patient who had a transplant of 2600 grafts split over two days. In both cases, recipient sites were created by the ARTAS robot before the grafts were extracted.
About Dr. Michael B. Wolfeld
Michael B. Wolfeld, M.D. is a board certified plastic surgeon and an attending physician at Lenox Hill Hospital on the Upper East Side of Manhattan, New York City. Dr. Wolfeld is an associate at Bernstein Medical where he performs hair transplants using the newest technologies including the ARTAS Robotic Hair Transplant system. He is nationally published and has given numerous lectures on topics in aesthetic surgery. Dr. Wolfeld was accepted into the highly competitive specialty of plastic and reconstructive surgery and has completed a six year training program in this specialty at the Mount Sinai Medical Center. He served as Chief Resident at Mount Sinai Medical Center and pursued an aesthetic fellowship at Lenox Hill Hospital and the prestigious Manhattan Eye, Ear & Throat Hospital. Dr. Wolfeld received his Bachelor of Science degree from Cornell University and earned his medical degree from SUNY Downstate Medical School.
About Bernstein Medical – Center for Hair Restoration
Bernstein Medical – Center for Hair Restoration; founded by Robert M. Bernstein, M.D., F.A.A.D. in 2005; is dedicated to the diagnosis and treatment of hair loss in men and women using the most advanced technologies. The state-of-the-art facility; located in midtown Manhattan, New York City; treats patients from around the globe. In 2011, Bernstein Medical became one of the first practices in the world to offer Robotic Hair Transplant procedures using the image-guided, computer-driven technology of the ARTAS Robotic System. Bernstein Medical is a beta-testing site of the robot’s new capabilities, including the creation of recipient sites.
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.
While there is no difference between robotic and manual FUE in terms of the number of follicles that each procedure can extract, robotic FUE does have the following advantages over manual FUE:
During the follicular unit extraction (or harvesting) phase of a hair transplant, there is less chance of damaging follicular units using a robot vs. a hand held device (e.g., Neograft), because the robot is more accurate. This means more grafts survive after transplant.
Robotic graft harvesting times are shorter than manual, e.g., while on average if a physician could manually extract 200-300 grafts per hour, the same physician could robotically extract up to 500-1000 grafts per hour1. This means a shorter procedure time for the patient.
Dr. Robert M. Bernstein presented the ARTAS Hair Studio™ digital hair transplant design software and robotic recipient site creation using the ARTAS® Robotic Hair Transplant system, each advances in key aspects of hair transplantation, at the International Society of Hair Restoration Surgeons (ISHRS) annual meeting in Kuala Lumpur, Malaysia on Saturday, October 11th, 2014.
Kuala Lumpur, Malaysia (PRWEB) October 31, 2014 — Robert M. Bernstein, M.D., F.A.A.D., a world-renowned hair transplant pioneer, has presented two advances in robotic hair transplant surgery to the hair restoration industry’s largest conference; an interactive hair restoration design software suite called ARTAS Hair Studio™ and recipient site creation capability in the ground-breaking ARTAS® Robotic Hair Transplant system. Dr. Bernstein’s presentation highlights the fact that the ARTAS System is the first system to integrate the planning and performance of a hair transplant procedure. Dr. Bernstein presented these new technologies at the 22nd Annual Science Meeting of the International Society of Hair Restoration Surgeons (ISHRS) in Kuala Lumpur, Malaysia, on October 11th, 2014.
ISHRS 2014 – 22nd Annual Scientific Meeting in Kuala Lumpur, Malaysia
ARTAS Hair Studio is a planning tool that assists the physician in the design phase of the hair restoration procedure. Dr. Bernstein’s presentation described how this software enables the physician to generate a three-dimensional model of the patient’s head and then create a treatment plan based on parameters such as the number of recipient sites, the angle of elevation of the hairs, and the direction of the hairs. With small modifications of the software, the technology can add “virtual” hair to the 3-D model and allow patients to see how the results will actually look. This will create a more interactive, educational experience for the patient and one that helps align the patient’s expectations with what is possible given their specific hair loss characteristics.
Dr. Bernstein showed how, using the new software, the surgeon can divide the treatment area into two or more sections and then program different recipient site densities for the different areas to closely mimic how hair grows in nature. The treatment plan created using ARTAS Hair Studio can be saved and then imported into the ARTAS hair transplant robot.
Once the design specifications have been imported, the ARTAS Robot can then create the recipient sites, the tiny incisions made in a patient’s scalp, into which transplanted grafts of naturally-occurring groups of 1-4 hairs, called follicular units, are placed.
