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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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First Master Class in Robotic Hair RestorationFirst Master Class in Robotic Hair Restoration

May 11th, 2018 – Robert M. Bernstein MD, a pioneer in modern hair transplantation, led five robotic hair restoration physicians in an intensive master class focusing on ARTAS robotic techniques, surgical planning and aesthetics. The day included a live ARTAS Robotic FUE procedure, a series of twelve presentations and a Q & A period. The ARTAS Hair Transplant System, developed by Restoration Robotics, is the only robotic system in the world designed to aid surgeons in hair restoration procedures.

Dr. Bernstein was chosen to teach the first ever Master Class on Robotic Hair Transplantation because of his innovative work in the field of hair restoration and his contributions in the development of the ARTAS Robotic System. Dr. Bernstein is a Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University and founder of Bernstein Medical – Center for Hair Restoration, a state-of-the-art hair transplant facility in NYC and a beta-test center for Restoration Robotics.

Topics covered by Dr. Bernstein in the Master Class included technical aspects of robotic surgery, challenges of donor and recipient planning, hairline design, and when best to use Follicular Unit Excision (FUE). In his live demonstration and hands-on training, Dr. Bernstein also covered the techniques of Follicular Unit Graft selection and Long Hair R-FUE.

Dr. Bernstein presenting at the ARTAS Master Class.Dr. Bernstein presenting at the ARTAS Master Class.

Dr. Bernstein published “Follicular Unit Transplantation” in 1995 which now serves as the groundwork for modern hair restoration. Follicular Unit Transplantation (FUT) is the technique where the donor hair is removed from the scalp in one long thin strip and dissected into individual follicular units. Dr. Bernstein pioneered Follicular Unit Excision (FUE) in 2002, with his colleague Dr. William Rassman. Follicular Unit Excision (FUE) is the process of using an instrument to make a small incision around the skin of a follicular unit to separate it from the existing tissue. In 2011, Dr. Bernstein worked with researchers from Restoration Robotics to improve the newly released ARTAS Robotic System. Bernstein Medical was one of the first facilities in the world to use the ARTAS Robot to perform FUE hair transplantation.

In the first-ever master class, Dr. Bernstein shared his deep knowledge of hair transplantation and his experience using the ARTAS Robot with fellow hair transplant surgeons who traveled across the country for this opportunity.

Posted by

Robert M. Bernstein, MD, New York, NY, [email protected]

The goals of most improvements in hair transplant techniques over the past 50 years have been to make donor harvesting less invasive, to increase accuracy for optimized growth, to generate grafts in a size that mimics nature, and to create recipient sites that result in natural hairlines that are aesthetically pleasing, but undetectable as a restoration.

One of the self-limiting factors in hair restoration, particularly follicular unit extraction (FUE), is that it has traditionally been subject to error caused by fatigue and other limitations of the human operator. This is a fundamental reason why the introduction of robotic technology for performing critical aspects of the FUE procedure has been such a game changer. In the hands of an experienced hair surgeon, the ARTAS™ Robotic Hair Transplant System is a powerful tool for creating natural and reproducible outcomes.

With the latest version of the platform, the recently released 9x upgrade, Restoration Robotics™ has engineered a faster and more accurate system for hair restoration. The improved accuracy of harvesting and shortened procedure increase graft viability. The smaller needles reduce scarring for a faster return to normal activity while allowing patients to wear shorter hairstyles.

Brief History of Hair Transplant Techniques

Norman Orentreich is widely credited with introducing the concept of “donor dominance” in the 1950s—the idea that transplanted hair continues to display the same characteristics of the hair from where it was taken. ((Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959.)) This means that continued growth at the recipient site is predicated on harvesting viable hairs from the donor site. In other words, the genetics for hair loss reside in the follicle rather than in the skin. However, due to limitations in graft harvesting technology, cosmetic outcomes of early transplant procedures were often unsatisfactory.

The large scars associated with early “hair plug” techniques were largely eliminated by the introduction of mini-grafts in the 1970s. ((Rassman WR, Pomerantz, MA. The art and science of minigrafting. Int J Aesthet Rest Surg 1993;1:27-36.)) This was followed by micro-grafts of 1-2 hairs. Mini-micrografting could be repeated hundreds or even thousands of times to cover large areas of baldness—but early manual techniques for doing so often yielded inconsistent graft quality and still resulted in scarring on the patient’s scalp, albeit less noticeable than previously. ((Rassman WR, Carson S. Micrografting in extensive quantities; The ideal hair restoration procedure. Dermatol Surg 1995; 21:306-311.))

In follicular unit transplantation (FUT), introduced in 1995 by Bernstein and Rassman, individual follicular units were dissected from the donor strip and became the new building blocks of the hair transplant. ((Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.)) Importantly, proper execution of FUT required the use of a stereo-microscope, a technique that was pioneered by Dr. Limmer. ((Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg 1994; 20:789-793.)) FUT/strip became popular because it produced completely natural results with minimal recipient site scarring and could be used to cover large areas of the scalp.

A limitation of FUT, however, was that patients often needed to wear longer hair styles to cover the linear scar in the donor area. Nevertheless, FUT improved graft viability, consistency, and naturalness compared to mini-micrografting, and it remains in use today as an option for patients who want to maximize hair yield and are not concerned about the linear scar.

In the mid-1990s, Dr. Woods began using a small punch-like instrument to create small, circular incisions in the skin around follicular units, separating them from the surrounding tissue. The follicular units are then pulled, or extracted, from the scalp, leaving tiny holes that heal in a few days. Dr. Woods was reluctant to share his techniques with the medical community; in 2002 Drs. Rassman and Bernstein, working with Columbia University, developed their own technique and published it in Dermatologic Surgery. The procedure then spread rapidly, and now over half of all hair transplant procedures performed today worldwide utilize FUE techniques. ((Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.))

A major advance to the FUE technique came with the two-step process devised by Dr. Harris. In his technique, a sharp punch was first used to score the surface of the skin and then a dull punch was used to dissect deeper into the tissue to avoid transection of follicles. This two-step technique was to become the basis for the future mechanism of robotic FUE. ((Harris JA. The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction (FUE). Hair Transplant Forum Intl. 2004; 14(5): 157, 163-4.))

FUE procedures allow recipients to wear shorter hairstyles due to the absence of a linear scar in the donor area, and they can typically return to physical activity sooner than after FUT. Yet, inherent difficulties in performing FUE, namely the requirement of keeping the follicular extraction instrument parallel and oriented along the axis of the follicle through the length of the graft, make it a technically challenging procedure. The introduction of the ARTAS Robotic Hair Transplant System in 2011 changed that dynamic by offering precision, control, and repeatability in follicle harvesting. Because it manages the exacting and repetitive work of extracting hundreds to thousands of grafts in a single session, physician fatigue and error are minimized. The potential to transect or damage the hair is reduced, and graft viability is increased.

Generational Improvements in Robotic Hair Transplantation

The first iteration of the ARTAS robot helped deliver accuracy and reproducibility in the form of a physician-assisted, computerized device with a three-dimensional optical system to locate and harvest follicular units directly from the donor area. By 2013, robotic recipient site making was added to help make the sites more uniform in depth and distribution and to avoid existing, healthy hair. Upon the recommendation of Dr. Bernstein, the manufacturer added another important upgrade in 2016 with a graft selection algorithm to select follicular units for harvesting based on the number of hairs they contain, producing greater hair density while leaving fewer scars in the donor area. ((Bernstein RM, Wolfeld MB. Robotic follicular unit graft selection. Dermatologic Surgery 2016; 42(6): 710-14.))

Restoration Robotics recently released the 9x ARTAS Robotic Hair Transplant System, the latest generation of its platform. It is faster and more accurate than previous versions and has better functionality. It also has improved artificial intelligence (AI) that reduces the potential for over-harvesting and enhances capabilities in recipient site making.

The easiest feature to appreciate with the 9x is that its raw speed is approximately 20% faster than the 8x. This is achieved by faster alignment with follicles, without sacrificing any precision in the approach angle for harvesting. The 9x features a dissection cycle of less than 2 seconds, meaning it can safely harvest roughly 1,300 grafts per hour—while still analyzing the scalp in micron-level precision. As with previous ARTAS versions, the cutting action is a two-step process, with an inner needle engaging the hair while the blunt outer punch separates the follicular unit from the remaining tissue.

Faster overall dissection is achieved with the 9x because the robot moves from one to the next follicle unit by skimming over the surface of the scalp, rather than retracting away from it between harvests.

The increased precision of the ARTAS 9x allows for the use of smaller needles for harvesting in appropriate candidates. The initial ARTAS system could only be used with a needle/punch apparatus that cut 1.0mm on the surface. The next iteration used a needle and punch of 0.9mm at the surface. The 9x has a 0.8mm option to allow very short hairstyles, although care should be taken in patient selection as there is less tolerance with a smaller punch.

The optics of the 9x have been completely reconfigured to use white LED illumination versus red, which allows extraction while harvesting without eye fatigue. The 9x is also easier to operate with some key features: a 1” extension on the robotic arm for longer reach and less need to reposition the patient; a smaller robotic head to permit acute angles of approach for harvesting; additional site making options, such as the ability to change the orientation (i.e., from sagittal to coronal) in different zones on the scalp; and a harvesting halo that is faster to apply and more comfortable for the patient.

AI and the Future of Hair Restoration

One of the more impressive aspects of working with the ARTAS System in hair restoration procedures is its already powerful AI. This feature makes it possible to detect select follicle units for harvesting. It also gives the platform the capability to automatically adjust the angle of approach, thereby reducing the potential to transect the hair follicle during harvesting.

One of the major upgrades in the 9x is the addition of an “empty site warning” that signals the operator that the harvest is not precise, allowing for adjustments in real-time. This builds on the already intuitive and user-responsive interface to add further quality control. Automatic scar detection has also been added so that the robot will skip over low-density areas to have more uniform harvesting. This is particularly important to our practice where we specialize in repair and corrective procedures.

The ARTAS platform is integrated with ARTAS Hair Studio™, an app-based technology with which the surgeon can consult with the candidate to simulate the final outcome. The ARTAS Hair Studio is also used by the physician to design the pattern for recipient site creation. With the 9x, Hair Studio has been upgraded so that instead of stitching together multiple photos to create a three-dimensional representation of patient’s scalp, it does so in a single photograph, making it faster and more efficient.

What is fundamental to understand about the 9x upgrade is that many of the additions have been specifically engineered based on user feedback, my own included. Restoration Robotics continues to work closely with physician users to understand needs in the clinic to produce a platform for hair restoration that is responsive to needs of the end user and the end beneficiary (the patient). In my hands, the 9x takes and makes an already powerful tool for hair restoration even faster and more accurate.

The statements, views, opinions, and analysis concerning Restoration Robotics and its technology expressed in this article are solely mine and are not intended to reflect the statements, view, opinions, and analysis of Restoration Robotics.

Posted by

Robert M. Bernstein, MD, New York, NY, [email protected]; Michael B. Wolfeld, MD, New York, NY, [email protected]

Disclosure: Drs. Bernstein and Wolfeld hold equity interest in Restoration Robotics, Inc. Dr. Bernstein is on its medical advisory board.

Since the publication of “What’s New in Robotic Hair Transplantation” (Hair Transplant Forum Int’l. 2017; 27(3):100-101), there have been important improvements to the robotic system in both its incision and recipient site creation capabilities. These advances fall into four overlapping categories:increased speed, increased accuracy, increased functionality, and improved artificial intelligence (AI). The overlap occurs since improvements in functionality, accuracy, and AI can also increase the overall speed of the procedure. A faster procedure decreases the time grafts are outside the body and allows the physician to perform larger cases without placing additional oxidative stress on the follicles.

