Bernstein Medical Center for Hair Restoration - Robotic FUE Benefits

Robotic FUE Benefits

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Q: Is it true that manual FUE hair transplant procedures are better than robotic hair transplants because the physician can adjust and feel the follicle when extracting? — M.H. ~ Great Neck, N.Y.

A: The ARTAS robot is a physician controlled, computerized device that uses a three-dimensional optical system to isolate follicular units from the back of the scalp in a hair transplant. The robotic system assists the physician in the extraction of grafts with precision and speed. Although there is some advantage to having “human feel” for the tissue, this is far outweighed by the fact that repetitive procedures performed manually thousands of times lead to operator fatigue and result in increased transection and damage to grafts. With the ARTAS robotic system, the quality of the first and the last graft harvested will be the same.

Read about advantages of the ARTAS Robot over manual FUE procedures

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Dr. Bernstein closed the 2017 ARTAS Users Meeting with a discussion of five advanced techniques in robotic hair transplant procedures that he developed at Bernstein Medical. His presentation covered the benefits of pre-making recipient sites, long-hair FUE, tensioner placement, feathering edges in harvesting, and robotic graft selection. The “Hair Restoration Pearls” presentation included case studies, photographs, and videos demonstrating the techniques to the audience of hair restoration physicians. The two-day affair; which was held in Coronado, California; was a huge success, with over 260 attendees from around the world representing 204 robotic hair restoration practices.

Pre-Making Recipient Sites
There are several advantages of pre-making recipient sites in Robotic FUE procedures. One of the most important is that grafts are out of the body for a shorter period, which increases graft survival. During placement, there is less bleeding and greater graft stickiness, which result in increased visibility for the physician, less graft popping, and up to a 30% decrease in placing time. By pre-making sites, the physician can determine the exact number of grafts needed in the hair transplant. Also, the healing process can begin in the recipient area in advance of placing. This creates a fertile bed of oxygenated tissue with factors that promote healing and the subsequent growth of the follicular unit grafts.

Long-Hair Robotic FUE

In Long-Hair Robotic FUE, the patient has their hair temporarily lifted with tape during the hair transplant surgery. The physician then harvests from the donor area in a linear configuration so that, after the procedure, the long hair is let down covering the harvested area. The long-hair technique can be applied using one harvesting row (which yields up to 1,600 grafts), a double-row (2,000 grafts), or two separate rows (2,400). Long-Hair Robotic FUE, using the ARTAS Robotic Hair Transplant System, allows the donor area to be camouflaged immediately after surgery and does not limit a patient’s ability return to work. It also makes robotic hair transplants more practical for women, who usually prefer not to shave their donor area.

Tensioner Placement

Dr. Bernstein discussed a new two-handed technique for applying the robotic tensioner to the patient’s scalp. The tensioner applies traction to the scalp, stabilizes the skin, limits bleeding, and provides a system of fiducials that the ARTAS robot “reads” for proper orientation. Dr. Bernstein showed a video in which he demonstrates the technique and discusses the importance of applying the silicon straps as vertically as possible to ensure the greatest tension and stability. The two-hand technique allows for reduced stress on the physician’s hands, better control, and more accurate placement of the tensioner. It also facilitates easier edge engagement to create tension on the skin in preparation for harvesting.

Feathering Edges
Feathering is a common technique to avoiding a squared-off, geometric look after the FUE procedure. It allows the patient to maintain a natural look while wearing their hair short after the procedure. Dr. Bernstein presented two different ways to feather using existing capabilities of the ARTAS system. Dr. Bernstein showed how the physician can both round the edges of the harvest area and decrease the density on the outer edges, with simple, reproducible techniques. Most importantly, he discussed the situations in which feathering is important and the ones in which it should not be used.

Robotic Follicular Unit Graft Selection

Robotic graft selection is an advance over the harvesting technique used in earlier iterations of the ARTAS robot. The robot previously harvested grafts at random. By creating a software algorithm designed to skip over one-hair units and select only the larger follicular units, the harvesting process improved in efficiency. According to Dr. Bernstein’s study, the clinical benefit is 11.4% more hairs per graft and 17% more hairs per harvest attempt using this technique. Larger follicular unit grafts can be dissected into one-hair units for use in the frontal hairline and other cosmetically important areas in order to create the most natural aesthetic outcome in the hair transplant while minimizing the number of recipient wounds.

