Robotics Interview

Dr. Bernstein was the guest on The Bald Truth talk show where he was interviewed by the founder of The Bald Truth and the International Alliance of Hair Restoration Surgeons (IAHRS), Spencer Kobren.

The discussion focused on robotic hair transplant surgery and the ARTAS^® Robotic System, but also touched on Follicular Unit Extraction (FUE) and Follicular Unit Transplant (FUT) hair transplant procedures, and the future of hair restoration.

Spencer Kobren: I’ve evolved a lot over the last 20-some-odd years, and I definitely have learned from not only my own mistakes but the mistakes of thousands of men and women who have unfortunately been burned by this $3.5B per year hair loss industry. Now the truth is: 2/3 of guys by the age of 35 will suffer with some degree of hair loss. 40% of hair loss sufferers are women. And the truth is, most everything that’s being sold out there that claims to stop, prevent, or treat hair loss is complete nonsense. Will not help you in any way, shape, or form. That’s just the way that it is. So, if you’re just tuning in for the first time, if you’re listening to us on iTunes Radio, or streaming radio, if you’re watching us on Daily Motion, or through the Guys From Queens Network, if you’re watching us through The Bald Truth, or if you are now listening to us on Clear Channel ‘I Heart Radio’, and this is your first time, understand that this is your safe place. I’m not here to sell you anything; I’m not here to bullshit you. I’m here to give you the facts. I’m here to guide you in the safest possible direction when it comes to anything, and everything, hair loss.

Tonight we have a really special guest, and I want to bring him on as soon as I can — the next 2-3 minutes, because he has a limited amount of time that he can be with us tonight.

But this is the guy — when I first started to research my book back in ’96-’97 — when I knew that I was going to get this book deal, and when I realized that I had to make a decision on whether or not to write a chapter on surgical hair restoration that was going to completely lambaste the entire field. Because, you have to understand, at the time everything that I was seeing was crap. Guys’ lives were literally being destroyed. Every company that invited me in — every clinic, every doctor — to look at their work, they were saying they were doing one thing; I was seeing something else with my own eyes. What I was seeing back in ’96 and ’97 was that surgical hair restoration did not seem to be a legitimate option, in my view.

Then I met Dr. Robert Bernstein. He showed me a technique — and the results of this technique, and the technique at the time was Follicular Unit Transplantation — that blew my mind.

I had never seen natural hair transplant results before. I had never even imagined that a hair transplant could look like this.

And it’s really because of Bob Bernstein that I decided to change my point of view when it came to surgical hair restoration.

I found that there were 11 doctors doing the same procedure that Bob was doing. And it was that month, when I first met Dr. Bernstein, that not only did I decide to write a chapter discussing Follicular Unit Transplantation and its benefits — compared to all the other techniques that were being performed back in the day, including flaps, and scalp reductions, and hair lifts, and all this crazy stuff that guys were doing. But it also gave me the idea to create the first recommended list of physicians that ever existed in any field of medicine.

As time has passed, obviously the industry has evolved greatly. The vast majority of the work out there, I have to say, even by some of the doctors who are not recommended by our organization, is pretty good! We’re not seeing, or at least for a while, we weren’t seeing a lot of the disasters that I saw years ago. But I’m starting to see things kind of, I guess the word is devolve.

Back in 1998-1999, I was contacted by Dr. Ray Woods, who was performing a technique at the time called the Woods Technique. And he was extracting one graft at a time, using very small punches, and moving those hairs, those intact follicular units, without leaving a linear scar. When I first saw this, I thought that this was going to be a game-changer. And I spoke to several doctors here in the U.S. and everyone said I was crazy.

Again, getting back to Bob Bernstein, initially I think he looked at it with a jaundiced eye, but he embraced the concept early on. And then he and Bill Rassman ended up writing the first paper on Follicular Unit Extraction, and I can say that the rest is history. But as things have evolved, and I’m going to get back to the point where I said that things have devolved, the market itself, consumers, online consumers especially, are really driving the market. And there are a lot of doctors who have incorporated FUE into their practice just to compete, just to say that they are utilizing this technique, that they are offering this technique to patients. And some of the work that I’m seeing is disastrous. I’m talking about stuff that was done in the last few months. I can’t even believe my eyes.

