Robotic Hair Restoration

The latest innovation to hair restoration surgery has been the introduction of a robotic system for harvesting grafts. This system uses the follicular unit extraction/follicular isolation technique method for harvesting follicular units, which is particularly well suited to the abilities of a robotic technology. The ARTAS system analyzes images of the donor area and then a dual-chamber needle and blunt dissecting punch are used to harvest the follicular units. The robotic technology is now being used in various locations around the world. This article discusses the use of the robotic system, its capabilities, and the advantages and disadvantages of the system.

Key points

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The robotic system of hair restoration is an important addition to the techniques used for hair restoration surgery.
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Robotic hair restoration is based on the follicular unit extraction/follicular isolation technique (FUE/FIT) harvesting process and provides the means to obtain such grafts in a reliable and efficient manner while maintaining low transection rates.
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The advantages and disadvantages associated with the robotic device are similar to those of manual or mechanized FUE/FIT harvesting.
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Using the robotic system a physician can more easily add hair replacement to his or her practice and not have to markedly increase staffing.

Introduction

The use of robotic mechanisms that assist in surgery have been available for more than two decades. The most prominent system is the Da Vinci system (Intuitive, Sunnyvale, CA) whereby a physician directs the movement of the robotic apparatus in various surgical procedures.

An advantage of a robotic system is that it can perform repetitive maneuvers with great precision. This ability to perform repetitive movement lends itself particularly well to the performance of hair restoration procedures when follicular unit extraction/follicular isolation technique (FUE/FIT) is used. The robot assumes some of the tasks that would require several assistants if a strip harvesting procedure is undertaken. The system also requires less time to be proficient with FUE/FIT compared with learning to do manual FUE/FIT surgery.

The ARTAS system (Restoration Robotics, Sunnyvale, CA) is a robotic device developed specifically for the FUE/FIT procedure. It is cleared by the Food and Drug Administration (FDA) and approved for use only in men for the purpose of hair transplantation.

FUE/FIT is a form of follicular unit grafting and is a technique for removing hair grafts based on obtaining intact follicular units or intact parts of a follicular unit from the donor area of a patient’s scalp and then implanting the grafts into appropriate recipient sites ( Figs. 1 and 2 ). The technique is essentially the old fashioned punch-graft procedure but performed with small punches, usually 0.7 to 1.2 mm in size. Whereas the 4- or 5-mm punches used in the older punch technique harvested multiple follicular units, which may or may not have been totally intact, the FUE/FIT process is designed to remove single follicular units or intact parts of a follicular unit.

The primary attraction for patients who seek FUE/FIT is that it is considered to be a less invasive or minimally invasive procedure compared with strip harvesting and most importantly, a linear scar is avoided. The patient may be able to wear his hair shorter than if a strip harvest was performed but there is a limitation to this, because the wounds from FUE can be visible if the head is closely shaved. The appearance of the scar from strip harvesting depends on multiple factors, such as donor density, strip width, tension on closure, scalp laxity, surgical technique, and the patient’s healing characteristics.

Some advocates of FUE/FIT believe that the recovery time is shorter and patients can assume strenuous activities sooner. They also suggest that the procedure is less painful than with strip harvesting. The wounds from FUE do tend to appear closed in 4 to 5 days, whereas a strip harvest patient has sutures or staples in place for 7 to 14 days.

The FUE/FIT procedure is considered well suited for a young patient who is uncertain as to whether he will ever want to shave his scalp or proceed with additional hair transplants. If he were to have a strip harvest, concealing the resultant scar could be a possible concern. Thus, the FUE technique gives the patient more flexibility in the future as to whether to have more procedures. FUE is also very helpful when the scalp is tight in the donor area after strip harvesting and therefore the number of grafts that can be obtained with further strip procedures is limited. FUE/FIT can also be very useful in obtaining grafts for insertion into existing linear strip harvest scars. FUE/FIT can also be used to harvest body hairs.

In regard to postoperative pain, the authors have found that with strip harvesting pain is well controlled with medication, such as oxycodone. Furthermore, with the use of liposomal-encapsulated bupivicaine (Exparel; Pacira Pharmaceuticals, Parsippany, NJ) postoperative pain is less commonly an issue with strip harvesting. The liposomal-encapsulated bupivicaine lasts up to 72 hours.

For the physician, an advantage to performing FUE is that fewer personnel are required compared with strip harvesting. This is because large strip harvest cases require several assistants to dissect the follicular unit grafts from the harvested donor strip tissue. With FUE, the procedure can be done with only one or two additional assistants whose role is to simply clean the grafts and sort them into follicular unit groups containing one, two, or three or more hairs.

The manual technique involves using a biopsy punch of some type and manually harvesting the follicular unit grafts. Many physicians use a sharp punch, whereas some use a combination of a sharp punch to enter the epidermis and then a dull punch to go into the dermis and fat. Some physicians use a motorized drill with a punch attachment for this type of harvesting. There are several variations of a motorized drill on the market ( Fig. 3 ). The use of a motorized drill can help skilled physicians harvest quickly and maintain low transections rates, with some physicians attaining harvest rates in excess of 400 grafts per hour with transection rates below 10%. It can be difficult, however, for some clinicians to develop the necessary skill set to attain low transection rates and adequate speed to perform the procedure efficiently. Additionally, FUE can be a tedious and tiring procedure for physician and patient.

At times transection rates can be quite high. In one FDA study the transection rate of manual FUE was noted to be about 26%, whereas the robotic procedure was rated to be 8%. The authors have found lower transection rates with their approach to FUE/FIT and believe that physicians can develop the skill to accomplish lower transection rates with the manual process than that reported by the FDA. In the authors’ own experience the transection rate for the robot can exceed 8%.

As a side note, it is important to make sure that the definition of transection rate is agreed on by all surgeons performing FUE. The author defines transection as a graft where any of the target hairs are severed. If the surgeon attempts to obtain a three-hair graft and harvests only two of the hairs while the third hair is damaged, then a transection has occurred. Some define a transection as a graft where none of the hairs were obtained.