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Q: I have a diagonal scar in the middle of my donor area that I got during a childhood accident and I am concerned that it will limit my options for hair restoration. Will this type of scar prevent me from having either FUT or FUE? Do you recommend one or the other? — R.F., Upper West Side, NY

A: Traumatic scars in the donor area do not preclude us from performing a hair transplant. With an FUT/strip procedure, we can remove all or part of the scar when we excise the donor strip. In Robotic FUE, the ARTAS Robot can be programmed to avoid a scar during harvesting. In either procedure, we can improve the appearance of the scar by implanting follicular unit grafts directly into the scar tissue. The hairs will grow permanently in the scar, just like ones we implant in the recipient area, and the scar will become harder to detect.

It is important to note that transplanted hair will not grow in a thickened scar. If your scar is thickened, the doctor can thin it out (soften it) with injections of cortisone. They are usually repeated at 4-6 week intervals in advance of the procedure. The number of injection sessions required depends upon the thickness of the scar and your individual response to the medication.

The presence of a traumatic scar should generally not determine which type of transplant you have. That should be decided in consultation with your physician based on factors such as how much volume you need, how you intend to style your hair, how short you would like to keep it, how soon you need to return to strenuous physical activity, and other general considerations for a hair transplant.

We recently posted photos from a patient who had a robotic hair transplant with a scar in his donor area. The photos include images of his donor area (with scar) before his procedure, immediately after robotic graft harvesting and 11 days post-op. View this patient’s before after photos.

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Q: Why is using the robot to create recipient sites useful in a hair transplant? — S.K., Jersey City, NJ

A: The ARTAS® Robotic Hair Transplant system eliminates the inconsistencies inherent in creating large numbers of recipient sites by hand. The robot can create sites at a rate of up to 2,000 per hour. Although there is more set-up time compared to sites made manually, once the physician specifies the parameters such as punch depth, punch angle, and site direction, recipient site creation is precise and rapid.

One of the benefits of robotic site creation is that the distribution of grafts over a fixed area of the scalp can be exact. For example, if one wants to transplant 1,000 grafts evenly over 50cm2 of area, this can be done with great precision and with uniform site spacing. In addition, the physician can vary the densities in select regions of the scalp and the robot will adjust the densities in other areas so that the total number of sites remains the same.

Another benefit of the new technology is that the robot can be programmed to avoid existing hair and select which specific hair diameters to avoid. The robot is programmed to keep a specified distance from the existing hair to ensure that the resident follicles will not be damaged and that the distribution of new hair is even and natural. This computerized mechanism appears to be more accurate than what can be done by hand and, importantly, does not sacrifice speed in the process.

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Dermatologic Surgery - December 2014A 2014 study in the journal Dermatologic Surgery measured follicular unit transection (follicle damage) during the extraction step of a robotic follicular unit extraction (R-FUE) procedure. The study found that robotic transection rates, using the ARTAS Robotic System, compared favorably with non-robotic (manual) FUE transection rates. ((Avram MR, Watkins SA. “Robotic follicular unit extraction in hair transplantation.” Dermatol Surg. 2014 Dec;40(12):1319-27))

The researchers found the average rate of transection over many robotic procedures to be 6.6%. This rate compared favorably to an average manual transection rate of 6.14% reported in a 2006 study ((Harris JA. “New methodology and instrumentation for follicular unit extraction: lower follicle transection rates and expanded patient candidacy.” Dermatol Surg. 2006;32:56–612.)) and was significantly lower than an average transection rate of 17.3% reported in 2008 study using manual techniques. ((Onda M, Igawa HH, Inoue K, Tanino R. “Novel technique of follicular unit extraction hair transplantation with a powered punching device.” Dermatol Surg. 2008;34:1683–8.))

While the study’s robotic FUE transection rates compared favorably to two reported manual transection rates, the authors stressed that more well-designed studies comparing robotic to manual FUE are needed.

The authors noted that “The main advantages of robotic FUE compared with the standard ellipse are its minimally invasive nature and the lack of a linear scar.”

This paper was reviewed by Dr. Bernstein. ((Bernstein RM. “Commentary on Robotic Follicular Unit Extraction in Hair Transplantation.” Dermatol Surg. 2015;41:279.))

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Q: What is the main difference between hair transplants using the robot versus other procedures? — M.P., Flatiron, NY

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.