Now the idea of creating a device, or a machine, or a robot, to take certain variables out of the equation when it comes to surgery I think is pretty compelling. Now there’s a big debate about whether or not these devices are actually good for the field or actually going to be damaging patients… But if anyone knows Dr. Bernstein, they know how conservative and how ethical he is. Dr. Bernstein has embraced the ARTAS Robotic System, or the ARTAS robot, and I wanted to bring him on the program tonight to discuss why he has chosen to go this route, and why he believes that this is really the future of Follicular Unit Extraction, of hair transplantation in general. And I have to say, before I bring him on the air, no matter what your thoughts are on the subject, no matter what you die-hard hair loss geeks — and I’m one of them, I’m one of you guys — thinks, this is the way the industry is evolving. Period. Good, bad, or indifferent, these devices are what are going to be offered in just about every practice eventually. So I wanted to bring Dr. Bernstein on to talk about why he’s embraced this, why he has gotten involved with the company, and you know, he’s a really trusted — one of our founding members of the IAHRS — he’s a really trusted hair transplant surgeon. And I thought to myself when I found out he was getting involved with this company that there’s got to be something to this.

SK: Dr. Bernstein is that you?

Dr. Robert M. Bernstein: How are you doing?

SK: I’m fine how are you?

RB: Nice to be on the show again!

SK: 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.

RB: 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.

SK: There’s no doubt that when it comes to any type of surgical application, this seems to be one type of surgery where robotics really makes sense. Like you said, it’s a laborious procedure; you have to really be able to concentrate. The fact that a machine can possibly do this repetitive motion thousands of times and have that ability to see that follicular unit and to extract that follicular unit intact; it’s absolutely amazing. But the biggest issue is, there are physicians out there, and there are the naysayers out there that claim that there’s no way that a device like this could replace the human touch.

RB: Well, it certainly does! I’ve been doing FUE for years, and doing it robotically now. When the ARTAS FUE robot first came out it wasn’t nearly as good as it is now – it’s now 3 years on the market. At the beginning we did just a couple of cases with it, now we’re using it for almost half of our patients. The company is in the office when we’re doing the procedures — the R&D department — and we’re constantly tweaking the system, changing the optics, changing the rotation, the angle, the depth. A lot of impressions that doctors got of the robot were two to three years ago. It’s really, really slick now, it’s to the point where in many cases we’re actually getting more hair than sites. What I mean by that is that we’re able to preserve the follicular units so well that we can harvest larger follicular units and get more hairs per graft than we need. We actually have to divide them up to get single-hair grafts.

SK: What about the concern that some physicians are putting out there that the size of the punch really doesn’t lend itself to the most elegant procedure and that there’s going to be possible peripheral damage to adjacent follicular units and a larger field of scarring with each punch. Does that make sense? Is that true?

RB: The robot, when it originally came out, used a 1-mm sharp punch and a 1.2-mm dull punch. I developed a smaller punch that we first started using about a year and a half ago. It consisted of a .9-mm sharp punch and a 1.1-mm dull [punch] under the surface and that seems to be perfect.

SK: Why don’t you explain to our listeners and viewers how the punch actually works, because obviously the smaller punch is what’s scoring the skin, correct?

RB: Right.

SK: And then how does the other punch actually go in and grab the follicular unit?

RB: The idea is actually quite interesting. The idea of a two-step procedure was Jim Harris’ in Colorado. He developed the SAFE System which does the two-step extraction with a hand-held unit. The way that the robot works is that it has a sharp two-pronged punch that goes down about a millimeter through the skin. The basic idea is that you have a sharp punch that cuts the skin and then you have a dull punch that goes deeper into the tissues. Because, as I mentioned before, the follicles splay outwards and you want to gather them into the hole (the lumen of the punch) rather than cut all the way down the follicle. So on the surface, the follicular units are tight, but the hair follicles splay out as you go deeper into the tissue. If you use a sharp punch on the surface and then a deeper [duller] punch below the surface —

SK: You’re not going to transect the grafts.