Increased Speed

The speed of the robot has increased through faster and more precise alignment with the hair in the follicular units.
The robot also saves a significant amount of time by staying closer to the scalp (approximately 2mm) while moving from unit to unit, rather than retracting after each harvest. By shortening the distance the robotic arm moves between incisions, the dissection cycle has decreased to less than 2 seconds, giving the robot a raw speed over 2,000 grafts per hour. In a clinical setting, this enables harvesting of up to 1,300 grafts per hour.

Although the obvious way to increase speed is to simply make the robot go faster, there are limitations to this, as it would decrease the ability of physicians to make real-time adjustments to the system. The robot has an automatic feedback loop that makes intra-operative modifications as the harvesting proceeds, and this significantly decreases the need for human intervention. However, when there is scarring or other situations of excessive patient variability, it is necessary for occasional “tweaking” (particularly of punch depth) to achieve an optimal outcome. In these situations, faster robot speed may be counterproductive.
With this in mind, new ways have been found to speed up the procedure without limiting the operator’s ability to respond. One has been to change the color of the light emitted by the optical system. In the past, a beam of red light illuminated the fiducials that the robot uses to guide the robotic arm, but the glare of this light is very difficult on the eyes.

Fig 1. Touchscreen user interfaceFIGURE 1. Yellow fiducials and white light guide incision.

By enabling the optical system to read “eye-friendly” white light, the surgical team is now able to remove grafts as soon as they are separated from the surrounding tissue, rather than having to wait for an entire grid to be finished.This allows the two steps in follicular unit excision—the graft separation from surrounding tissue (incision) and the actual removal (extraction)—to proceed in parallel, rather than in series, in order to decrease operating time.

The new optical system also enables the robot to recognize the tensioner from a distance. Previously, the physician had to manually bring the robot toward the scalp (a step called “forced drag”), until the robot was close enough to recognize the fiducials on a grey-colored tensioner. This now happens automatically, with the robot recognizing a yellow tensioner from a distance and then homing in on the fiducials as it moves closer to the scalp, eliminating the time needed for the extra step (Figure 1).

FIGURE 2. 3-D image for site creation using one photoFIGURE 2. 3-D image for site creation using one photo

Recipient site creation has been a significant new capability of the robotic system. The advantages of robotic site creation include the ability to avoid existing terminal hair (minimizing injury) and to create new recipient sites in a precise distribution that complements the existing hair. A limitation of this technology is that the physician needs to develop a 3-D computer-based model of each patient’s scalp to communicate the transplant design to the robot. The old model required the fusion of 5 two-dimensional images, a process that required a significant amount of time. The newest iteration can build a three-dimensional model using only one image, greatly decreasing the time needed for this important step (Figure 2).

Increased Accuracy

There has been a recent trend in FUE towards using smaller punches. Although these authors feel that in many cases the increased risk of transection from smaller diameter punches outweighs the benefit of reduced wounding and concomitant smaller scars, it is important that the robot has this capability for physicians who prefer these punches.

The sharp/blunt system in the original robot (released in 2011) used a 1.0mm sharp pronged needle that penetrated the skin about 1mm and was immediately followed by a rotating, dull punch with a slightly larger diameter that went deeper into the scalp. The current system includes a 0.9mm needle that is the workhorse for most cases. With refinements in the optical system, the needle/punch diameter was able to be reduced further. The new needle option is 0.8mm.

The needle has also been redesigned so that the physician can choose between 2 and 4 prongs, with the former being preferable in softer tissue and the latter in firmer skin or scarred scalp (Figures 3 through 6).

FIGURE 3. 1.0, 0.9 and 0.8mm needlesFIGURE 3. 1.0, 0.9 and 0.8mm needles
FIGURE 4. Recipient wounds: 0.8mm (left) and 0.9mm (right)FIGURE 4. Recipient wounds: 0.8mm (left) and 0.9mm (right)


FIGURE 5. 0.8mm needle: 1-, 2-, 3- , and 4-hair follicular unit graftsFIGURE 5. 0.8mm needle: 1-, 2-, 3- , and 4-hair follicular unit grafts
FIGURE 6. 0.9mm needle: 1-, 2-, 3- , and 4-hair follicular unit graftsFIGURE 6. 0.9mm needle: 1-, 2-, 3- , and 4-hair follicular unit grafts

Increased Functionality

In prior iterations, when the robotic arm was in a position that was too cramped and from which it could not automatically recover, the user needed to go through a six-step manual process using a stand-alone pendant to guide the robot to a neutral “safe” position.

FIGURE 7. Compact robotic head FIGURE 7. Compact robotic head

The Arm Brake Release is a new functionality that places a single button on the arm that, when pressed, quickly moves the arm away, allowing the operator to readjust the patient’s position.
Modifications of the robotic arm (which give it greater reach) and changes to the robotic head (which reduce its bulk) enable the robot to access a much greater area of the scalp without the need for repositioning the patient. This reduces a significant amount of procedural time as well. Another advantage of the smaller head is that the robotic arm can approach the patient at more acute angles without collision, adding more flexibility to both harvesting and site creation (harvesting to 35°, site making to 30°). The more acute angles required a redesign of the headrest so that the arm would have unimpeded access to the scalp (Figure 7).

FIGURE 8. Universal blade holderFIGURE 8. Universal blade holder

Prior iterations of the robotic system used hypodermic needles of varying sizes (18g-21g) for recipient site making. In response to the wide range of physician preferences, the robot now has a universal holder that can accommodate almost any type of site making tool. These include square-tipped blades, angled blades, and chisel and spear point blades, as well as the original hypodermic needles. These can be easily interchanged during the procedure (Figure 8).

Artificial intelligence

FIGURE 9. Automatic scar detection FIGURE 9. Automatic scar detection

An automatic collision recovery system will automatically retract the robotic arm if the arm approaches the patient at an angle that is too acute, or cramped to operate, or if any part of the robot (other than the operating tip) inadvertently touches the patient. Once retracted, the patient can be repositioned so that the FUE session can proceed.
One of the frustrations of FUE is the occasional empty site that represents either a graft that was pushed too deeply into the scalp or one that was completely removed. The new empty site warning icons complement physician observation by using color-coded symbols (green, yellow, and red) to alert the doctor to the occurrence of empty sites.
Finally, the ARTAS software can now automatically detect regions with low (or no) hair density and block those areas from being harvested. This capability decreases human error and saves time by automatically performing a function that prevents creating zones with very little or no hair coverage (Figure 9).

In sum, new improvements in the speed, functionality, accuracy, and artificial intelligence of the robotic system have significantly shortened the duration of the overall procedure. Besides being more convenient for patients and more expedient for the operating physician, the shortened operating time decreases the time grafts are outside the body, an important factor in ensuring optimal growth of the transplanted hair.

Posted by

Robert M. Bernstein, MD, New York, NY; William Rassman, MD, Los Angeles, CA
Hair Transplant Forum International 2018; 28(1):6

Robert M. Bernstein and William R. Rassman began a chain of responses
to this change of nomenclature:

This article on FUE ((Mejia, R. MD, Florida, J, USA. Redefining the “E” in FUE: Excision = Incision + Extraction. Hair Transplant Forum International 2018;28(1):1,5–11.)) name change adds significant clarity to the nomenclature of hair transplantation. Renaming Follicular Unit Extraction to Follicular Unit Excision acknowledges two distinct steps — incision and extraction — that will make communicating with our patients easier and more concise. It will also allow clinicians and researchers to think more clearly about the two steps of FUE, both separately and together, when addressing such issues as transection, suction injury, punch design, automation, and robotics. Although Shakespeare aptly pointed out that at times a name can be quite irrelevant: “What’s in a name? That which we call a rose by any other name would smell as sweet” [Romeo and Juliet, II, ii, 1-2], in this case the important change in wording should have lasting significance.

For further information read the ISHRS newsletter on the updated terminology.

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Q: I thought that FUE extraction is performed in a way that it cannot be detected. Therefore, it is best to distribute the pattern evenly starting from the safe zone and fading out on the sides. The ARTAS results often show a smaller extraction area and harder edges (no transition from extraction to non-extraction area). Does this lead to a higher risk to detect the surgery? — H.K. ~ Chicago, I.L.

A: Feathering of the extraction zone in FUE is a technique where the distance between the extractions gradually increases as one reaches the border of the extracted zone. When this technique should be used depends upon the short- and long-term goals of the patient. If the patient’s main goal of the FUE procedure is to wear their hair very short, then the technique of feathering and rounding the edges to have a less distinct border is appropriate, as this will decrease the visibility of the harvested area.

However, if a person does not wear his hair very short (nor plans to) and maximizing the donor supply is paramount, then a more organized pattern, with less feathering, will give a greater long-term yield and a more even distribution. The reason is that the healing of FUE wounds distorts adjacent follicular units making subsequent extraction in the same regions more difficult and increases the risk of transection. For this reason, in subsequent procedures we generally prefer to harvest in new areas. If we need to harvest more hair from the same area, we rarely go back more than once.

When one feathers extensively in the donor area, this utilizes a larger surface area of the scalp with less graft yield, so it may become necessary to go back over the same area to obtain additional grafts, often multiple times. This risks increased transection and an uneven, mottled appearance to the donor area.

If a person wears his hair very short, then feathering is critical (even though it makes subsequent extraction more problematic). It is very easy to feather and round edges with the ARTAS robot, but we make the decision to do so based upon the specific needs and goals of the patient.

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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

Posted by

Robert M. Bernstein, MD, New York, NY, [email protected]; Michael B. Wolfeld, MD, New York, NY, [email protected]; Jennifer Krejci MD, San Antonio, TX, [email protected]

Disclosures: Dr. Bernstein and Dr. Wolfeld hold equity interest in Restoration Robotics, Inc. Dr. Bernstein is a medical consultant to the company and is on its medical advisory board.

ABSTRACT

Since the introduction of robotic FUE technology over five years ago, there have been numerous upgrades to the system. The current paper describes the most recent advances. These include a more user-friendly interface, the ability to select for larger follicular units, greater range-of-motion of the robotic arm, improved methods for stabilizing the scalp and newly designed needles for more accurate harvesting.

Background

The ARTAS Robotic System, developed by Restoration Robotics Inc., was first available for commercial use in 2011. Continued improvements in both its hardware and software have made it an increasingly valuable tool for physicians performing follicular unit extraction (FUE). Over 180 hair restoration surgeons world-wide currently use robotic technology to assist them in their FUE procedures. Recent advances in the robotic system have increased its speed and precision and new modifications have made it more user-friendly. The robotic system can be used for both harvesting and site creation. This writing focuses on improvements to robotic graft harvesting.

Touchscreen User Interface

Fig 1. Touchscreen user interfaceFig 1. Touchscreen user interface

The robotic system is an interactive, computer-assisted suite of hardware and software that uses optical-guidance robotics to identify and isolate follicular units in the donor area and create sites for grafts in the recipient area. In the earlier iterations, doctors used a mouse to control the operations of the robot. This required the physician to be seated with one hand resting on the mouse and slowed down the procedure. A touch screen has been developed to make operating the robot more intuitive and to speed up the ability to make real-time adjustments while the physician is standing and observing the patient. Most of the controls are aggregated to one area on this screen for ease of use. The touchscreen can be used alone or with the traditional mouse and keyboard, depending upon the user’s preference. (Figure 1.)

