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.
Dr. Bernstein also updated the meeting attendees on the robot’s recipient site creation technique that he introduced the prior year and some best practices in incorporating the ARTAS Hair Studio software into clinical practice.
Q: I was told that I have low hair density in the donor area. Will multiple hair transplant procedures improve the results of my hair restoration? — J.G., Hoboken, NJ
A: Yes, but subsequent procedures would be smaller and there is a point of diminishing returns where additional procedures would yield so little hair that they would not be practical. There is a finite donor supply and once this is tapped, no more hair transplants are possible, regardless if one uses FUT or FUE.
NY1, a New York City television channel, has featured Dr. Bernstein in a segment on robotic hair transplantation.
Here is a transcript of the video:
A new robot could help return hair to those of us who, as we get older, find ourselves a bit follically challenged. Called the ARTAS System from Restoration Robotics, it was recently approved by the FDA to help with a type of hair transplantation technique called follicular unit transplantation where follicular units, groups of one to four hairs, are removed directly from the back of the head and transplanted on the top and front. Removing those units has always proved to be the toughest part of this method, but the robot changes that, which is why even Dr. Robert Bernstein – the man who’s widely credited with developing follicular unit transplantation and [follicular unit extraction] – jumped to be among the first in the U.S. to use the device.
“A follicular unit is about a half a millimeter and you have a one-millimeter circle that has to go dead center over it to punch this out. So when you’re doing it by eye and you’re doing thousands of them over time you’re missing them over time it’s not exactly precise. The robot is dead center each time and follows the angle of the hair,” explains Bernstein.
While the robot doesn’t really have any direct impact on how the transplant will ultimately look – that’s still up to the doctor’s expertise and artistic skill. What it does do is give the doctor a better quality sample of hair with which to work.
“There’s always damage to the follicles when you’re doing it because you’re doing it by hand through these very tiny incisions and so the yield is going to be less and so with a robot if you try to get out 100 follicles you’ll get very close to 100 follicles,” says Bernstein.
Again, the robot just makes the incision, the doctor still has to pull the hair, make sites on the front where the transplants will go and then actually make the transplants. However, developers say they are working on having future versions of the ARTAS System help with the entire process.
Dr. Bernstein was interviewed by Skin & Allergy News in their article, “Microscopic Dissection Offers Superior Yield” The complete article is below:
Skin & Allergy News
February 1999
Microscopic Dissection Offers Superior Yield
Articles by Anna Nidecker
Senior Writer
Washington — The dissecting microscope takes some getting used to, but using it makes more efficient use of donor hair during follicular unit transplantation than magnifying loupes with transillumination, reported Dr. Robert Bernstein of Columbia University College of Physicians and Surgeons, New York.
“A limiting factor in all hair restoration surgery is the patient’s finite donor supply. […] Meticulous stereomicroscopic dissection should help preserve the supply and ultimately provide the patient with the most transplantable hair,” he said at the annual meeting of the International Society of Hair Restoration Surgery.
Dr. Bernstein compared the follicular unit graft yields of dissections performed with stereoscopic microscopes and with loupes and backlighting. Initial sectioning of the intact strip was done with loupes, as the staff had not yet mastered the skill of slivering that is needed to section the intact strip under microscopic guidance.
“This method may be useful for a team in transition, a model for staffs in transition to using the microscope,” the hair transplant surgeon suggested.
Tips on Transition to Microscopes
The microscope offers a better yield with follicular transplantation, but some doctors feel that abruptly switching from loupe magnification may send an office into turmoil.
Microscopes will be well received by staff if they clearly understand the benefits and are eased into the transition, Dr. Bernstein said.
Dr. David Seager advised physicians planning the transition to the use of microscopes to let staff observe microscopic dissection at another clinic with an established program, and to send them somewhere to be trained before they start. The Toronto hair transplant surgeon also advised buying a couple of microscopes and letting the staff “play” with them for a while, cutting at their own leisurely rate before entering into a high-pressure transplant session.
Dr. Bernstein also recommended easing slowly into the transition by first training a small portion of staff, which will not affect the overall time of surgery.
Another option is to hire a couple of new technicians and train them from the beginning with microscopic dissection, Dr. Seager suggested.
“You’ll be amazed at the beautiful grafts they will be cutting in a couple of weeks. […] It may be only 40 grafts an hour, but these newcomers will be cutting better grafts than even your 8-year veterans,” he said. “Old staff will look at these new technicians and their grafts, and, if they take pride in their work, they will be quite jealous and will be really eager to catch up.”
Dr. Bernstein agreed: “The value of the microscope may be more significant in the hands of less experienced dissectors. […] There’s some advantage even at the outset.”
Continued resistance from staff should be met with a deadline: ‘Anyone who can’t or won’t fit in, tell them they can do something else in the office, but they won’t be doing transplanting,” Dr. Seager said.
In 41 patients, the donor strip was harvested with a double-bladed knife from the midportion of the permanent zone in the back of the scalp.
The strip was divided into two equal parts along the midline; these were further divided into 2- to 3-mm wide vertical sections using loupes and a straight razor. Sections from one of these donor strip halves were further dissected into follicular units using a 10x power microscope; sections from the other donor strip half were dissected using magnifying loupes.
Follicular units cut using the microscope contained an average of 2.41 hairs; those cut using loupe magnification yielded 2.28 hairs. Use of the microscope also yielded 10% more follicular units and 17% more hair overall, compared with use of loupes.
The grafts were dissected and sorted into follicular units containing one to four hairs, and all hair and hair fragments judged to be potentially viable were counted towards the yield (Dermatol. Surg. 24[8]:875-80, 1998).
Microscopic dissection took from two to four times as long as loupe magnified dissection when technicians first began using the microscopes. After 3 months, the procedure still took twice as long with the microscopes. But by the end of the study 1 year later, it took only 10% longer, a rate they currently maintain, Dr. Bernstein said.
Hand-eye coordination was a factor which automatically improved, and the inefficient movement of grafts in and out of the microscopic field was solved with better organization, he said. Technicians with a tendency to obsessively sculpt grafts under the microscope can be educated to limit this sculpting, which does not affect the quality of the transplant.
Use of the microscope also led to fewer reports of back and neck strain by assistants. They also reported easier dissection when there was donor scarring, and with blond or light-colored hair.
Besides the benefit at the stage of dissecting the sections—as shown in this study—microscopes can improve yield by 5%-10% at the “slivering” stage. Yield can be improved an additional 15%-20% by avoiding use of the multibladed knife at the donor harvesting stage.
Loupe advocates argue that microscopes unduly slow down the procedure and that staff resistance to this new technology may be an insurmountable problem in some practices. They also lament the higher economic cost of purchasing the microscopes, training the staff, and slowing down dissection time with no clear benefits.
Dr. Bernstein said that the benefits of microscopic dissection far outweigh these minor inconveniences and should be incorporated into hair transplant procedures.
Dr. Bernstein Presenting at ARTAS User Group Meeting 2015
College of Physicians and Surgeons, New York.