RB: Right, you can harvest without transecting the grafts. The reason why you can’t use a sharp punch all the way is because the angle of the follicle is around 30 degrees on the surface. If you start with a dull punch it has a tendency to skid along the surface. So the way the robot works is that the smaller punch has prongs and it goes through the surface and creates a mild suction, and this stabilizes the skin. It also can sense scalp movement, patient movement, so it can move with the patient, and then the dull punch goes around the outside of the smaller punch.

SK: I’m actually glad you brought up that point, because that is one point that one particular doctor keeps bringing up online. When a patient breathes the patient’s head moves. His point is that a robot, or any kind of mechanical device, isn’t going to go along with that movement. You’re telling us that it’s actually able to sense that movement.

RB: It absolutely does.

SK: Wow. Now that’s actually a revelation, and no one is talking about that online and I think it’s very important.

RB: The technology is really unbelievable. The consistency of the robot, especially with the smaller punch, is great. For African-Americans we still use the larger punch. It’s analogous to what we do by hand. People who have very curly hair have follicles that curve under the skin, so you need a wider punch so you don’t have transection.

SK: What about these claims — now that you’re saying that you’re using a .9mm punch for scoring the skin — what about these claims that certain doctors are making that you’re going to be leaving a larger field of scar tissue? Obviously that’s not the case if you’re using a smaller punch.

RB: No, that’s not the case. It heals perfectly. The idea is to capture the whole follicular unit and you know I’m obsessed with that. We’ve found that with the .9mm (sharp) / 1.1mm (blunt) combination you get the whole follicular unit. The other thing that is interesting is that in our office, we don’t use one-hair grafts. We program the robot so that it skips over the 1s. That is what I was alluding to before. If you’re making a hole, it doesn’t make sense to go for a 1-, you go for a 3- or 4-hair graft, and then because our staff is so good at microscopic dissection from their experience with FUT, we’ll take that larger follicular unit, a 4-hair graft, and we’ll dissect off a 1-. So we’ll use that for the hairline. We can get twice as many grafts with half as many holes, and much less wounding.

SK: Wow.

RB: It’s really those kinds of nuances that we’ve been able to build into the robot, as it has evolved, that have made it so much more robust.

SK: You also made a point earlier saying that a lot of what is being written about, and a lot of what the doctors, some of the physicians out there think, is based on what was happening three years ago. So now that all of this is coming to light, and now that I’m sure you’ve shared this information with your colleagues, and I’m sure Restoration Robotics has shared this information, why are people so resistant? There are a lot of guys out there who say this really isn’t the way the field should be evolving.

RB: Well Spencer, it’s interesting. You remember way back, I think it was 1996, 1997 when no doctors wanted to buy a microscope?

SK: Yeah, I do!

RB: This is the same thing!

SK: It’s interesting to see how many people are resistant to things at the beginning, and once they embrace it they realize, wait a second; this is really the right way to go.

RB: If you see the current iteration of the FUE robot, it’s pretty amazing. To get back to your question the robot costs a lot of money for the doctor, so you have to lay out a lot, a lot of doctors don’t have that kind of volume of patients. Also, you pay per click. In other words the robotic company gets a cut on every graft that’s harvested.

SK: Yeah, but there’s also a lease option. Let’s face it, the cost of an average hair transplant is going to be $7500-12,000, I think they’re leasing them for what $4,000 per month? I would say that any reasonable hair transplant practice could afford to lease that device.

RB: I agree with you. What’s happening is that the doctor looks at this and says “Oh the company is getting a percentage of every graft that is harvested.” To me, I look at it differently, I say “Wow. That’s great!” The company has a stake in the game; they’re going to want to make sure that the robot is functioning, that it gets the upgrades all that stuff. I’d much rather have the company in bed with me rather than experience the problem I had in general dermatology where a company sold me a laser and then they weren’t around to service it. In many ways having the company as a partner is actually good with this high-tech type of device.