Follicular Unit Graft Selection

Fig 2. Follicular unit graft selectionFig 2. Follicular unit graft selection

The follicular unit (FU) graft selection capability of the robotic system has been added to enable physicians to select follicular units based on hair content. The physician now has the option to harvest larger follicular units and skip over smaller ones, particularly one-hair units. The purpose is to harvest the most hair through the smallest number of wounds. FU graft selection has two main benefits: 1) It can generate a greater number of larger FU grafts to maximize the fullness of the restoration, and 2) it can be used to harvest larger FUs that can be microscopically dissected to generate a greater number of smaller grafts with a minimal number of donor wounds. Skipping over one-hair follicular units increases the number of hairs per graft by 11.4% with the one-pass method (selecting for FUs with 2 or more hairs) and 6.6% with the two-pass technique (adding a second pass to harvest 1-hair FUs skipped in the first pass) compared to a random selection of grafts. ((Bernstein RM, Wolfeld MB. Robotic follicular unit graft selection. Dermatologic Surgery 2016; 42(6): 710-14.)) (Figure 2.)

Locking Tensioner Tool

The tensioner is a compressible, polycarbonate device that is used to assist the vision system and to stretch and stabilize the skin prior to extraction. Fiducials, on the top of the tensioner’s rectangular surface, are used by the robot’s optical system to orient the arm for harvesting and to record the location of previously harvested grafts. (A fiducial is a marker placed in the field of view of an imaging system for use as a point of reference or a measure.) The undersurface has pins that grip the skin. (Figure 3.) The tensioner is compressed with a handle placed on the donor scalp and then allowed to passively expand, stretching the skin. (Figure 4.) It is secured with elastic straps to the patient’s headrest. (Figure 5.)

Fig 3. Pins on undersurface of tensionerFig 3. Pins on undersurface of tensioner
Fig 4. Tensioner with locking tool and standFig 4. Tensioner with locking tool and stand

The re-designed tensioner tool has a thumb-activated catch and release mechanism, so that once the tensioner is grasped, constant pressure is not needed. This makes it easier to operate and places significantly less stress on the physician’s hands. It also allows the tensioner and handle to be loaded and placed on a stand that holds the instrument and protects the pins when not in use. This keeps the handle in a position to be grabbed easily. (Figure 4.) The handle can thus be set up in advance, increasing the speed of this step of the procedure.

Improved Halo

Fig 5. Double-notched halo to secure elastic strapsFig 5. Double-notched halo to secure elastic straps

The tensioner is held in place by 1) pins that grip the skin, 2) the recoil of the compressed tensioner, and 3) elastic straps that are stretched and secured in grooves located on the base of the headrest and/or on a halo device. The advantage of a halo is that the forces are lateral (rather than downward) and thus more comfortable for the patient. It also causes less torque on the tensioner, allowing it to better follow the contour of the patient’s scalp. A newly designed halo has a double-notch and central protuberance that makes the bands more secure and enables the physician to more rapidly secure the bands using one hand. (Figure 5.)

Arm Spacer to Increase Range of Motion

Fig 6. One-inch spacer to increase range of motionFig 6. One-inch spacer to increase range of motion

A one-inch extension of the robotic arm allows the instrument to harvest at a more acute angle than was previously possible. It also increases the range of motion of the robotic arm. It is particularly useful when harvesting on the sides and lower occipital regions of the scalp. The greater reach increases the number of grafts that can be harvested without repositioning the patient, thereby saving operating time and leaving the patient undisturbed. (Figure 6.)

Improved Image Processing for Glare

Glare can interfere with the optimal functioning of the optical system. It may be caused by the light of the needle mechanism or the natural light of a bright operating room. When glare is present, it affects how the system identifies the hair and can prevent the system from recognizing hair that would be eligible for harvesting. With improved digital image processing, the system can better visualize existing hair, even in areas of glare within the grid. As a result, the number of grafts harvested per grid is increased.

Assisted Force-Drag

For the robotic arm to engage with the donor scalp, it must be aligned with the fiducials on the top of the tensioner. In the past, this alignment had to be performed manually. The new “Assisted Force-Drag” technology enables the robot to self-align to the tensioner as soon as the fiducials are detected by the vision system. This feature obviates the need for the manual step and allows for an overall faster workflow.

Puncture Depth (PD) Band Detection

Fig 7. Bands on 2- and 4-pronged needlesFig 7. Bands on 2- and 4-pronged needles

The robot uses a two-step, sharp/blunt punch technique based on the ideas of Dr. Jim Harris. Puncture depth bands enable the robot’s computer to measure the depth of the needle (punch) in the scalp. The robot then uses this information to improve the accuracy of the subsequent puncture. Puncture depth band detection may be affected by the presence of blood, hair, and shadows from the tensioner. Improved algorithms that guide PD band detection have increased its accuracy by 9% compared to earlier versions, even in the face of these artifacts. (Figure 7.)

4-Prong Needle

The robot was initially designed with a two-pronged, sharp-punch. The advantage of this design was that the long prongs were able to anchor lax skin. A disadvantage was that it was less efficient when the scalp was tighter, or more fibrotic, and when the arm had to operate at a more acute angle to the surface of the scalp. To mitigate this limitation, a 4-prong needle was developed. The 4-prongs allow for cleaner incisions with better anchoring to tissue at acute angles. This advance results in improved yield, especially in areas below the occiput and on the side of the head. It is also more effective in patients with tougher tissue. (Figure 7.) A 3-pronged needle is currently being developed for tight and/or fibrotic skin as well as lax skin.

6-mm Punch

Fig 8. 6-mm punchFig 8. 6-mm punch

The original robotic system used a 4-mm rotating dull-punch to dissect the body of the graft from the surrounding tissue. The limitation of this design is that it was less effective in patients with longer hair follicles (i.e., greater than 4.5mm). With longer hair follicles, the collar of the 4-mm punch pushed on the skin and, as a result, splayed the grafts and/or bent the bulbs.

The new punch is 6-mm tip-to-shoulder so that full dissection of longer follicles can be accomplished with less distortion of the skin. This modification avoids damage to the lower portion of the grafts. (Figures 8, 9.).

Fig 9. Grafts 7-mm in length harvested using a 19-gauge, 4-prong needle and 6-mm dull punch
Fig 9. Grafts 7-mm in length harvested using a 19-gauge, 4-prong needle and 6-mm dull punch

The Future

A host of new modifications are in the pipeline. In addition to the 3-prong needle, a color camera is being developed that allows the robot to read white-light. This will make the operating field easier on the eyes (compared to the current red lights). Other advances include improved dissection, a smaller punch (0.8mm), an automatic scar detector, a 20% increase in harvesting speed, the ability for physicians to harvest at an angle as low as 30 degrees from the scalp, and several advances that will make site creation more user-friendly.

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ARTAS 9x - First Commercial Case at Bernstein MedicalFirst ever case with ARTAS 9x at Bernstein Medical – Click to watch video

In April 2017, Bernstein Medical – Center for Hair Restoration became the first hair restoration practice to perform robotic hair transplant surgery using the new ARTAS Robotic System 9x. ARTAS 9x is a major upgrade of the hair transplant robot, enabling faster and more precise Robotic FUE procedures.

Some of the hardware improvements to the system include a white light LED, color camera and tensioner, 20-gauge harvesting needle, robotic base extender, new needle mechanism cover, and more comfortable headrest and halo. Software upgrades include better scar detection, faster harvesting, ability to zoom into the main viewing screen, and improved ARTAS Hair Studio software.

Color Camera and White LED Light

The original ARTAS robotic system used a black and white optical system and a red LED light. It used a red light source so that blood on the scalp wouldn’t interfere with the ARTAS algorithms. However, clinical staff found that the red light caused eye fatigue over time.

The new optical system uses color cameras and white LED lights so technicians can extract grafts while the system is still harvesting without risk of eye fatigue. The color cameras also allow the robot to associate colors with shapes increasing the visual sharpness and accuracy of the system.

ARTAS 9x - White vs Red LED LightPrevious versions of the robot used a red LED light (left), ARTAS 9x uses a white light (right)

Assisted Force-Drag

In order for the robot to begin harvesting or site making, it must first align the robotic arm to the grid area defined by a tensioner device. In previous versions of the robot, the robotic arm needed to be manually aligned with the fiducials (indicators) on the top of the tensioner. The new Assisted Force-Drag technology enables the robot to self-align as soon as the fiducials are detected by the optical system. This speeds up the procedure and makes it more efficient by minimizing set-up time between grids.

Robotic Arm Base Extender

Restoration Robotics has modified the robotic arm by adding a base extender in order to achieve a longer reach without increasing the size and weight of the robot itself. The longer reach decreases the need for patient repositioning and chair adjustments and thus decreases the duration of the procedure.

Automatic Scar Detection

ARTAS 9x - Improved Scar DetectionARTAS 9x detects and blocks harvesting from areas with scarring

The ARTAS robotic software can now detect areas with low (or no) hair density and systematically block those areas and that immediately around it from being harvested. The step was done manually in earlier versions. This shortens harvesting time in patients with scarring as it automatically prevents overharvesting in these areas.

Recipient Site Making Blade Holder

Originally, robotic site creation used needles to create recipient sites in the patient’s scalp. However, some physicians prefer to use blades over needles. To address this, Restoration Robotics has developed a blade holder so that surgeons can use either needles or blades. The new blade holder also allows the use of 3rd party blade tips, further enabling the doctor to customize the procedure.

20-Guage Harvesting Needle

The ARTAS 9x robot has the capability of using a very fine 20-guage harvesting needle and punch that permits grafts to be removed though a significantly smaller incision. When appropriate, the use of this needle allows for a harvest with less tissue attached to the grafts. This reduces the need for trimming grafts and speeds up the procedure. It further minimizes the size of the recipient wounds.

Newly Designed Robotic Arm, Headrest, and Halo

The head of the ARTAS robot arm has been reduced in size to increase its mobility and decrease the need for repositioning the patient. This increases patient comfort and shortens the operating time.

An improved site making headrest includes a new, more comfortable pillow with a memory foam layer. The harvesting halo now has rounded edges that allow for secure, faster tensioner placement.

ARTAS Hair Studio

The ARTAS Hair Studio is also improved, now requiring the physician to take just one photo to create the 3D image of the patient’s scalp. With the 9x version of the ARTAS Hair Studio, the surgeon can now zoom in on the user interface screen during recipient site creation and simultaneously examine details and monitor the entire procedure.

Robotic FUE at Bernstein Medical

Bernstein Medical’s Robotic Hair Transplant Center of New York® is among the first facilities in the world to use the ARTAS robot to perform FUE, a procedure pioneered by Dr. Bernstein. Our practice is a beta-test site for this innovative hair restoration technology and Dr. Bernstein is a medical adviser to Restoration Robotics, the company that manufactures the ARTAS robot.

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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: As a medical advisor and an end-user of the ARTAS Robotic System, do you see any impact of your involvement with Restoration Robotics? — J.V. ~ Miami, F.L.

A: Restoration Robotics has been very responsive to the needs of its physicians and to their patients. Because I work closely with Restoration Roboticsin the development of new improvement and advances they are often introduced first in our practice.

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Onalytica - Robotics Top 100 Influencers

Onalytica, a company that provides Influencer Relationship Management software and services, has named Dr. Bernstein one of the top influencers (#39 out of 100) on the topic of robotics due to his pioneering work in robotic hair transplant surgery with the ARTAS Robotic System.

Onalytica surveyed more than 550,000 tweets mentioning “robotics” or “robotic” over a span of 90 days (September – November 2016), including over 96,000 engaged twitter users, then used proprietary software to rank the most influential individuals and brands in the Twittersphere. The listing takes into account the level of engagement of each user’s tweets, the relevance to the topic, the influencer’s number of followers, and how frequently the influencer is listed in others’ Twitter lists. Dr. Bernstein is the only surgeon, hair transplant or otherwise, listed in the Top 40 of individual influencers.

