Dr. Bernstein Introduces Robotic Implantation of Follicular Unit Grafts at the ISHRS 26th World Congress

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Dr. Bernstein Introduces Robotic Implantation of Follicular Unit Grafts at the ISHRS 26th World Congress

Dr. 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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Dr. Bernstein Gives First Master Class in Robotic Hair Transplantation

First 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 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.

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Innovations In Robotic Hair Restoration

Robert M. Bernstein, MD, New York, NY, rbernstein@bernsteinmedical.com

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.

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Advances in Robotic FUE

Robert M. Bernstein, MD, New York, NY, rbernstein@bernsteinmedical.com; Michael B. Wolfeld, MD, New York, NY, mwolfeld@bernsteinmedical.com

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.

FIGURE 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 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 needles

FIGURE 4. Recipient wounds: 0.8mm (left) and 0.9mm (right)

FIGURE 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 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

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 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

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.

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Commentary on Redefining the “E” in FUE: Excision = Incision + Extraction

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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When is it Best to Feather in Robotic FUE?

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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Is Manual FUE Better Than Robotic FUE Because The Physician Can “Feel” The Follicle During Extraction?

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

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

Read about advantages of the ARTAS Robot over manual FUE procedures

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What’s New in Robotic Hair Transplantation

Robert M. Bernstein, MD, New York, NY, rbernstein@bernsteinmedical.com; Michael B. Wolfeld, MD, New York, NY, mwolfeld@bernsteinmedical.com; Jennifer Krejci MD, San Antonio, TX, jkrejci@limmerhtc.com

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 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 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 tensioner

Fig 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 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 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 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 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

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.

Robotics in FUE

Dr. Bernstein Introduces the ARTAS iX

How Implantation Works

ARTAS Robotic Hair Transplants at Bernstein Medical

Brief History of Hair Transplant Techniques

Generational Improvements in Robotic Hair Transplantation

AI and the Future of Hair Restoration

Increased Speed

Increased Accuracy

Increased Functionality

Artificial intelligence

ABSTRACT

Background

Touchscreen User Interface

Follicular Unit Graft Selection

Locking Tensioner Tool

Improved Halo

Arm Spacer to Increase Range of Motion

Improved Image Processing for Glare

Assisted Force-Drag

Puncture Depth (PD) Band Detection

4-Prong Needle

6-mm Punch

The Future

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