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Restoration Robotics

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
Before Robotic Hair Transplant
Day 2 Following ARTAS Procedure
Day 2 Following ARTAS Procedure
3mo Post-op: Shaved with #2 Clipper
3mo Post-op: Shaved with #2 Clipper
3mo Post-op: Shaved with #1 Clipper
3mo Post-op: Shaved with #1 Clipper
3mo Post-op: Shaved with Peanut Clippers
3mo Post-op: Shaved with Peanut Clippers
3mo Post-op: Shaved with Peanut Clippers (Close Up)
3mo Post-op: Shaved with Peanut Clippers (Close Up)
3mo Post-op: Shaved to the Skin
3mo Post-op: Shaved to the Skin
3mo Post-op: Shaved to the Skin (Close Up)
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.

Dr. Bernstein describes advanced Robotic FUE techniques used at Bernstein Medical (VIDEO)
Read about Robotic Hair Transplantation

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Q: How many follicles can you transplant with robotic FUE compared to manual FUE? — R.V., Upper West Side, N.Y.

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 hour ((Chang, H.H. Robotics, artificial intelligence, and the future of hair transplantation. Prime Dermatology, July/August 2014.)). This means a shorter procedure time for the patient.

Read more about the advantages of Robotic FUE.

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Q: I have read a bit about the ARTAS robot and how it uses an “image-guided” system, but what does that mean? And how is the robot’s imaging system different than a human surgeon viewing the grafts with the naked eye? — S.V., Middle Village, N.Y.

A: That is a great question and it gets to one of the key benefits of the robotic hair transplant system: its accuracy. When a surgeon is performing FUE using manual techniques, they must wear a headset that magnifies the scalp so they can see the follicular units more clearly than with the naked eye. The surgeon must visually and mentally process subtle nuances of the skin and follicular units for every one of the hundreds or thousands of units that are extracted. The ARTAS robot magnifies the surface of the skin in much the same way, but to a much greater extent. In addition, it is not subject to the limitations of the human eye, or human hand, and it is not subject to human error. The surgeon may not have exact hand-eye coordination. The surgeon may be concentrating on one aspect of the extraction, say following the angle of the hair, but might ignore another important aspect of the follicle, say its depth in the skin or its orientation. And, of course, the surgeon tires, both physically and mentally, from performing the hundreds or thousands of repetitive motions.

The robot’s image-guided system, on the other hand, does not experience these limitations. The robot magnifies the skin, detects each follicular unit and the nuances of the skin/hair characteristics, and then extracts that follicular unit with precision. When the imaging system detects changes to the skin, this new information is fed into the computer in real-time and the system adjusts automatically based on this feedback as it continues to harvest grafts. There is no distracting the robot, and the robot will not forget, or ignore, key variables in the extraction. The robot can extract thousands of follicular units without tiring from repetition or slowing down the extraction.

Based on my own practical experience using the robot, it is clear that the robot’s ability to estimate the position of the follicles under the skin and to extract it with precision is superior to manual techniques. Having used the ARTAS system for over three years, and having helped make improvements to the device since the first iteration, I have seen robotic technology substantially improve the outcome for my patients.

Video Display of the ARTAS Robot Image-Guided System




Display: ARTAS Robot Image-Guided System

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The Aesthetic Guide - ARTAS® Improves Hair Graft Accuracy and Consistency

Dr. Robert Bernstein discusses the benefits of the ARTAS® Robotic Hair Transplant system in The Aesthetic Guide, a leading periodical in the field of aesthetic surgery. The article examines how robotic Follicular Unit Extraction (FUE) procedures are an improvement over FUE using handheld devices.

In the article, Dr. Bernstein explains how surgeons performing manual FUE need to calculate the angle, spacing, direction, depth, and orientation for each follicular unit harvested. The fact that this process must be repeated up to thousands of times per patient gives the manual FUE procedure significant variability.

Dr. Bernstein touches on a key reason why the image-guided robot is an improvement over manual techniques:

“The ARTAS robot is one of the first technologies used in practice where the computer of the robot is actually obtaining feedback from the anatomy of the patient. In this case, the robot is getting feedback regarding the distribution and direction of hair follicles. That information is communicated to the computer in real time and the computer makes adjustments as it continues to harvest the grafts, which is why the system is so accurate.”