Dr. Ordon and Dr. Bernstein discussing the latest advances in the ARTAS® Robotic Hair Transplant SystemDr. Bernstein and Dr. Ordon of The Doctors discussing advances in Robotic FUE

Robotics is a hot topic in the tech sector and according to one report, the service robotics market is expected to surpass $18 billion by the year 2020. Robotics has an increasing number of uses in healthcare, and thanks to Dr. Bernstein and Restoration Robotics the ARTAS system will continue to be on the cutting edge in surgical applications of robotics in the treatment of hair loss for years to come.

Make sure to follow @bernsteinhair for the latest on robotic hair transplants.

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Q: I have read that the ARTAS System works best on straight black hair. Is this an option for gray hair? How about wavy or curly hair? – P.W., Fort Lee, NJ

A: The ARTAS robotic system can be used in patients with any hair color although in order for the robot to visualize white hair (or very light blond hair) the hair must be dyed. Curly hair is also not a problem as the donor hair in a robotic procedure is shaved to approximately 1 mm in length so a wave or curl is eliminated. In patients of African descent, where the hair below the surface of the skin may be curved, a slightly larger punch can be used. we have patients dye their hair the evening before or the day of the procedure. For convenience, only the hair in the donor area (back and sides) where the robot will be doing the harvesting needs to be dyed.

In patients who prefer not to shave or dye the entire back and sides of the scalp, we can perform the ARTAS robotic FUE using the long-hair technique. With this technique, you will grow your hair on the back and sides of the scalp a bit longer so it can cover the harvested area. On the day of the procedure, we will lift up the hair, clip a long thin band of donor hair and then extract follicular units from this limited region of the scalp. After the procedure, you can simply comb down your hair to cover the donor zone. The area that has been harvested (and possibly dyed depending on your hair color) will not be visible.

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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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Dr. Ordon and Dr. Bernstein discussing the latest advances in the ARTAS® Robotic Hair Transplant SystemDr. Ordon and Dr. Bernstein discussing the latest advances in the ARTAS® Robotic Hair Transplant System

Dr. Andrew Ordon — Emmy-nominated co-host of the award-winning talk show “The Doctors” — and Dr. Robert Bernstein met at Bernstein Medical – Center for Hair Restoration in New York City on March 3, 2016, to discuss the latest advances in robotic hair transplantation.

Some of the topics they discussed include the advanced LED touchscreen interface (illustrated above), a new automated graft selection capability, and the robot’s upgraded image-guidance system, which enables more precise harvesting and a further reduction of graft transection.

Dr. Bernstein appeared on “The Doctors” in 2012. On that program, he discussed how the precision technology of the ARTAS Robotic Hair Transplant System enables doctors to extract thousands of follicular units without human error entering the equation.

Video: Dr. Bernstein on “The Doctors”

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Dr. Bernstein Discusses the Latest in Robotic Hair Transplant Surgery on The Bald Truth

Dr. Bernstein appeared on The Bald Truth, where he was interviewed by the show’s host, Spencer Kobren, about the ARTAS® Robotic Hair Transplant system for FUE and the latest updates to the robot. He also discussed increased demand for FUE procedures, and hair transplants in general, around the world.

Bernstein Medical was among the first facilities in the world to use the ARTAS Robotic System to perform Follicular Unit Extraction (FUE) hair transplants, a procedure pioneered by Dr. Bernstein. Bernstein Medical is a beta-test site for this innovative technology. Physicians at Bernstein Medical have introduced new applications for the robot, including: custom punch sizes, robotic recipient site creation, automated follicular unit graft selection, and a “long-hair Robotic FUE” technique that allows the patient to keep their hair longer in the donor area. Every FUE hair transplant at Bernstein Medical uses the ARTAS Robotic System. Dr. Bernstein is a medical advisor to Restoration Robotics, the company that manufactures the ARTAS hair transplant system.

Watch video of the interview and read a transcript
Read more about Robotic FUE
Read our Robotic Hair Transplant FAQ

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New York Post

Dr. Bernstein was quoted in a New York Post article on the growing popularity of surgical hair restoration. In the article, Dr. Bernstein explained how celebrity hair transplants have become a driving factor behind the fading of the decades-long stigma of hair transplants.

“Soccer players, football players — they’re admitting they’ve had the surgery. Patients bring in pictures of [George] Clooney, Brad Pitt. The stigma of the old plugs is fading,” [said Dr. Bernstein.]

While celebs aren’t writing signed confessions, there’s plenty of speculation about which high-profile men may have gotten procedures — such as LeBron James, Kevin Costner, John Travolta and Jeremy Piven.

Advancement in hair transplant technology may also be lending a hand. Follicular Unit Transplant (FUT) surgery and newer techniques, such as Robotic FUE, have all but eliminated the old corn-row style “hair plugs” that were commonplace twenty years ago.

The article discusses how the hair restoration industry saw a 27% increase in hair transplant procedures worldwide since 2012. The newest data released by the International Society of Hair Restoration Surgery (ISHRS) values the global surgical hair restoration market at nearly $2.5 billion.

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Dr. Robert M. Bernstein, pioneer of modern hair transplant procedures and a Clinical Professor of Dermatology at Columbia University in New York, was included in New York Magazine’s ‘Best Doctors’ issue for the 16th consecutive year.

Best Doctors 2015 - New York Magazine

New York, NY — Robert M. Bernstein, MD, MBA, FAAD, a Clinical Professor of Dermatology at Columbia University in New York and renowned pioneer of Follicular Unit Transplantation (FUT) and Robotic Follicular Unit Extraction (Robotic FUE) hair transplant procedures, was included in New York Magazine’s annual ‘Best Doctors’ issue for the sixteenth consecutive year.

On being chosen for his sixteenth consecutive ‘Best Doctors’ issue, Dr. Bernstein said: “I am honored to be considered among the best doctors in New York and it is a credit to the hardworking staff at Bernstein Medical that, after two decades of incredible progress, we are still making significant advances in the surgical treatment of hair loss.”

Recognition of Dr. Bernstein and his contributions to the field of surgical hair restoration comes as he continues to push the envelope with advances in Robotic FUE hair transplants, improving more traditional hair restoration techniques and exploring adjuvant treatments.

Among the improvements Dr. Bernstein has made to the robotic hair transplant procedure include: automated selection of follicular unit grafts, robotic creation of recipient sites, reducing wound size, and a “long-hair” FUE technique that allows a patient to have an FUE hair transplant without the donor area being visible in the post-op period. Collectively these improvements make the robot more efficient, reduce scarring from the procedure, and improve the outcome for patients. Dr. Bernstein’s internationally renowned hair restoration facility, Bernstein Medical – Center for Hair Restoration, is a beta-testing site for Restoration Robotics, Inc., the company that produces the ARTAS® robot. Dr. Bernstein is a medical advisor to the company.

New York Magazine’s ‘Best Doctors’ issue is a special annual edition of the acclaimed magazine which contains a directory of the New York City area’s best physicians. The directory is created by Castle Connolly, Ltd., through a survey of doctors in the New York Tri-State area. To be included, doctors in New York, New Jersey and Connecticut are nominated by their peers and then must pass a rigorous physician-led review of their qualifications, reputation, and skill in diagnosis and treating patients. Castle Connolly also publishes America’s Top Doctors, which has included Dr. Bernstein in all fourteen editions.

About Robert M. Bernstein, M.D., F.A.A.D.

Dr. Robert M. Bernstein is a Clinical Professor of Dermatology at Columbia University in New York, founder and lead surgeon at Bernstein Medical – Center for Hair Restoration, and renowned pioneer of Follicular Unit Transplantation (FUT) and Robotic Follicular Unit Extraction (Robotic FUE) hair transplant procedures. Dr. Bernstein was the first to describe Follicular Unit Transplantation and Follicular Unit Extraction in the medical literature, and his more than 60 medical publications have fundamentally transformed surgical hair restoration. Dr. Bernstein has received the Platinum Follicle Award, the highest honor in the field given by the International Society of Hair Restoration Surgery (ISHRS), and has appeared as a hair restoration expert on many notable television programs and news and lifestyle publications over the years. Examples include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, New York Times, Wall Street Journal, Men’s Health Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies. Dr. Bernstein graduated with honors from Tulane University, received the degree of Doctor of Medicine at the University of Medicine and Dentistry of NJ, and did his training in Dermatology at the Albert Einstein College of Medicine. Dr. Bernstein also holds an M.B.A. from Columbia University.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration, founded by Dr. Bernstein in 2005, is dedicated to the diagnosis and treatment of hair loss in men and women using the most advanced technologies. The state-of-the-art facility is located in midtown Manhattan, New York City and treats patients who visit from 58 countries and all 50 states. The board-certified physicians and highly-trained clinical assistants at Bernstein Medical take pride in providing the highest level of treatment and care for all patients. In 2011, Bernstein Medical became one of the first practices in the world to offer Robotic FUE hair transplant procedures using the image-guided, computer-driven technology of the ARTAS Robotic System. Bernstein Medical is a beta-testing site for this technology.

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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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Q: I have been reading about Robotic FUE and have seen some photos on your website of you operating the ARTAS robot using what looks like a remote control. What is that thing and how does it control the robot? — C.B., Greenwich, CT

Dr. Bernstein Operating the ARTAS FUE Robot
Dr. Bernstein Operating the ARTAS FUE Robot

A: The ARTAS robot uses a dual operating system when performing follicular unit extraction. One station consists of a desktop computer adjacent to the robot. This station is used to establish the basic parameters of the transplant such as the spacing of grafts, the angle and depth of the harvest, which size follicular units will be targeted, and a host of other important variables.

The hand-held pendant is used by the operator situated next to the patient. The remote has more limited options – the main ones being depth adjustment and to immediately suspend the action of the robot. Many of the parameters are determined automatically by the robot’s computer to maximize the accuracy of the harvesting. The robot also makes real-time adjustments to these variables during the hair restoration procedure.

The physician sets the parameters at the computer monitor and, once the settings are determined, he/she sets the tensioner grid on the patient’s scalp. The tensioner determines where the grafts will be harvested. The grid is moved approximately every 130 harvests. The robot can be operated at the computer terminal and through a mobile pendant. The physician often alternates with a trained assistant between that station and using the pendant.

Besides the involvement in the operation of the robot, there are many other important physician-dependent steps to the hair transplant including the planning and design of the procedure, and recipient site creation. Other steps, such as the microscopic sorting and trimming of harvested follicular unit grafts and graft placement, are often performed by trained staff, but require the physician’s close supervision.

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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: How does the ARTAS robot control the depth of the incision in Robotic FUE? — B.V., Old Greenwich, CT

A: The ARTAS robotic system is equipped with advanced sensors that determine the precise depth of the sharp and blunt needles used both in the graft harvesting step and for recipient site creation. The robot automatically adjusts to the precise depth needed for the non-traumatic extraction of the grafts. The tip of the punching mechanism contains depth markings so that the physician can visually override the punch when he wants to fine-tune its action. While monitoring the procedure in real time, if it is observed that the punches are too superficial or too deep, punch depth can be modified using the robot’s computer system.

The physician can also use the ARTAS system to precisely control the depth of recipient sites. As with harvesting, the robot automatically adjusts the depth based on parameters set by the physician and the doctor can then make further adjustments, in real-time, during the procedure.