SK: There are patients who are calling physicians’ offices, patients who are contacting me, who asking about the Neograft procedure or the ARTAS procedure, and there’s this kind of confusion in the marketplace where consumers, instead of looking at these devices as what they are, they’re tools for physicians and their practices to use to perform surgical hair restoration, they’re kind of being marketed as a procedure. So I think there’s a lot of confusion in the market. People think that the Neograft is similar to the ARTAS and maybe you can describe the differences to our listeners because we’re “in the know” so obviously I know what the differences are, but a lot of people believe they are very, very similar.

RB: Spencer, that’s a great point. The most important thing is that the ARTAS robot, at least at this point, is just a harvesting system, and the extraction is only one part of the procedure. In FUE, you also have site creation, graft placement, and then really the most important part which is the planning, the patient evaluation, checking patient’s densities. There’s so much more to a hair transplant, and so the thing is, as you said, it’s just a tool and it needs to be in the right hands. It’s up to physicians; we have a fiduciary responsibility to do what’s best for patients and [medical] societies and boards are supposed to regulate that. Because all of these instruments are new, it’s really hard for the public to get their heads around them, especially because marketing is so slick. The Neograft machine has been around a long time, and basically I think the Neograft is the worst of all worlds. It’s a hand-held device, it’s a sharp-cutting, single-step, high-speed instrument, that uses suction to pull out the grafts.

If you’ve ever seen an FUE procedure, when you score the graft, when you make the cut with the punch, whether it’s by robot or by hand, you’re only cutting the sides. The bottom of the graft is still attached to the underlying skin – actually the connective tissue and the fat. If you gently pull on the graft, you can tease it away leaving the bottom intact, but if you use suction you’ll very often shear the thing apart. A suction instrument, which is what the Neograft is, is really detrimental to the grafts, besides the fact that the suction dries out the grafts.

SK: Yeah, I was going to say, there’s a lot of concern about desiccation, drying out of the grafts.

RB: The other problem with shearing the grafts is that the grafts come out, but then they have to go back in. And to go back in the scalp, if the bulbs are either damaged or fragmented, or folded over when you put them in the scalp, it’s obviously going to be a terrible result. So you have doctors who are not necessarily skilled, who have to use a hand-held machine, which is extremely difficult. And then the technology itself is not good. Neograft seems like it is high-tech, but it’s really not. It’s not robotic, it’s hand-held, you don’t have good visualization, and the worst thing is that it uses suction and it’s just a single, sharp punch.

SK: There are physicians out there who are definitely going to disagree with you. They’re going to say that in their hands, the Neograft has been a great tool in their practices. And obviously there are plenty of guys out there who have had a procedure performed with a Neograft who have good results. So I’m sure that in some cases, obviously you don’t want to implant any garbage, but I’m sure that in some cases — what percentage of the grafts do you think are ok in an average Neograft procedure, do you have any idea? Have you actually sat there and watched an entire procedure and taken a look at the grafts?

RB: I have watched, and there’s a lot of damage. And also, it’s hugely patient dependent. If you have a patient with thick, coarse hair you can basically do anything and [the grafts] will come out. But it’s the bulk of these patients, and patients with fine hair or a loose scalp, where these things come undone. It’s so hard to look at one case and make a judgment. In medicine, it’s always two things. One is the statistics and the other is just the idea. I think if you understand how a hair transplant works, and how Follicular Unit Extraction works, it’s pretty obvious that things like suction and sharp punches are not going to be as good as doing it by other methods.

RB: While I was waiting for your call I thought you were going to ask some questions about the growth of the industry and the census. I was looking at the last ISHRS census, and one of the things that I was really struck by that I never noticed before is that the [census] looked at the amount of work that was done in busy practices vs. light practices. They break them down by medical and surgical. And it turns out that in practices with low volume the medical and surgical patients are almost even, where in busy practices, where doctors have a lot more experience, the ratio goes way down for surgery to medicine.

SK: Yeah. Sure.

RB: Essentially what that is, these new guys that are doing —

SK: They’re just taking anybody on.

RB: Yes, they’re doing procedures on everyone that walks in the door. I think the whole conversation should revolve around how to get doctors who are interested in hair to learn hair, or don’t bother. Because, as you know, it’s a serious business where, these young people are really mutilated when their procedures are bad. FUE, FUT, all of them, in the wrong hands or on the wrong patient, can ruin someone’s life.