The robot’s capability of making microscopic adjustments in real time, based on the characteristics of the patient’s skin, is a technological breakthrough in the field of hair restoration. Not only does the robot not tire when performing thousands of graft dissections, it estimates the position of the follicle under the skin more reliably than a human. According to Dr. Bernstein; “the accuracy of the robot remains consistent,” throughout the entire procedure, graft by graft.

The Aesthetic Guide - ARTAS Improves Hair Graft Accuracy and Consistency

This accuracy and consistency is critical in a hair transplant because the yield of healthy, viable grafts is one of the key factors in a successful procedure. If a surgeon, using manual techniques, transects (or cuts) a graft or doesn’t cut deeply enough into the skin tissue, then that graft might not survive the transplant. If a number of transected or damaged grafts don’t survive the transplant, then the result of the procedure will be limited in the aesthetic benefit that the surgery was designed to provide.

The article, which is titled “ARTAS Improves Hair Graft Accuracy and Consistency,” notes that Dr. Bernstein was one of the first physicians in the United States to use FUE robot in his practice, “one of the leading hair restoration centers in the country.”

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Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE? — R.V., Stamford, CT

A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually?

The goal of a hair transplant is not to simply transplant as many grafts as possible but to achieve the best possible cosmetic result given the number of hair follicles in your donor reserve. Remember, this is always a limited supply.

While there is no difference between robotic and manual FUE in terms of the number of follicular unit grafts that each can extract, robotic FUE does differ from manual FUE in several important ways.

First, there is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.

Second, while the robot is not necessarily faster than the human surgeon, the robot is much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.

Read more about Robotic Hair Transplant

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Q:  I’ve heard that robotic-assisted FUE is better than manual FUE, but what exactly is the main advantage of Robotic FUE? — N.K., Bergen County, NJ

A: Robotic FUE is a significant improvement over other FUE techniques for a number of reasons. The accuracy and ability of a robot to perform countless repetitive motions are key reasons why robotic techniques are an improvement over manual techniques.

In a manual procedure, the skill and speed of a physician are under constant stress, as he or she must follow the angle and depth of the hair precisely hundreds to thousands of times. This task is almost impossible for even the best surgeons to perform without risking harm to the integrity of the follicles. Entering the skin at the wrong angle risks transecting or cutting the follicles and may render them useless for transplantation. Making too shallow an incision can also damage follicles, as the important base of the follicle can become sheared off when it is subsequently extracted.

The robot is engineered to avoid these problems, and so the number of viable grafts that the robot extracts is increased. As a result, the likelihood of the success of the transplant is greater using the robotic system.

Read more about Robotic Hair Transplant

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Dr. Bernstein, ARTAS Robot for FUE in Brazil's Veja MagazineDr. Bernstein was quoted in an article on robotic follicular unit extraction (FUE) that appeared in Brazil’s Veja Magazine. It is titled, “Vai Ficar Mais Fácil Deixar de Ser Careca,” which translates to, “It Will Be Easier To Stop Being Bald.”

The article describes how the ARTAS System improves on traditional FUE procedures. It contains a diagram which shows that the hair transplant robot can extract almost twice as many follicular units as extraction techniques that use manual methods. Whereas manual procedures can yield about 400 follicular units in one hour, the robot for FUE can extract 750 units in an hour. The article indicates that the total duration of a hair transplant procedure can be significantly reduced using the new robotic system.

The magazine, which focuses on Brazilian business and culture, quotes Dr. Bernstein:

“É muito difícil retirar os folículos manualmente”, diz Robert Bernstein, um dos pioneiros a fazer o transplante capilar manual e a user o ARTAS.”

Translated, it reads:

“It is very difficult to manually remove the follicles,” says Dr. Robert Bernstein, one of the pioneers of manual hair transplants and of the ARTAS System.

The person pictured with the article is celebrity actor Bruce Willis. Under the photo is the caption “Duro de Crescer: Raros são os atores, como Bruce Willis, para quem a ausência de fios só faz aumentar o charme.” This translates to: “Hard to Grow: Rare are the actors like Bruce Willis, for whom the absence of hair increases the charm.”

Bernstein Medical – Center for Hair Restoration treats patients from all over the world, including Brazil and South America. Anyone who is unable to visit our center in New York City for a consultation may submit a photo consultation.

Read more about the benefits of Robotic FUE

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