Recipient Site Creation at Bernstein Medical Using ARTAS Robotic System
In his presentation to the ISHRS, Dr. Bernstein described several advantages of robotic site creation over manual site creation, including: the elimination of inconsistencies in creating large numbers of recipient sites by hand, precise distribution of follicular unit grafts, automatic adjustment to site densities, and automatic avoidance of existing hairs without sacrificing speed. The robot uses advanced sensory equipment and optical cues to locate potential recipient sites on the scalp and then quickly and accurately make the incisions based on the pre-programmed parameters. The robot can create up to 2,000 recipient sites in approximately one hour.
Dr. Bernstein noted that these advances represent an integration of the design and planning processes with the actual performance of the procedure. Whereas in the past, the doctor would describe the treatment plan to the patient and then manually implement the prescribed plan, today’s computerized robotic system allows the physician to digitally design the hair transplant treatment plan, and then that plan directs the robot in the operating room.
Restoration Robotics Inc., the company that developed the robot, collaborated with Dr. Bernstein, using the Bernstein Medical – Center for Hair Restoration facility as a beta-testing site, to upgrade the ARTAS robot and test these and other advances. The ultimate goal is to deliver a robot that will mechanize every surgical aspect of an FUE hair transplant procedure.
About Robert M. Bernstein, MD, MBA, FAAD
Dr. Bernstein’s published articles on follicular unit hair transplant procedures have been called “Bibles” for the industry. He has received the Platinum Follicle Award, the highest honor in the field. He is a fellow of the International Society of Hair Restoration Surgery (ISHRS). Dr. Bernstein has appeared as a hair restoration expert on many notable television programs and in many news and lifestyle publications over the years. Examples include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, New York Times, Wall Street Journal, Men’s Health Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies. Dr. Bernstein graduated with honors from Tulane University, received the degree of Doctor of Medicine at the University of Medicine and Dentistry of NJ, and completed his training in Dermatology at the Albert Einstein College of Medicine. Dr. Bernstein is a Clinical Professor of Dermatology at Columbia University.
About Bernstein Medical – Center for Hair Restoration
Bernstein Medical – Center for Hair Restoration, the facility Dr. Bernstein founded in 2005, is dedicated to the diagnosis and treatment of hair loss in men and women using the most advanced technologies. The state-of-the-art facility is located in midtown Manhattan, New York City and treats patients from around the globe. In 2011, Bernstein Medical became one of the first practices in the world to offer Robotic FUE procedures using the image-guided, computer-driven technology of the ARTAS Robotic System. Bernstein Medical is a beta-testing site of the robot’s new capability including the creation of recipient sites and Dr. Bernstein is a medical advisor to the company that produces the robotic system, Restoration Robotics, Inc. The board-certified physicians and highly-trained clinical assistants at Bernstein Medical take pride in providing the highest level of treatment and care for all patients.
Restoration Robotics, Inc. has announced that the ARTAS Robotic System has harvested its 10 Millionth Hair, a major accomplishment for the three-year-old robot. The company attributes the success of achieving the 10 Millionth Hair in this short time span to rapid adoption by hair transplant industry leaders, like hair restoration pioneer Dr. Robert Bernstein.
The ARTAS robot is the only image-guided, physician-assisted robotic system for harvesting follicular units.
On the achievement, Jim McCollum, President and Chief Executive Officer of Restoration Robotics, said:
“The ARTAS Robotic System is fast becoming the gold standard in hair transplantation and enables hair restoration surgeons to enhance the patient experience and achieve unsurpassed outcomes. Our 10 Millionth Hair verifies the increased interest in patients pursuing a highly precise, undetectable hair transplant with a high degree of patient satisfaction. Interested patients are researching and demanding the ARTAS Robotic Hair Transplant Procedure.”
The ARTAS Robotic System received 510k clearance from the Food and Drug Administration (FDA) in 2011 after a decade of research, testing, and clinical trials. Dr. Bernstein is an advisor to the company and, since its launch in 2011, he has offered several modifications to the initial iteration of the robot that have improved its performance and usability. Bernstein Medical – Center for Hair Restoration was the first facility on the East Coast of the United States, and one of the first hair transplant practices in the world, to use the system. Bernstein Medical is also a beta-testing site for the robot, and many upgrades to the hardware and software of the unit have been tested and perfected in our Manhattan hair restoration facility. All FUE hair transplants at Bernstein Medical are performed with the aid of the ARTAS robot.
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