SK: I know a guy here in Los Angeles who is a really great, board-certified plastic surgeon. He got a hold of a Neograft; he put up a website, now he is a hair restoration specialist. He’s been in contact with me, he’s a really nice guy, and I think he does incredible breasts, and noses, and chins, but he’s never performed hair restoration. He tells me how excited he is to get into this side of the field. And I’m thinking to myself, “God I really hope he takes the time to see some procedures, learn how to do it correctly.” I don’t know him that well, so I didn’t really get into it with him, but this is what I’m seeing, and I’m seeing it more and more. I have to tell you Dr. Bernstein, I believe — and I mentioned how the industry is kind of devolving in some respects — that we’re going to be seeing a lot more walking wounded now that these devices are in the wrong hands.

RB: I agree with you. There are general trends; in medicine it gets tougher to make a living, more people are doing cosmetic procedures, it’s pervasive in all fields. To decrease the cost of medical care they are going down the food chain, where physicians do less and less and there’s more physician’s assistants and nurses that are doing more and more of the procedures.

SK: A simple thing, which seems simple, like injectables. Necrosis from injectables is on the rise and is growing exponentially. In my view it’s because people who are relatively untrained are being hired by these doctors to do these injectables. To inject fillers and Botox and people are being harmed when they don’t even realize this is a possibility when they walk into the office. They think it’s just this innocuous procedure.

RB: Right. It’s the duty of the physician to speak with the patient, give the informed consent, just like the many practices where they have salesmen do the consult and then at the back end the doctor walks in just to smile and sign off on it. The doctor’s duty is really the front end too; make sure the patient understands the procedure. That’s the art of medicine. But it also takes the most time.

SK: Sadly, that’s just not the reality. There are guys like you. There are other guys who are a part of what we do. That’s why it’s a relatively small number compared to the entire field. It’s frightening, it really is doc. Because, I’m telling you, and I’m seeing it now, there was a time, probably about 5 or 6 years where the reports of really bad work — Now there were guys who have had unrealistic expectations who have contacted us. I’m talking about the “pluggy” work, the really bad work, we weren’t seeing it. I’m seeing it again. I’m seeing hair transplants that aren’t growing, and these are all — most of them — are FUE procedures.

RB: Right.

SK: So, listen, you’re right, what are you going to do? You do what you do; you do it the right way. You try to guide your patients by providing them with all the information they need to make an educated decision. But there are plenty of doctors out there that, sadly, that they need to pay for their kid’s private school tuition and their Mercedes Benz payments and they feel like they’re under the gun and medicine has changed dramatically — and it’s going to get even worse. So when they see these patients walk through the door, they don’t take the time to educate them because they want to get them in the chair.

RB: Also, the problem with hair transplants is the lag of a year between the procedure and when you can get a sense that things went wrong. Often the patients feel guilty about doing the procedure, they just go on to someone else, they don’t complain. Often they don’t even go back to the same doctor.

SK: That’s true.

RB: Services like The Bald Truth provide an incredible service for people to speak out and feel like they have a community for people who have been harmed. It’s the psychology of men, as you know, that they keep things secret when there’s a problem.

SK: I know that you are still obviously a huge proponent of Follicular Unit Transplantation, and you stated earlier that about 50% of your practice is FUE done with the ARTAS, and I’m assuming that the other 50% of your practice is still FUT.

RB: Right.

SK: We’ve spoken about this before. I’m still a huge believer that FUT is an important procedure that shouldn’t be lost.

RB: Yes, I totally agree. And the way that I think about it, and the way I explain it to patients, is that FUT is going to give you the most volume for the amount of donor hair used. The reason is, is that when you take a strip; you’re taking the mid-portion of the permanent zone. In other words, you’re going to take a strip that’s maybe a centimeter, centimeter and a half in width. When you do FUE you need an area 5 times that height so that the hairs being harvested are from the less-than-ideal area. The further you go from the mid-portion of the donor zone the closer to the neck and toward the balding area [the hair] is going to be less stable over time. So the quality of the hair, by definition, can’t be quite as good.

