Dr. Bernstein heads discussion on Robotic FUE at the 20th annual meeting of the International Society of Hair Restoration Surgery (ISHRS) which took place October 17-20, 2012.
Dr. Bernstein led a roundtable discussion in the ‘Coffee with the Experts’ session on robotic follicular unit extraction. See above photo of the session (click on it to view a larger version). Some of the topics he covered were; the proper indications for FUE, the advantages of Robotic FUE over other methods, how doctors can best implement robotic hair transplants in their practices and recent advances in robotic technology. He was also a panelist at the Finasteride Symposium and gave a presentation on protocol in prescribing Finasteride to hair restoration patients.
Program biography on Dr. Bernstein
Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., Clinical Professor of Dermatology, Columbia University, is an early adopter of the ARTAS System for Robotic-FUE. Bernstein Medical, PC, serves as a beta-site to study new product features and enhancements. Dr. Bernstein’s contributions and expertise have materialized in making the ARTAS System more user friendly, improving the harvesting technique and making the ARTAS procedure more compelling for patients at this early stage of commercialization of the product. Pre-Making Recipient Sites to Increase Graft Survival in Manual and Robotic FUE Procedures, has been submitted for publication.
Dr. Bernstein’s comments on roundtable discussion
One of the most important new advances in hair transplantation is Robotic Follicular Unit Extraction (R-FUE). I have been using the new ARTAS Robot, manufactured by Restoration Robotics, for almost a year now. It has made FUE a more exacting and reliable procedure. The “Coffee with the Experts” session that I gave on the topic of Robotic FUE at the ISHRS was standing room only, attesting to the great interest that members of our society have in this new technology.
The theoretical advantage of using a robot to minimize human error in a very repetitive procedure was acknowledged by most members of the discussion group. The ARTAS system has the advantage of using a combination of sharp punch and blunt dissection, a model that was based on Dr. Jim Harris’ SAFE System and one that we have found to work best with the hand-held devices. It also allows us to remove grafts with forceps, rather than by suction. This feature is important since strong suction used to remove the grafts can be more damaging than mechanical removal with forceps.
Its dissection technique uses two punches which are concentrically arranged – a small diameter, sharp bi-beveled punch is nested within an outer, dull punch. The inner punch has a cutting end to score the upper most part of the skin and the outer punch has a blunt edge that dissects the follicular units from the surrounding tissue. We have also found that grafts harvested with Robotic FUE showed less transection compared to other devices that we have used and contained more of the surrounding protective tissue, so it is assumed that this will lead to improved graft survival, but this has not yet been proven.
We find that the robot is more versatile in its ability to harvest grafts from patients with different hair characteristics and from different parts of the scalp. Although there is still variability in the ease of extraction among patients of different racial backgrounds, in our experience, the differences are less when compared to a hand-held system. Also, with the robotic system it seems easier to extract grafts from the sides of the scalp where the hair lies flatter on the skin.
In our practice, we are now able to comfortably extract 2,000 grafts in one day and over 2,500 grafts in two consecutive days. Some of the doctors at the discussion claimed to be able to consistently extract far greater numbers in a single session using manual methods, but it is hard to compare speed without comparing graft quality and transection rates.
One of the exciting things about the new device is that it is continuously evolving. As a beta-site studying new enhancements and features, we have seen all the nuanced changes that continually improve the technique. The initial version of the robot required many intra-operative adjustments to depth, angulation, and the speed of punch rotation, so there were a number of adjustments to monitor. The current system needs far less human intervention than with earlier versions and is simpler to operate, but significant experience is still needed to get the best results. Of course, all the other issues of a hair transplant including; planning, design, site creation, atraumatic graft insertion, etc. persist.
One of my special interests had been to offer patients Robotic FUE with a smaller punch size. We have been working with a 0.9mm punch (the standard is 1.0mm) and have found that this shortens healing time, decreases donor scarring and increases the number of follicular units that can safely be harvested in a specific area. It also creates grafts that require less trimming. On the other side of the coin, some patients, especially African-Americans have less transection with the larger punch, so it is important to be able to customize the technique to the particular person.
Another important modification of the technique that we have implemented since the introduction of the ARTAS system, but that is also applicable to FUE in general, is pre-making recipient sites. This is done either prior to extraction in a one-day procedure or at the beginning of the first day in a two-day procedure. With this change, as soon as the grafts are harvested, they can be placed immediately into the recipient scalp. Not only does this minimize the time that grafts are outside the body, but; by allowing the healing process to begin in the recipient area; it minimizes popping, increases visibility when placing (due to less bleeding), and may create a better environment in which the newly transplanted grafts can grow.
Some of the concerns that doctors had were the relatively high start-up cost in purchasing the robot, the amount of set-up time at the beginning of each procedure and the need, at present, to use two ORs – one for robotic harvesting and one for placing. At present, the patient can only lie on the robotic device face-down. While this position is necessary for the robotic arm to have full access to the donor area, it does not allow easy access to the front or top of the scalp. As a result, graft placement must be performed using a separate operating chair, necessitating the use of two operating rooms for one patient. It is anticipated that within a year, the robotic operating table will be re-designed so that harvesting and placing can be performed in the same room.
Besides some set-up time, one of the things that slows down the robotic process is the tensioner mechanism used to stretch the scalp. Although this feature has the advantage of decreasing damage to follicles, it must be moved every 100 to 150 grafts. With a larger and easier to use tensioner already designed, the delay from its re-positioning should be significantly decreased.
Another concern expressed was that the robot harvests grafts in a somewhat geometric pattern. With experience, one is able to overlap grids and feather the edges so that this appearance, even if temporary, is minimized. New software is planned which can do this automatically.
At the time of the meeting, there were twelve centers in the United States offering Robotic FUE with additional practices in the queue. There was also a strong interest in Robotic FUE among physicians outside the US, particularly in South Korea, Taiwan and Japan.