Bernstein Medical - Center for Hair Restoration - Robotic FUE vs Manual FUE
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Dr. Bernstein presenting at the ISHRS 26th Annual World CongressDr. Bernstein presenting at the ISHRS 26th Annual World Congress.

Robert M. Bernstein MD, FAAD and Christine M. Shaver MD, FAAD of Bernstein Medical attended the 26th World Congress of the International Society of Hair Restoration Surgeons (ISHRS). At the congress, Dr. Bernstein introduced the newest robotic technology in the field of hair transplantation, the ARTAS iX, to an audience of over 550 hair restoration physicians.

Dr. Bernstein Introduces the ARTAS iX

Dr. Bernstein explains that the ARTAS iX now automates the implantation step of a hair transplant procedure by utilizing totally new hardware and software algorithms. The newly designed operating chair provides more flexibility for the surgeon and more comfort for the patient. This ARTAS iX also improves the accuracy and efficiency of the robotic FUE procedure.
With implantation, three of the four aspects of a hair transplant (excision, site creation, implantation) have now been successfully automated. Only graft extraction is left as the remaining step.

How Implantation Works

While performing an FUE procedure with the ARTAS iX, harvested grafts are loaded — 25 at a time – into rectangular cartridges. These cartridges are then inserted into the arm of the robot that implants the grafts directly into the scalp. A major advantage of using cartridges, rather than the manual technique, is more delicate handling of the grafts with less risk of graft injury. When grafts are implanted manually, they are typically grasped by the bulb, or just below the sebaceous glands, and then brought into the incision risking considerable damage in the process. With ARTAS iX, grafts are held at the epidermal end and then gently placed into the cartridge. This technique eliminates unnecessary injury to the growth of the transplanted hair by avoiding the lower and mid-portions of the follicles.

With the use of the ARTAS iX, the physician digitally creates a recipient site plan that communicates directly with the robot. The doctor programs the specific size, distribution, density, direction, and angle of the sites for the follicular unit grafts. The ARTAS iX’s vision system identifies where the grafts are to be placed, using the fiducials on the scalp as guides, and leads the robotic arm into position. Once the system automatically orients itself over the patient’s recipient area, implantation begins. The ARTAS iX can implant up to 500 grafts per hour.

ARTAS Robotic Hair Transplants at Bernstein Medical

Bernstein Medical was one of the first hair restoration practices in the world to use the ARTAS robot for FUE, a procedure pioneered by Dr. Bernstein and his colleague Dr. William Rassman. Bernstein Medical is a beta-test site for the ARTAS robotic systems. In 2013, Bernstein Medical was named an ARTAS Clinical Center of Excellence. Bernstein Medical is the first practice to offer the ARTAS iX.

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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 Speaks at ISHRS 2016Dr. Bernstein Speaks at ISHRS 2016

Dr. Robert M. Bernstein, Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical – Center for Hair Restoration, presented the results of his study on robotic hair transplantation at the annual ISHRS World Congress held in Las Vegas, Nevada on Friday, September 30, 2016. Dr. Bernstein presented an advance in the technology of the ARTAS® Robotic Hair Transplant System, called automated or robotic graft selection, which minimizes scarring and improves outcomes of robotic hair transplant procedures.

New York, NY — Dr. Robert M. Bernstein, Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical – Center for Hair Restoration, presented results of his study, “Robotic Follicular Unit Graft Selection,” at the 2016 ISHRS World Congress held in Las Vegas, Nevada. Graft selection is a key advance in the ARTAS Robotic Hair Transplant System, a hardware and software suite that automates aspects of the Follicular Unit Extraction (FUE) hair transplant procedure. The enhancement makes Robotic FUE more efficient and improves patient outcomes.

Dr. Bernstein presented the results of a peer-reviewed, bilateral controlled, randomized study which was published in the June 2016 issue of the journal Dermatologic Surgery. The study found that robotic graft selection can yield 17% more hairs per harvest attempt and 11.4% more hairs per graft than the prior system, which selected grafts at random. By automating the graft selection process, the ARTAS robot creates fewer wounds, which leads to fewer scars in the donor area – the area in the back and sides of the scalp from which follicular units are harvested – and an improved aesthetic outcome.

Graft selection is a process in FUE hair transplants to be used as each follicular unit — a tiny, naturally occurring bundle of one to four hair follicles — is chosen for extraction. Physicians who perform FUE procedures using manual, hand-held devices visually select each of the up to two thousand grafts that are extracted in an FUE hair transplant. Complicating the process, if too many large units are extracted, there may not be enough small units for transplantation to aesthetically sensitive areas like the frontal hairline. Extracting too many small units may result in unnecessary wounding in the donor area. The surgeon has to balance extracting the greatest number of follicles with creating the fewest possible wounds.

Early versions of the ARTAS robot, which automates several key steps in an FUE procedure, selected follicular units randomly. Dr. Bernstein, who has been collaborating with Restoration Robotics Inc. since its clinical release in 2011, set about to develop this robotic graft selection function. The result of this collaboration is a sophisticated automated graft selection system that makes the ARTAS robot more efficient and improves aesthetic outcomes of Robotic FUE hair transplant procedures. Dr. Bernstein introduced preliminary results of the graft selection study at the annual ARTAS User Group Meeting in February 2015.

Dr. Bernstein presented final results of the study at the 24th ISHRS World Congress held in Las Vegas, Nevada on Friday, September 30, 2016. The International Society of Hair Restoration Surgeons (ISHRS) is the pre-eminent association of hair transplant surgeons in the world, with more than 1,200 members from 70 countries. Dr. Bernstein participates in this annual event , often to present results of a major study published that year. This year he also lead a discussion session titled “Robotic FUE – Advances and Evolution”.

About Robert M. Bernstein, MD, MBA, FAAD, FISHRS

Dr. Robert M. Bernstein is a Clinical Professor of Dermatology at Columbia University in New York; renowned hair transplant pioneer; and founder of Bernstein Medical – Center for Hair Restoration. His more than 70 medical publications have fundamentally transformed the field of hair restoration and he has received the highest honor in the field given by the International Society of Hair Restoration Surgery (ISHRS). Dr. Bernstein has been featured on: The Oprah Winfrey Show, The Doctors on CBS, Good Morning America, The Today Show, The Dr. Oz Show, CBS News, ABC News, Fox News, Univision, and many other television programs. He has been interviewed by GQ Magazine, Men’s Health, Vogue, Columbia Business, The Columbia Journalist, The Wall Street Journal, and The New York Times.

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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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Dr. Bernstein Presenting at ARTAS® User Group Meeting 2015Dr. 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.

Click here to read about Robotic Follicular Unit Graft Selection

Click here to read about Robotic Hair Transplants


ARTAS User Group Meeting 2015

Dr. Bernstein Presenting at ARTAS User Group Meeting 2015
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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.

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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: Does transplanted hair grow faster after robotic FUE? — P.P., Flatiron, NY

A: There is no difference in the rate of growth between manual FUE verses robotic FUE. However, with Robotic FUE, the actual growth should be better due to less transection, i.e., less damage to follicles during the harvest.

In general, one can expect transplanted hair to start to grow within two to five months with the transplanted hair taking on its final appearance after approximately one year.

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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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