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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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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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Dr. Robert M. Bernstein presented the ARTAS Hair Studio™ digital hair transplant design software and robotic recipient site creation using the ARTAS® Robotic Hair Transplant system, each advances in key aspects of hair transplantation, at the International Society of Hair Restoration Surgeons (ISHRS) annual meeting in Kuala Lumpur, Malaysia on Saturday, October 11th, 2014.

Kuala Lumpur, Malaysia (PRWEB) October 31, 2014 — Robert M. Bernstein, M.D., F.A.A.D., a world-renowned hair transplant pioneer, has presented two advances in robotic hair transplant surgery to the hair restoration industry’s largest conference; an interactive hair restoration design software suite called ARTAS Hair Studio™ and recipient site creation capability in the ground-breaking ARTAS® Robotic Hair Transplant system. Dr. Bernstein’s presentation highlights the fact that the ARTAS System is the first system to integrate the planning and performance of a hair transplant procedure. Dr. Bernstein presented these new technologies at the 22nd Annual Science Meeting of the International Society of Hair Restoration Surgeons (ISHRS) in Kuala Lumpur, Malaysia, on October 11th, 2014.

ISHRS 2014 - 22nd Annual Scientific Meeting - Kuala Lumpur, Malaysia
ISHRS 2014 – 22nd Annual Scientific Meeting in Kuala Lumpur, Malaysia

ARTAS Hair Studio is a planning tool that assists the physician in the design phase of the hair restoration procedure. Dr. Bernstein’s presentation described how this software enables the physician to generate a three-dimensional model of the patient’s head and then create a treatment plan based on parameters such as the number of recipient sites, the angle of elevation of the hairs, and the direction of the hairs. With small modifications of the software, the technology can add “virtual” hair to the 3-D model and allow patients to see how the results will actually look. This will create a more interactive, educational experience for the patient and one that helps align the patient’s expectations with what is possible given their specific hair loss characteristics.

Dr. Bernstein showed how, using the new software, the surgeon can divide the treatment area into two or more sections and then program different recipient site densities for the different areas to closely mimic how hair grows in nature. The treatment plan created using ARTAS Hair Studio can be saved and then imported into the ARTAS hair transplant robot.

Once the design specifications have been imported, the ARTAS Robot can then create the recipient sites, the tiny incisions made in a patient’s scalp, into which transplanted grafts of naturally-occurring groups of 1-4 hairs, called follicular units, are placed.

Recipient Site Creation at Bernstein Medical Using ARTAS Robotic System
Recipient Site Creation at Bernstein Medical Using ARTAS Robotic System

In his presentation to the ISHRS, Dr. Bernstein described several advantages of robotic site creation over manual site creation, including: the elimination of inconsistencies in creating large numbers of recipient sites by hand, precise distribution of follicular unit grafts, automatic adjustment to site densities, and automatic avoidance of existing hairs without sacrificing speed. The robot uses advanced sensory equipment and optical cues to locate potential recipient sites on the scalp and then quickly and accurately make the incisions based on the pre-programmed parameters. The robot can create up to 2,000 recipient sites in approximately one hour.

Dr. Bernstein noted that these advances represent an integration of the design and planning processes with the actual performance of the procedure. Whereas in the past, the doctor would describe the treatment plan to the patient and then manually implement the prescribed plan, today’s computerized robotic system allows the physician to digitally design the hair transplant treatment plan, and then that plan directs the robot in the operating room.

Restoration Robotics Inc., the company that developed the robot, collaborated with Dr. Bernstein, using the Bernstein Medical – Center for Hair Restoration facility as a beta-testing site, to upgrade the ARTAS robot and test these and other advances. The ultimate goal is to deliver a robot that will mechanize every surgical aspect of an FUE hair transplant procedure.

About Robert M. Bernstein, MD, MBA, FAAD

Dr. Bernstein’s published articles on follicular unit hair transplant procedures have been called “Bibles” for the industry. He has received the Platinum Follicle Award, the highest honor in the field. He is a fellow of the International Society of Hair Restoration Surgery (ISHRS). Dr. Bernstein has appeared as a hair restoration expert on many notable television programs and in many news and lifestyle publications over the years. Examples include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, New York Times, Wall Street Journal, Men’s Health Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies. Dr. Bernstein graduated with honors from Tulane University, received the degree of Doctor of Medicine at the University of Medicine and Dentistry of NJ, and completed his training in Dermatology at the Albert Einstein College of Medicine. Dr. Bernstein is a Clinical Professor of Dermatology at Columbia University.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration, the facility Dr. Bernstein founded in 2005, is dedicated to the diagnosis and treatment of hair loss in men and women using the most advanced technologies. The state-of-the-art facility is located in midtown Manhattan, New York City and treats patients from around the globe. In 2011, Bernstein Medical became one of the first practices in the world to offer Robotic FUE procedures using the image-guided, computer-driven technology of the ARTAS Robotic System. Bernstein Medical is a beta-testing site of the robot’s new capability including the creation of recipient sites and Dr. Bernstein is a medical advisor to the company that produces the robotic system, Restoration Robotics, Inc. The board-certified physicians and highly-trained clinical assistants at Bernstein Medical take pride in providing the highest level of treatment and care for all patients.

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ARTAS® Robotic Hair Transplant System

Restoration Robotics, Inc. has announced that the ARTAS® Robotic System has harvested its 10 Millionth Hair, a major accomplishment for the three-year-old robot. The company attributes the success of achieving the 10 Millionth Hair in this short time span to rapid adoption by hair transplant industry leaders, like hair restoration pioneer Dr. Robert Bernstein.

The ARTAS robot is the only image-guided, physician-assisted robotic system for harvesting follicular units.

On the achievement, Jim McCollum, President and Chief Executive Officer of Restoration Robotics, said:

“The ARTAS Robotic System is fast becoming the gold standard in hair transplantation and enables hair restoration surgeons to enhance the patient experience and achieve unsurpassed outcomes. Our 10 Millionth Hair verifies the increased interest in patients pursuing a highly precise, undetectable hair transplant with a high degree of patient satisfaction. Interested patients are researching and demanding the ARTAS Robotic Hair Transplant Procedure.”

The ARTAS Robotic System received 510k clearance from the Food and Drug Administration (FDA) in 2011 after a decade of research, testing, and clinical trials. Dr. Bernstein is an advisor to the company and, since its launch in 2011, he has offered several modifications to the initial iteration of the robot that have improved its performance and usability. Bernstein Medical – Center for Hair Restoration was the first facility on the East Coast of the United States, and one of the first hair transplant practices in the world, to use the system. Bernstein Medical is also a beta-testing site for the robot, and many upgrades to the hardware and software of the unit have been tested and perfected in our Manhattan hair restoration facility. All FUE hair transplants at Bernstein Medical are performed with the aid of the ARTAS robot.

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After years of jokes about his continually receding hairline, LeBron James, basketball superstar and winner of two NBA championships and four NBA Most Valuable Player Awards, stunned the sports world on September 16th, 2014 when he revealed a newly restored hairline while promoting his new LeBron 12 shoe at Nike World Headquarters.

FUE Hair Transplant Most Likely Responsible for LeBron James’ New Hairline

Folks are now asking – where, when and how did LeBron get that great new hairline?

While no one knows for sure (and LeBron, so far, hasn’t said a word), Katie Nolan, the host of FoxSports.com’s No Filter, rejects the idea that LeBron’s new life in Cleveland is less stressful than it was in Miami and that’s what allowed his hairline to return. Instead, she strongly suspects that it is the result of an advanced surgical hair restoration technique called Follicular Unit Extraction, or FUE, which produces hair transplant outcomes that look completely natural.

She also suspects the use of low-level laser therapy (LLLT) which new research has shown to be an effective treatment for male and female pattern hair loss.

Katie Nolan breaks it all down for you in her No Filter segment below, “LeBron James unveils his new hair (and some shoes).”

Read about FUE Hair Transplants

View Before & After Photos of some of our hair transplant patients

Visit Bernstein Medical for a one-on-one hair loss consultation with one of our board certified physicians

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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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Dr. Bernstein was interviewed by Spencer Kobren on The Bald Truth, the critically acclaimed broadcast on hair loss and hair restoration. They discussed the latest in robotic hair transplant surgery, the ARTAS® Robotic System, FUE and FUT hair transplant procedures, and the future of hair restoration.

Spencer Kobren: It’s great to have you back. And I know you only have about a half an hour – actually about 20 minutes now… Let’s get straight to the point. You heard my opening, you kind of know how I feel about the way that the industry is moving, the direction the industry is moving in, and also my concern about now that these devices are really starting to become a bigger part of the market, I believe that these devices are getting into the wrong hands. Now let’s just start with why you’ve embraced it and then we can go into how the industry is evolving.

Dr. Bernstein: Follicular Unit Transplantation via strip was a pretty straight-forward procedure, and once we figured out how to use microscopes to dissect out the follicular units and train the staff on microscopic dissection, it was pretty much a slam dunk. It was just a question of other doctors embracing it and patients understanding what it is and demanding the procedure. With Follicular Unit Extraction it’s really a much different animal. The technique is very, very tricky. And the reason why it’s tricky is because the dissection is done essentially blind. The hair follicle changes direction as it goes deeper in the skin, and also the hairs that comprise a follicular unit splay outward — they fan outwards — so it’s very tricky to get a very small punch around an intact follicular unit. When you do this by hand thousands of times, it’s really, really hard for a physician to concentrate and be consistent and not get bored out of his mind. Also, you don’t have all the visual cues that you have under a microscope. So this repetitive procedure lends itself to robotics. For years we worked on the technique, first with a sharp punch, then a dull punch, then a two-step technique where we used a sharp punch to score the skin and then a deeper [duller] punch under it. Each got better and better, but it never was really consistent, and it certainly was very, very dependent on the user, the patient, and how you’re feeling that day. So this procedure lends itself to robotics. I first learned about the robotic procedure very early in 2011 and when I first saw the robot it made total sense to me.

The Bald Truth is America’s longest running self help radio show for men’s hair loss. Kobren is the Founder and President of the American Hair Loss Association and a founder of the International Alliance of Hair Restoration Surgeons (IAHRS).

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Dr. Robert M. Bernstein has been included in New York Magazine’s annual ‘Best Doctors’ issue for the 15th consecutive year. Dr. Bernstein, a Clinical Professor of Dermatology at Columbia University, is a world-renowned hair transplant surgeon and pioneer of robotic hair transplant procedures.

Best Doctors 2014 - New York Magazine
New York Magazine ‘Best Doctors’ 2014

New York, NY — Robert M. Bernstein, MD, MBA, FAAD, a Clinical Professor of Dermatology at Columbia University in New York and a pioneer of modern hair transplant procedures, is honored to be included in New York Magazine’s annual ‘Best Doctors’ issue for the fifteenth consecutive year.

Dr. Bernstein’s two decades of innovation in surgical hair restoration and dedication to his patients at Bernstein Medical – Center for Hair Restoration have earned him placement in the 2014 edition of the peer-nominated ‘Best Doctors’ issue. The respect his colleagues have for his work stems from his leadership and dedication to advancing and improving surgical hair restoration procedures.

When asked about being included in his fifteenth consecutive issue of ‘Best Doctors,’ Dr. Bernstein said:

“As a physician, my singular focus is on providing patients with the best options for hair restoration and performing transplant surgery using the most advanced technologies. That my work is recognized by the medical community is both an honor and a testament to how far the field of hair transplantation has come since the days of the older, less-natural procedures.”