Also, you’re never going to be able to get the accuracy of good microscopic dissection with a punch, regardless of whether it is controlled by a robot or not. So the basic procedure should be, in my view, Follicular Unit Transplantation via strip. But there are many situations where not having a line scar is preferable. So what we do is we have FUT as the default and if there are reasons to do FUE, we do it. It turns out many people want to have the option of keeping their hair very short, they don’t want to have any constraints on exercise, they don’t want to have the risk of a wide scar. Especially in younger people who are physically active, a widened scar is actually a very real risk. It’s a greater risk in Asian patients, certainly in younger patients who are now much more physically active.

SK: And Asians tend to Keloid more than Caucasians, am I right?

RB: Yes. They are good candidates [for FUE], and sometimes people just don’t want the stigma of having a line scar. Unfortunately there’s also this scare against FUT because FUT is not always done properly and then [physicians] hype against it if they only do FUE.

SK: Well that’s the thing; [FUT] is looked at as an archaic procedure, that there’s no place for it.

RB: Like in Europe, the vast majority of doctors are now doing FUE —

SK: I know!

RB: — It’s almost malpractice to do a strip. If you do a strip and screw up in Europe it’s a problem.

SK: I know. Listen and everyone thinks that the guys that are continuing to practice and continuing to perform a strip are doing it for some nefarious reason. Either they’re lazy, or they’re able to do more strips in a day. I try to tell prospective patients, I try to tell my listeners and my readers, that there’s no way that you can get 100% of that sweet spot, that DHT-resistant sweet spot, with Follicular Unit Extraction. I don’t care what kind of crazy math some of these doctors are putting out there. It’s just not going to happen. So, if you want the most bang for the buck, if you want to get the most hair moved, it’s probably best, if you are the right candidate, to do a combination of both strip and FUE.

RB: It depends on so many factors. Sometimes when you do multiple strips the scar starts to widen, and that’s a constraint and it limits you. It really depends. But yes, if you’re going to get the most bang, the most hair, you would use a combination of both.

SK: Yeah. And I think that it’s unfortunate that strip is going the way of the Dodo, there’s no doubt about it. We’ve seen where the industry is going.

RB: The problem is that for new doctors, when you can do FUE, even though it may not be appropriate for all patients, you don’t need a big staff, you don’t need to be trained on microscopes, and so the barrier to entry is much lower.

SK: That’s right.

RB: But to build a team of 6 or 7 dissectors is very formidable for new doctors.

SK: But what I find interesting, and that’s a great point, is I spoke to an IAHRS member the other day who went in for his third hair transplant surgery. And this is a guy that, a lot of his practice is FUE, and he chose to get a strip. Now, obviously, he already has a linear scar, but this is a hair transplant surgeon, and he made that decision.

RB: The other thing that we discuss with patients, and it’s not talked about too much, is that you have a very wide band of harvested area with FUE, and so in a young person you don’t know how bald they’re going to be. If someone becomes a Norwood 7, that donor fringe is going to dip down below the area that was harvested and you could see the stipples from the extraction, and although it’s not anywhere near as unsightly as a line scar, you can still see it; whereas, if you have a line scar it can easily be buried in the fringe if the scar is placed in the right spot.

The other thing, too, is that as people get older, the chances of having a widened scar go down significantly. Really, FUE has a very, very strong place for younger patients. Older patients, where they have much more balding and need the most volume, then a strip becomes more powerful.

SK: Let me ask you, doc, do you think that strip is just going to go away eventually? Even though it’s a very viable procedure and in many cases it probably is the one to perform…

RB: If you look at the numbers it seems like FUE is increasing in market by about 5% per year and is about 35%, so, unless that changes, yes, in another 7 years, FUT will be gone.

SK: You made a very good point, and this is the way of the world, the new guys are not even considering learning how to do a strip for the reasons that you pointed out. And also, out of pure marketing reasons, it doesn’t make sense for them to learn a procedure that is marketed as an antiquated procedure. That’s it.

RB: Unfortunately, Follicular Unit Extraction, it’s a newer procedure, but it’s not necessarily better in all cases. It’s really hard for the patient to sort that out.

