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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.

Read about robotic FUE hair transplantation

Posted by
Robert M. Bernstein M.D.

by Jeff Teumer, PhD
Hair Transplant International Forum, Volume 18, Number 3, May/June 2008

Follicular cell implantation (FCI) is based on the ability of the dermal papilla (DP) cells, found at the bottom of hair follicles, to stimulate new hairs to form. DP cells can be grown and multiplied in a culture so that a very small number of cells can produce enough follicles to cover an entire bald scalp.

In order to produce new follicles, two types of cells must be present. The first is Keratinocytes, the major cell type in the hair follicle, and the second are dermal papillae cells (DP) which lie in the upper part of the dermis, just below the hair follicle. It appears that the DP cells can induce the overlying keratinocytes to form hair follicles. There are a number of proposed techniques for hair regeneration that use combinations of cells that are implanted in the skin. The two major techniques involve either transplanting dermal papillae cells by themselves into the skin or implanting them with keratinocytes. These techniques can be used with or without an associated matrix used to help orient the newly forming follicles.

Implanting Dermal Papillae Cells Alone

  1. Implanting DP cells by themselves into the dermis, with the hope that they will cause the overlying skin cells (keratinocytes) to be transformed from normal skin cells into hair follicles. This method is called “follicular neo-genesis” since new hair is formed where none previously existed.
  2. Cells of the dermal papillae are placed alongside miniaturized follicles. The transplanted cells would induce the keratinocytes of the miniaturized follicles to grow into a terminal hair. A potential advantage of this technique is that the existing miniaturized follicles already have the proper structure and orientation to produce a natural look growth.

Implanting Dermal Papillae with Keratinocytes

  1. A mixed suspension of cultured keratinocytes and DP cells are implanted into the skin.
  2. Keratinocytes and DP cells are cultured together such that full or partial hair formation takes place in a culture dish. These culture-grown hairs, or “proto-hairs,” are then implanted into the patient. The advantage of using a proto-hair is that there would be better control over the direction of hair growth because of the structural orientation of the proto-hair.

Cell Implantation using a Matrix

  1. A variation of the above techniques is to use a matrix to help orient the implanted cells. This could be either an artificial matrix composed of materials such Dacron or it could be a biological matrix composed of collagen or other tissue components. The matrix would act like a scaffold to help cells organize to form a follicle. If the matrix were filamentous (like a hair) it could help direct the growth of the growing follicle. A matrix could be used with dermal papillae cells alone or in combination with cultured keratinocytes.

With all of the varied approaches for FCI, the aim is to combine keratinocytes and DP cells to efficiently and reproducibly generate thousands of follicles for hair restoration. In some cases, cells are combined in vivo and all of the hair formation must take place in the body after implantation, while in others, some hair formation takes place in culture before implantation.

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Q: Can dermabrasion help eliminate the circular edges of raised plug grafts caused by old hair transplants? Is this similar to the suturing and excision look?

A: Although dermabrasion can flatten elevated edges, it will not eliminate the round, white, circular scars that result from old punch graft hair transplants. The scarring in these procedures goes all the way through the dermis to the fat. Dermabrasion can only go down to the upper part of the dermis without causing further scarring.

Graft excision with suturing removes the plug as well as the underlying scar and eliminates the tell-tale circular marks of the older hair restoration procedures.

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Q: Could you tell me in case there is an infection at the donor area following a hair transplant, will it prevent the hair to grow after healing if the donor area closed by Trichophytic Closure? What are the problems which may the infection cause? — S.S., Park Slope, NY

A: Infection may cause the donor incision to heal more slowly or with a widened scar after a hair transplant. It may affect any closure, Trichophytic or not.

The risk of infection after a hair restoration procedure is made worse by a tight closure, but not necessarily a Trichophytic closure, unless too much skin was removed at the edges leaving the dermis (deeper part of the skin) exposed.

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Q: What can be done if I want to have a hair transplant and my scalp is very tight from prior surgeries? — R.R., Long Island, N.Y.

A: Follicular Unit Extraction is ideal in very tight scalps, provided that there is enough hair to extract without leaving the donor area too thin and provided that the follicles are not too distorted from the scarring.

With strip harvesting, undermining techniques may be helpful to close the wound edges once the strip is removed.

In undermining, the surgeon uses either a sharp instrument (scalpel) or blunt instrument (the dull edge of scissors) to separate the upper layers of the scalp (dermis and epidermis) from the lower part of the scalp (fascia). The hair transplant surgeon accomplishes this by spreading apart the fat layer of the skin or by cutting through scar tissue.

Undermining allows the upper layers of skin to literally slide over the lower layers and can significantly increase the ability to close a tight wound. However, if not done carefully, it may increase the risk of bleeding and injury to nerves and occasionally may damage hair follicles.

Undermining is usually used with a layered closure where the deeper tissues are brought together first with a layer of absorbable sutures before the surface of the skin is sutured closed with sutures that are removed.

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