Dr. Bernstein’s latest work is in developing new applications for robotic hair transplant procedures. In addition to being among the first in the world to incorporate the ARTAS® robotic system into his practice, Dr. Bernstein was the first to describe Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) into the catalog of medical literature. He has authored over 60 publications in scientific journals. These writings have fundamentally transformed the hair transplant procedure from older “plug procedures,” into a modern technique that uses precise robotic technology to extract individual follicular units from the back of the scalp. A recent historical review of dermatologic surgery published in the Journal of the American Academy of Dermatology recognized Dr. Bernstein’s work in FUT and FUE as allowing “the once elusive goal of a completely natural-looking hair transplant to finally be achieved.”

New York Magazine’s ‘Best Doctors’ issue is a special annual edition of the acclaimed magazine which contains a directory of the New York area’s best physicians selected by Castle Connolly, Ltd. Physicians throughout New York, New Jersey and Connecticut are nominated by their peers as part of their survey and must also pass a rigorous physician-led review of the doctor’s qualifications, reputation, skill in diagnosis and treating patients.

About Robert M. Bernstein, M.D., F.A.A.D.

Dr. Robert M. Bernstein’s published articles on Follicular Unit Transplantation have been called “Bibles” on that methodology. He has received the Platinum Follicle Award, the highest honor in the field, and has been named the Surgeon of the Month and Pioneer of the Month by the International Society of Hair Restoration Surgery (ISHRS). Dr. Bernstein has appeared as a hair restoration expert on many notable television programs and in many news and lifestyle publications over the years. Examples include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, New York Times, Wall Street Journal, Men’s Health Magazine, and more. He is also co-author of Hair Loss & Replacement for Dummies. Dr. Bernstein graduated with honors from Tulane University, received the degree of Doctor of Medicine at the University of Medicine and Dentistry of NJ, and did his training in Dermatology at the Albert Einstein College of Medicine. Dr. Bernstein also holds an M.B.A. from Columbia University.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration, the facility Dr. Bernstein founded in 2005, is dedicated to the diagnosis and treatment of hair loss in men and women using the most advanced technologies. The state-of-the-art facility is located in midtown Manhattan, New York City and treats patients from around the world. In 2011, Bernstein Medical became one of the first practices in the world to offer Robotic FUE procedures using the image-guided, computer-driven technology of the ARTAS Robotic System. Bernstein Medical is a beta-testing site of the robot’s new capability including the creation of hair transplant recipient sites. The board-certified physicians and highly-trained clinical assistants at Bernstein Medical take pride in providing the highest level of treatment and care for all patients.

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ARTAS Robotic System display monitor showing parameters for the creation of recipient sitesARTAS Robotic System display monitor showing parameters for the creation of recipient sites

New York, NY (PRWEB) — Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., founder of Bernstein Medical – Center for Hair Restoration, introduced new technology that allows the ARTAS Robotic System to accomplish a critical step in hair transplant surgery, the creation of recipient sites. Presenting at the 2nd ARTAS User Group Meeting, Dr. Bernstein previewed the recipient site creation technology that brings the robotic system one step closer to performing critical aspects of the labor-intensive, hair transplant procedure.

The ARTAS System is currently able to harvest intact follicular unit grafts from the permanent area in back of one’s scalp using precise robotic technology. This is the most difficult aspect of a follicular unit extraction hair transplant – the newer type of hair restoration procedure that avoids a linear scar in the back of the scalp. Now that site creation can also be done robotically, only one step remains – graft placement.

The ARTAS Robotic System maps the surgeon's hairline design onto a 3-D model of the patient's headThe ARTAS Robotic System maps the surgeon’s hairline design onto a 3-D model of the patient’s head

For the recipient site creation, the doctor first draws a hairline and other markings directly onto the patient’s scalp to delineate the surgical plan. Next, multiple photographs are taken and fed into software, called the ARTAS™ Hair Studio, which converts the images into a 3-D model of the actual patient. This computer model can be manipulated and saved for the patient’s procedure. Using the ARTAS™ Hair Studio software, the physician then specifies the angle, direction, density, and randomness of the recipient site incisions to create the most natural look. During the procedure, the robot uses image-guided technology to avoid existing hairs while it creates up to 1,500 recipient sites per hour. In performing recipient site creation, the robot automates a process that can be physically demanding and prone to human error.

On the advancement, Dr. Bernstein said:

“This development is a crucial step towards a robotic system that can perform every aspect of a hair transplant. A great deal of credit goes to the engineers of Restoration Robotics who have worked to make automated recipient site creation a reality. I am proud that this work not only improves hair transplants for patients, but adds to the increasingly important trend of using robotic technology in medicine.”

The site creation technology that Dr. Bernstein debuted at the ARTAS User Group Meeting; which was held in California (Laguna Niguel, CA) on February 7th and 8th, 2014; will be available to hair restoration physicians in the fall of 2014. Gabe Zingeratti Ph.D, head of R&D at Restoration Robotics, Inc., presented details of the technology, which was beta-tested at Bernstein Medical – Center for Hair Restoration. With the next generation ARTAS® Robotic System rolling out in the coming months, the focus of research will then be on the final phase of robotic hair transplantation, the robotic insertion of follicular unit grafts into recipient sites. This last step will take several more years to develop.

The ARTAS Robotic System, developed by Restoration Robotics, is currently in use by hair restoration physicians around the world to automate the extraction of grafts of skin and hair called follicular units.. Follicular units, which are natural groupings of one to four hair follicles, form the biological basis of the modern hair transplant procedure. Once extracted from the back of the patient’s scalp, the follicular unit grafts are then inserted into recipient sites in the balding area of the scalp where they grow hairs that are immune to the effects of common hair loss.

No stranger to innovative advances in hair transplant surgery, Dr. Bernstein introduced Follicular Unit Transplantation (FUT) to medical literature in a 1995 publication. FUT transformed hair transplants from the use of large grafts of skin and hair, known colloquially as “hair plugs,” to a more medically-oriented procedure that produces completely natural-appearing results. Dr. Bernstein with his colleague Dr. Bill Rassman again broke new ground with his 2002 publication that introduced the concept of Follicular Unit Extraction (FUE) to scientific literature. Dr. Bernstein was the first physician on the East Coast of the United Sates, and one of the first in the world, to use the ARTAS System to perform FUE using the new robotic technology.

About Robert M. Bernstein, M.D., F.A.A.D.

Dr. Robert M. Bernstein is a Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical – Center for Hair Restoration. His landmark scientific papers are considered seminal works in the field of hair transplant surgery. Other publications include textbook chapters on dermatologic surgery and books, like Hair Loss and Replacement for Dummies, aimed at the consumer audience. He has been selected as one of New York Magazine’s “Best Doctors” for fourteen consecutive years and has appeared as a hair loss and hair transplantation expert on The Oprah Winfrey Show, The Dr. Oz Show, Good Morning America, The Today Show, CBS News, Fox News, and The Discovery Channel. Dr. Bernstein has been interviewed or featured in articles in the New York Times, GQ Magazine, Men’s Health, Interview Magazine, Vogue, and others.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration, founded in 2005, is a state-of-the-art facility and international referral center for the treatment of hair loss that is located in midtown Manhattan, New York City. Hair transplant surgery, hair repair surgery, and eyebrow restoration are performed using Dr. Bernstein’s pioneering techniques of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE).

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Columbia BusinessDr. Bernstein is featured in Columbia Business, the alumni magazine of the Columbia Business School, for having “revolutionized the field of hair restoration.” Dr. Bernstein, who received an MBA from the renowned university in 2004, is quoted as having seen an opportunity in 1995 to transform hair transplantation from a procedure using “hair plugs” to one with significantly more natural results. In collaboration with Dr. William Rassman he introduced Follicular Unit Transplantation (FUT) which, the article notes, is now the “gold standard” for modern surgical hair restoration.

Also mentioned in the article, which is titled “Hair Hero,” are his pioneering work in robotic hair transplant procedures, his receiving the Platinum Follicle Award, and his appearances in the popular media including a feature on Good Morning America.

Dr. Bernstein is a Clinical Professor of Dermatology at the College of Physicians & Surgeons of Columbia University, where he instructs residents in general dermatology and the specialized art of hair restoration surgery.

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Journal of the American Academy of DermatologyDr. Bernstein is credited with introducing the “follicular unit” to surgical hair restoration, the innovation that allowed for a “completely natural-looking hair transplant” to be achieved. The commentary on Dr. Bernstein’s contributions to the field of hair transplantation are outlined in an historical review of dermatologic surgery that appeared in the Journal of the American Academy of Dermatology.

Dr. Bernstein is noted as being responsible for moving the field of hair restoration surgery away from large graft “plugs” and mini-micrografts to follicular units:

The following year, dermatologists Bernstein et al laid down the conceptual framework for follicular unit transplantation in their 1995 article, “Follicular transplantation.” In 1997, they detailed its clinical application in the paired articles, “Follicular transplantation: patient evaluation and surgical planning” and “The aesthetics of follicular transplantation.”

The 2 advances, the application of the stereomicroscope to follicular dissection and the use of follicular units as the basic element of hair transplantation, arose from a background in dermatology. They moved the field of hair restoration surgery from plugs and mini-micrografting, where this basic anatomical feature of the hair follicle was ignored, to follicular unit transplantation, where the follicular unit became sacrosanct. These 2 ideas, when put to clinical use, allowed the once elusive goal of a completely natural-looking hair transplant to finally be achieved.

Dr. Bernstein’s pioneering of the Follicular Unit Transplant (FUT) procedure still resonates, almost two decades later, as the follicular unit continues to be the anatomical structure that is transplanted in hair transplant surgeries worldwide.

The article then describes how Dr. Bernstein, along with his colleague Dr. Rassman, laid the foundation for the next major developments in hair restoration; first with his description of the Follicular Unit Extraction (FUE) technique and more recently with innovation in robotic hair restoration technology.

With the publication of the article, “Follicular unit extraction,” in 2002, the follicular unit extraction procedure gained popular appeal and was rapidly adopted by doctors worldwide. The authors cautioned on the limitations of this harvesting technique and the risk of follicular damage. Dermatologists Berman, Zering, and Bernstein, along with their colleagues in other specialties, continue to work on the problem of harvesting in follicular unit extraction, with the application of robotic technology showing particular promise.”

Taken together, these passages underscore how Dr. Bernstein’s research and medical publications have fundamentally transformed the field of hair restoration to the benefit of patients and physicians alike. While many other very talented physicians have had a substantial impact on hair restoration procedures ever since the hair transplant concept was first proposed by Dr. Norman Orentreich in the 1950s, Dr. Bernstein has contributed the key innovations that have made modern, natural-looking hair transplant surgery a medical and aesthetic possibility.

The article is titled, “Current status of surgery in dermatology.” The Journal of the American Academy of Dermatology is the official journal of The American Academy of Dermatology (AAD), the largest, most influential and most representative dermatology group in the United States.

Reference

C. William Hanke, Ronald L. Moy, Randall K. Roenigk, Henry H. Roenigk Jr., James M. Spencer, Emily P. Tierney, Cynthia L. Bartus, Robert M. Bernstein, Marc D. Brown, Mariano Busso, Alastair Carruthers, Jean Carruthers, Omar A. Ibrahimi, Arielle N.B. Kauvar, Kathryn M. Kent, Nils Krueger, Marina Landau, Aimee L. Leonard, Stephen H. Mandy, Thomas E. Rohrer, Neil S. Sadick, Luitgard G. Wiest, Current status of surgery in dermatology, Journal of the American Academy of Dermatology, Volume 69, Issue 6, December 2013, Pages 972-1001, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2013.04.067.