SK: It’s hard for the patient, and the fact is the reason it’s hard for them to sort that out is FUE is being marketing in a very specific way. It’s FUE vs. Strip. It’s “no scar” or “scar-less” – which, we know the procedure is not scar-less — compared to having a linear scar in the back of your head. So in any consumer’s mind, they don’t understand the nuances of the procedure, it’s a no-brainer; they’re going to pick the procedure that leaves no linear scar. Period. State-of-the-art, and that’s the way it’s being marketed, there’s no changing it. But I am glad that you’re involved in helping to develop this robot. You’ve been doing this, how long have you been doing transplants now, 20 years?

RB: Full-time since ’95.

SK: Full-time since ’95, and you’ve seen it all, doc. I think it’s great that you’re involved. And it’s important — we didn’t give full disclosure prior to you coming on the air — you are now on the Board of Restoration Robotics.

RB: I’m an advisor.

SK: I’m glad that you are. Because I don’t think they would have gotten to that iteration where they’re using the smaller punch. Initially, I think when a machine like this is developed; in the first iteration their goal is just to be able get the hair out precisely. They made not have understood the nuances of the procedure, and the different punch sizes and how that effects future procedures and how that effects the way the scalp is going to look. But I think initially the machine was developed with Jim Harris right?

RB: Yes. As I said before it was based upon his two step technique, the sharp/blunt technique. So it really took the best of his ideas and automated it. That’s why it’s a great instrument.

SK: Well, this is what I can say. For the guys who are watching from Restoration Robotics, there’s no doubt in my mind that your robot is the future of this industry. Good, bad, or indifferent, and I am not making any judgments here. I have seen some good results from the ARTAS and I know that Dr. Bernstein is working with you guys and it’s exciting that you’re creating smaller punches. Do you think you might get to even a smaller punch, like a .8mm?

RB: I think that this [0.9-mm] unit is the sweet spot in size. One of the beauties of this [.9mm] size punch is that we can get larger follicular units, so there’s less transection. And then use the microscopes to get individual hairs. So, probably not. We tried different sizes and this seems to be ideal.

SK: Before I let you go, I know this is important, and I know this isn’t available yet, but you have worked on a way to create recipient sites with the ARTAS system as well. Do you want to talk about that for a second?

RB: Sure. The recipient site creation, the actual making of the sites is a no-brainer for the robot. It can do it, so to speak, with its eyes closed, it’s easy. The interesting part of the recipient sites is that it lends itself to the design of the transplant, which is a very complicated thing. Restoration Robotics has developed the ARTAS Hair Studio to allow the doctor to take the physical image of the patient, convert it to a 3-D image, a computerized 3-D image, and then design the hair transplant first on the patient and then tweak it on the computer. It’s still in its infancy, but it’s obviously going to be the wave of the future. The importance of making sites with the robot is not necessarily to actually do that, but eventually we hope that the robot will be able to insert the grafts, to do the whole procedure. And to insert the grafts it has to make the sites first. The site creation is really the intermediate step toward the long-term goal of automating the major three parts of the hair transplant.

SK: So you think the goal is to basically make hair transplantation dummy proof. Any physician can have this device in their practice.

RB: Again, everything else, patient selection, the design, use of medication, all of that — is really critical.

SK: — I agree with that, doc, and I know this is something that you truly believe in, but the truth is once this considered is dummy-proof, everyone’s going to get one. It’s going to be one in almost every dermatologist’s office, which is good at least that it’s going to be in a dermatologist’s office because at least they understand hair, but any doctors getting into cosmetic surgery is going to have the ability get one of these machines and start a hair restoration practice.

And like I said, even if the machine is extracting the grafts, and even if the machine is doing the complete design, and even inserting the grafts, there are still certain nuances that only an experienced physician would understand even when they’re calibrating the machine. You know, to create the hairline and whatever. There’s got to be — it’s great for hair restoration. As far as more guys are going to choose surgical hair restoration now that there’s going to be a procedure that is going to promise less down-time, faster healing, that is more automated, that is practically dummy-proof. It’s going to grow the field, and more guys are going to have hair on their head. But I still think there’s going to be a lot of damage done.

RB: Totally agree.