Read more about Dr. Bernstein’s history of innovation in hair transplant surgery

Read Dr. Bernstein’s landmark medical publications

Download and read ‘Current status of surgery in dermatology’ (pdf)

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The 21st Annual Scientific Meeting of the International Society of Hair Restoration Surgery was held in San Francisco from October 13 through 26, 2013. The meeting covers the most important scientific and clinical advances in the field of surgical hair restoration.

As a member of the panel on “Difficult Cases,” that explored challenging and atypical medical conditions and their treatment, Dr. Bernstein presented the “Management of Frontal Fibrosing Alopecia.” This condition is a form of primary scarring hair loss. Dr. Bernstein chose to discuss this disease because it can be mistaken for common baldness; however, since the transplanted hair will be destroyed by the disease process, it is a contra-indication for hair transplantation. Since missing this diagnosis can lead to unnecessary and ineffectual surgery, an awareness of its signs and symptoms are important for every physician managing patients with hair loss.

On the panel on “Post Finasteride Syndrome,” Dr. Bernstein was part of a group that reviewed the latest studies on the efficacy and safety of finasteride in the treatment of androgenetic alopecia. They discussed possible adverse events including claims of persistent sexual dysfunction (Post Finasteride Syndrome) and concerns relating to prostate cancer. They also discussed the challenges that arise in caring for patients when scientific research and the mass media give conflicting information.

In the Symposium “Question the Expert,” Dr. Bernstein presented a case of Diffuse Un-patterned alopeica (DUPA). This condition was first detailed by Dr. Bernstein in his landmark paper “Follicular Transplantation: Patient Evaluation and Surgical Planning,” that was published in Dermatologic Surgery in 1997. DUPA is a form of androgenetic alopecia that presents as rapid generalized hair loss in young adults. Besides being a significant psychological burden for young men and women, its identification is extremely important since medical intervention can have a significant positive impact when instituted early. On the other hand, a misdiagnosis that leads to surgery can result in a failed hair transplant and donor scarring that may become visible over time.

Dr. Bernstein was also the Keynote Speaker for the ARTAS International Users Forum. His presentation, titled “Follicular Unit Extraction: Then and Now,” discussed the evolution of FUT, FUE and Robotic-FUE and how it relates to today’s hair restoration practice. Of particular significance was the natural progression of FUE instrumentation from hand-held manual tools to robotic assisted hair transplantation. Dr. Bernstein explained that in the future, robotic capabilities will not be limited to graft extraction, but eventually will perform each aspect of the transplant including recipient site creation, and graft placement. See “Dr. Bernstein Gives Keynote Presentation On Robotic Hair Transplantation” for more details on the presentation and some photographs of the event.

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Dr. Bernstein Presenting ‘Follicular Unit Extraction: Then and Now’

Dr. Bernstein was honored to deliver the keynote address at the ARTAS International Users Forum in San Francisco, California. Dr. Bernstein’s presentation, “Follicular Unit Extraction: Then and Now,” was a review of the evolution of surgical hair restoration from Follicular Unit Transplantation (FUT) through Follicular Unit Extraction (FUE) to the cutting edge technique of Robotic-FUE.

The presentation described the steps that resulted in the use, and growth in popularity, of the state-of-the-art ARTAS Robotic System for FUE. Dr. Bernstein pointed out that with the introduction of each procedure — FUT, FUE, and Robotic-FUE — there was initially a rocky reception with physicians. In each instance, however, the surgeons’ concerns were overcome first by strong, patient interest and then by clinical studies that confirmed the procedures’ usefulness.

Dr. Bernstein discussed how FUE procedures progressed from the use of hand-held instruments to the computer-assisted, image-guided ARTAS Robot. One of the initial hurdles of FUE procedures using hand-held devices was a high rate of follicular unit transection (cutting of the follicles). Restoration Robotics, Inc., the company that developed the ARTAS system, used a “sharp/blunt” punch technique that was introduced by Jim Harris in his 2004 publication on the SAFE System for FUE. The sharp/blunt technique, that was validated in 2006 by Dr. Bernstein’s research publication, “New Instrumentation for Three-Step Follicular Unit Extraction,” reduced transection of follicles when compared to older instrumentation. Dr. Bernstein then detailed modifications to the system that he proposed in order to improve the ARTAS robot. These improvements include: a smaller tip for the sharp/blunt punch, selection of larger over smaller follicular units, tensioner placement, ‘feathering’ the ends of the tensioner, and pre-making recipient sites before extracting the follicular unit grafts.

Looking to the future, Dr. Bernstein mapped out the further evolution of the Robotic FUE procedure and the tasks it will be required to perform. In future procedures, the physician will not only guide the robot on extracting follicular units, but also in creating recipient sites and, further down the road, placing grafts into the recipient sites. Graft placement will represent the most significant challenge to the robotic system as this step is the most sensitive to patient to patient variability. Once this last step is accomplished, a fully automated hair transplant should be possible, eliminating much of the human error in the mechanical aspects of the hair restoration process.

More photos from the event:

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New York Magazine’s 2013 ‘Best Doctors’ issue includes Dr. Robert M. Bernstein, a pioneer of modern hair transplant procedures, making this the 14th consecutive year Dr. Bernstein has appeared in the special annual issue.

New York Magazine 'Best Doctors' 2013New York, NY — Robert M. Bernstein, M.D., F.A.A.D., Clinical Professor of Dermatology at Columbia University in New York and a pioneer of modern hair transplant procedures, was included in the ‘Best Doctors’ issue of New York Magazine for the fourteenth consecutive year.

Dr. Bernstein earned his placement in the Best Doctors issue, and his reputation as world-renowned hair restoration physician, through a 20 year career of developing surgical techniques and adopting and guiding technological advances in the industry. His more than 60 medical publications on Follicular Unit Transplantation (FUT), Follicular Unit Extraction (FUE), and Robotic FUE (R-FUE) have revolutionized the field of hair restoration and provide the foundation for hair transplant surgeons worldwide.

The New York Magazine ‘Best Doctors’ issue is an annual issue of the magazine that contains a directory of the New York area’s best physicians. The directory is based on the results of a peer-reviewed survey that is conducted by Castle Connolly, Ltd. The company also publishes the guidebook “Top Doctors: New York Metro Area,” based on the same survey of doctors. As part of the survey, physicians are nominated from across the New York metropolitan area including Manhattan, Brooklyn, Queens, The Bronx, Staten Island, Westchester County, Long Island, and counties in New Jersey and Connecticut. The recommendations are based on the nominated doctor’s qualifications, reputation, skill in diagnosis, skill in treating patients, and other criteria. A physician-led research team at Castle Connolly tabulates and vets the nominations and compiles the final list.

Bernstein Medical – Center for Hair Restoration, the facility Dr. Bernstein founded in 2005, is a state-of-the-art hair loss treatment facility in New York City that serves men and women from around the world. The center specializes in FUT, FUE and R-FUE hair transplants, and also performs corrective hair transplants and offers medical treatments for hair loss patients who are not indicated for a transplant. In 2011, Bernstein Medical became the first hair restoration facility on the East Coast to offer Robotic FUE procedures using the ARTAS Robotic System. Dr. Bernstein has worked closely with Restoration Robotics, Inc. to improve both the robotic technology and the R-FUE procedure protocol.

Dr. Bernstein has appeared on many notable media programs and publications over the years. Some of these include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, The Early Show, Fox News, National Public Radio, NY1, New York Times, Wall Street Journal, Men’s Health Magazine, GQ Magazine, Telemundo, “O” the Oprah Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies and has received the Platinum Follicle Award, Surgeon of the Month, and Pioneer of the Month honors from the International Society of Hair Restoration Surgery (ISHRS).

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Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise. — N.C., Paris, France

A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.

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Q: I am an African-American man with tight curly hair. Will the FUE robot be able to work on curly hair? — E.O., Manhattan, N.Y.

A: Yes, the ARTAS robot for FUE can be adapted for African-American hair when performing follicular unit extraction. We use a punch that is 0.1mm wider in diameter than the instrument used for Caucasians. It allows us to incorporate the slightly larger volume of tissue that results from the curved hair and enables us to accomplish the hair transplant with less in jury to follicles than if a smaller instrument were used.

See before & after hair transplant photos of patients with curly hair

Read about Robotic Hair Transplantation

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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

Read about our hair restoration patients

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Q: I read your post that the ARTAS robot doesn’t work well in patients who want FUE but have blond hair. I have dark skin and hair, does that present a problem for the machine? — J.S., London, England, U.K.

A: The ARTAS Robot performs follicular unit extraction just as well with blond hair as dark hair, but not white hair. It is simple to just to dye the white donor hair prior to the hair transplant procedure. This donor hair will be clipped very short the morning of surgery removed anyway, so it will not present too much of a cosmetic issue.

See before & after hair transplant photos organized by hair character

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Hair Restoration in Women, Dr. Bernstein Featured in 'New You' Magazine

Dr. Bernstein and Bernstein Medical – Center for Hair Restoration were featured in New You magazine’s article “My Hair Lady.” The main topic of the article is hair transplantation in women, however it also touches on hair loss in women, Follicular Unit Transplantation (FUT), medication and other products.

On Bernstein Medical – Center for Hair Restoration:

The Manhattan office of Bob Bernstein, just steps from Park Avenue, is the kind of space that makes successful men feel at home — a good thing for one of the country’s foremost specialists in hair restoration (and the co-author of Hair Loss for Dummies). The layout is part design statement, part science lab, slick with granite, slate, and glass and full of microscopes and high tech gizmos. Among the space’s most noteworthy gadgets is one of only twelve robots in the world programmed to help perform hair transplants, which has a home in Dr. Bernstein’s office.

A female patient of ours discussing the “taboo” of hair transplantation in women:

Sara Lyles, 62, whose hair loss was caused by a styling technique, said that when Dr. Bernstein performed her hair transplant 12 years ago, the subject was taboo. “Women never talked about it, and I was so embarrassed that I avoided all social functions,” she recalls. “I’m African American and I slept in large tight rollers to keep frizzing under control. The traction destroyed my frontal hairline.”

At the time, she would have been mortified if someone found out she had undergone a transplant. “Even my hairdresser had no clue,” she says. “Dr. Bernstein not only gave me my hair back, he gave me my life back.”

Dr. Bernstein on the amazing progress of the hair restoration industry:

As Dr. Bernstein emerges from his operating room, sporting green scrubs and green Nikes that match the room’s tiles, he shakes his head and sighs. “When I went into practice back in the eighties, transplantation was almost barbaric and Rogaine was the only alternative,” he remembers. He marvels at the advances and choices he and others now have to over. “I never would have thought I would be working with robots, lasers, and cloning.”

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Dr. Bernstein Leads Robotic FUE 'Coffee With Experts' At ISHRS 20th Annual Meeting

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.

Read about the latest in Robotic FUE

Read about how Dr. Bernstein has improved Robotic FUE procedures

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New York, NY (PRWEB) — Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., a world-renowned hair transplant surgeon, presented a series of improvements to hair transplant procedures which use the ARTAS Robotic System for Follicular Unit Extraction (FUE). These updates include revisions to the FUE surgical protocol and technical adjustments to the robotic extraction system. He presented his refinements at the first user meeting held by the developers of the system; Restoration Robotics, Inc.; on September 14 – 16 in Denver, Colorado.

Dr. Bernstein receives recognition from Restoration RoboticsDr. Bernstein receives recognition from Restoration Robotics

Dr. Bernstein described his series of improvements in a lecture to an elite group of physicians who are among the first adopters in the industry of the image-guided, robotic-assisted system. The updates are designed to improve the results of FUE hair transplantation by enhancing both the surgical protocols of the procedure as well as the functionality of the robotic system. In FUE, small groups of one to four hairs, called follicular units, are extracted individually from the back and sides of the scalp and are then implanted into recipient sites, which are tiny holes that the surgeon creates in a balding area of the scalp.

Dr. Bernstein discussing robotic-assisted FUE at Restoration Robotics' first user meetingDr. Bernstein discussing robotic-assisted FUE at Restoration Robotics’ first user meeting

The most important update to the FUE procedure that Dr. Bernstein proposed is for surgeons to create recipient sites before they extract the grafts, rather than create the sites after grafts are extracted. Drawing on his decades of experience in hair transplantation, Dr. Bernstein developed this technique of “pre-making” recipient sites in order to maximize survival of the grafts during the hair transplant. Using this technique, extracted grafts are outside the body for a shorter duration of time. It also minimizes instances of “popping,” in which grafts are exposed to desiccation (drying) and hypoxia (low oxygen) before they are inserted back into the scalp. By “pre-making” the recipient sites, these harmful factors are mitigated and a greater number of the grafts grow into viable, hair-producing follicular units. Dr. Bernstein encourages surgeons to use this technique on all FUE procedures, whether using manual methods or robotic instrumentation.

When asked to comment on his improvements to the robotic FUE procedure, Dr. Bernstein said:

“It was fortuitous timing that the ARTAS Robot became available just as I was developing my refinements to the FUE procedure. The combination of the automated robot for graft extraction with the technique of pre-making recipient sites has led to a significant improvement in hair transplant surgery.”

Dr. Bernstein is the founder of Bernstein Medical – Center for Hair Restoration, and he is recognized world-wide for his innovative work in the treatment of hair loss. He is among the first hair transplant surgeons in North America to utilize the ARTAS Robot for FUE in his practice.

Being an early adopter of the advanced follicular unit extraction system has enabled him to work with Restoration Robotics to refine it to his exacting standards. Dr. Bernstein has, again, put his fingerprints on a revolutionary upgrade to the hair transplantation industry. He was the first to describe FUT and FUE procedures in the medical literature, in 1995 and 2002 respectively. In contrast to FUE, where follicular units are extracted individually, in FUT procedures a strip of skin is removed from the back of the scalp, it is then dissected into follicular units, and those follicular unit grafts are then implanted into recipient sites in the patient’s scalp.

About Dr. Bernstein

Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S. is a Clinical Professor of Dermatology at Columbia University and a pioneer in the field of hair restoration. His landmark scientific papers are considered seminal works in the field of hair transplant surgery, and he is the most widely published author on the topic having published more than sixty articles, editorial reviews, books, and textbook chapters.

Dr. Bernstein has been selected as one of New York Magazine’s “Best Doctor’s” for thirteen consecutive years and he has appeared as a hair loss and hair transplantation expert on The Oprah Winfrey Show, The Dr. Oz Show, Good Morning America, The Today Show, The Discovery Channel, CBS News, Fox News, and National Public Radio. Dr. Bernstein has been interviewed or featured in articles in GQ Magazine, Men’s Health, Interview Magazine, Vogue, the New York Times, and others.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration is a state-of-the-art hair restoration facility and international referral center, located in midtown Manhattan, New York City. The center is dedicated to the diagnosis and treatment of hair loss in men and women. Hair transplant surgery, hair repair surgery, and eyebrow restoration are performed using Dr. Bernstein’s pioneering techniques of Follicular Unit Transplantation (FUT) and robotic Follicular Unit Extraction (R-FUE).

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Robotic FUE has improved Follicular Unit Extraction by automating what has been a labor intensive and often inexact manual procedure. It is the latest in a long line of improvements made to hair restoration procedures that lead to better results for hair transplant patients. Dr. Bernstein’s recent publication in Hair Transplant Forum International improves the FUE procedure even further, whether performing follicular unit extraction with the FUE robot or by hand.

In his article, Dr. Bernstein suggests two techniques to enhance the FUE procedure. First, he recommends that surgeons create recipient sites prior to extraction, in order to decrease the time grafts are in their holding solution outside the body. Second, he suggests adding time between site creation and graft harvesting and placement, to allow recipient site healing to progress.

Pre-Making Recipient Sites

As is discussed in the full article (which is available for viewing and download in our Medical Publications section), by making recipient sites first, the time grafts are out of the body will be reduced.FUE procedures lend themselves to easily reversing the normal hair transplant sequence of graft (strip) harvesting followed by dissection and site creation.

These “pre-made” recipient sites will also exhibit less bleeding than newly created sites and will exhibit the stickiness that makes older sites easier to place grafts into with less popping (a common source of graft injury). Besides allowing the placing step to proceed more quickly, pre-making sites will reduce the risk of mechanical injury inherent in repositioning elevated grafts.

After Site Creation, Add Delay between Graft Harvesting and Placement

While Dr. Bernstein acknowledges the expediency for the hair restoration physician, as well as the comfort of the patient in a single-day session, he suggests that, to facilitate growth after a transplant, multiple-day procedures should be considered in large hair transplant sessions that involve the placement of thousands of grafts.

In conclusion, these two modifications -— pre-making recipient sites and adding a delay before graft placement -— to the FUE procedure can potentially contribute to better growth due to easier, less traumatic graft insertion, a shortened time “out of body,” and the creation of a more fertile bed for the implanted grafts.

View the full article to read details about these and other potential advantages of pre-making recipient sites

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CBS News Report On Robotic FUE Features Dr. BernsteinDr. Bernstein was featured in a CBS News report on robotic hair transplantation. During Dr. Max Gomez’s visit to the Bernstein Medical – Center for Hair Restoration, Dr. Bernstein discusses with Dr. Gomez the difference between FUT and FUE hair transplants, how the robotic system works, and the benefits of extracting hair follicles using robotic FUE rather than by traditional hand-held methods.

Read a transcript of the piece:

CBS 2 News Anchor Chris Wragge: These days we’ve seen robots doing everything from vacuuming our floors to building cars. You may have even had surgery done with the help of a robot. But what about something personal and cosmetic like a hair transplant? Our Dr. Max Gomez tells us about a robot doing just that.

Dr. Max Gomez: Well that’s right Chris. Now first we should make clear that robots in medicine don’t act alone, at least not yet. They’re always under the direction of a doctor. Now, that said, what robots are really good at are tedious, repetitive tasks that need to be done quickly and accurately. Something like a hair transplant.

Dr. Gomez: A full head of hair is called a person’s “crowning glory”. Sure, going bald is a common fashion statement, but most people are like Sam.

Sam, Hair Transplant Patient: I wanted more hair on my head, obviously, and I didn’t want to be bothered with any of the other treatments that are available.

Dr. Gomez: For Sam that meant a hair transplant, where donor hair follicles are taken from the back of the head and transplanted to the thinning areas, usually on top or the former hairline.

Dr. Robert M. Bernstein: The hair on the back and sides of the scalp are not effected by the same genetic process that the hair on the top of the scalp is.

Dr. Gomez: That donor hair is typically taken from a strip of scalp that is cut out and then sutured closed, but that’s not the best choice for everyone.

Dr. Bernstein: Some patients, who want to wear their hair very short, that line can be a problem. Also, there are some people who are at risk of having a wider scar.

Dr. Gomez: The solution is to randomly extract individual follicular units, small groups of one to four hairs.

Dr. Bernstein: The procedure is very labor intensive and you have to do thousands of these in a single session.

Dr. Gomez: Enter the ARTAS robot. It’s a sophisticated hair mapping and extraction system. Once the donor area is identified, the robot maps all of the follicles, and then randomly extracts them with a series of punches. It can even tell the angle the hair is growing at to avoid damaging it.

Dr. Bernstein: It is much more precise than the human hand. It doesn’t tire if you’re doing thousands of grafts. It’s the same every single time.

Dr. Gomez: And here’s the result a few weeks later. Even with short hair, the random extraction means it’s virtually impossible to tell where the donor hairs came from.

Now, the rest of the transplant procedure is pretty much the same as without the robot. That’s where the art comes in. Deciding where, how many, how dense, and at what angle the donor hairs are inserted, that’s what makes a hair transplant look natural. And a well-done transplant is amazingly natural.

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Dr. Robert M. Bernstein — pioneer of the follicular unit transplantation (FUT), follicular unit extraction (FUE), and Robotic FUE hair transplant procedures — was selected for the 13th consecutive year to be included in New York Magazine’s ‘Best Doctors’ issue.

New York Magazine - Best Doctors 2012New York, NY — Robert M. Bernstein, M.D., F.A.A.D., the world-renowned hair transplant physician, pioneer of the Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) and founder of Bernstein Medical – Center for Hair Restoration, was included in New York Magazine’s ‘Best Doctors‘ issue for the thirteenth consecutive year.

When asked of his inclusion in this annual peer-reviewed list, Dr. Bernstein, a Clinical Professor of Dermatology at Columbia University in New York City, said:

“It is such an honor to be recognized by New York Magazine. Our passion for providing the best hair loss treatments has served as the impetus for pushing the envelope in utilizing new state-of-the-art hair restoration techniques such as Robotic assisted hair transplants.”

New York Magazine’s Best Doctors issue is a directory of physicians that is compiled through a peer-review survey conducted by Castle Connolly Medical Ltd. The company also publishes “Top Doctors: New York Metro Area,” a guidebook based on the results of the same survey of doctors. Each year, physicians in the New York metropolitan area — including Manhattan, Brooklyn, Queens, The Bronx, Staten Island, Westchester County, Long Island, and counties in New Jersey and Connecticut — nominate their choice of the best doctors in a specific field. The physicians make their recommendations based on criteria including: qualifications, reputation, skill in diagnosis, and skill in treating patients.

Dr. Bernstein, a native New Yorker, has spent two decades developing new hair transplant techniques. His medical publications on FUT and FUE hair transplantation have revolutionized the field of hair restoration surgery and provide the basis for modern techniques used by hair transplant surgeons worldwide. Bernstein Medical – Center for Hair Restoration is a state-of-the-art hair restoration facility in New York City. Located in midtown Manhattan since 2005, the center is dedicated to the diagnosis and treatment of hair loss in men and women and specializes in both corrective hair transplants as well as the traditional restorative FUT and FUE techniques. Dr. Bernstein is the first hair transplant doctor on the East Coast to offer Robotic FUE hair transplantation to hair loss patients.

Dr. Bernstein has regularly appeared in notable media programs and publications over the years. Some highlights include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, CBS News, The Early Show, Fox News, National Public Radio, NY1, New York Times, Men’s Health Magazine, GQ Magazine, Telemundo, “O” the Oprah Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies.

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Dr. Bernstein Featured With "First Of Its Kind" Robotic Hair Transplant System On NY1
Dr. Bernstein with ARTAS System for Robotic FUE

Dr. Bernstein not only pioneers hair transplant procedures, but hair restoration technology as well. The NY1 television station, based in New York City, visited Bernstein Medical to see a demonstration and talk about the newest tool in the hair restoration toolkit, the ARTAS Robot for Hair Restoration.

The NY1 piece shows the robotic FUE system in action at Bernstein Medical, with views of the robotic arm, the image-guided system, the punch tool, and the user interface.

The segment also reports that Dr. Bernstein is among the first hair transplant physicians to use the technology:

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.

Dr. Bernstein speaks to one of the main benefits of the robot, the increased efficiency in extracting follicular unit grafts.

NY1 serves 2.1 million people in the tri-state area, including all five boroughs — Manhattan, Brooklyn, Queens, Staten Island, and The Bronx –– parts of Westchester and Hudson Valley, as well as cities and towns in Bergen County and Hudson County in New Jersey.

Read more about Robotic Hair Transplantation

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