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Robotic Hair Transplants

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Robotic Hair Transplants

Abstract

A major advance in Follicular Unit Extraction is the introduction of a robotically controlled, image guided system to remove intact follicular units directly from the scalp. The robotic device increases the accuracy of graft harvesting, which in turn minimizes damage to hair follicles and reduces harvesting time. Each of these factors potentially contributes to increased graft survival. The technology also enables FUE to be performed on a wider variety of patients. This paper discusses this new robotic technology.
F U E (FUE)
is a method of harvesting donor
hair where individual follicular units
(naturally occurring groups of -
hairs) are removed directly from the
scalp. is method diers from the
standard Follicular Unit Transplanta-
tion (FUT) procedure where one thin,
long strip is removed from the back
of the scalp and is then dissected into
individual follicular units with the aid of
stereomicroscopes.
In FUE, an instrument is used to
make a small, circular incision in the
skin around a follicular unit, separating
it from the surrounding tissue. e unit
is then removed from the scalp, leav-
ing a tiny hole. is process is repeated
until the desired number of follicular
unit grafts is obtained. e holes,
approximately -mm in size, heal over
the course of seven to ten days, leaving
tiny white scars that are camouaged
by the hair in the back and sides of the
scalp.
Tiny “recipient sites” are made in
the balding area of the scalp, using a
ne needlepoint instrument, where
the extracted grafts will be inserted.
e creation of recipient sites and the
placing of follicular unit grafts are
essentially the same in FUE and FUT.
e dierences between the procedures
lie in the quality and quantity of grafts
obtained as well as the appearance of
the donor area.
Follicular Unit Transplantation
In FUT, the removal of a donor strip
from the back of the scalp leaves a
long, thin scar. While the scar is usually
camouaged by the person’s hair, it can
be a problem if the patient wants to
wear his or her hair very short. A linear
incision can also be a problem for a very
athletic person who doesn’t want any
limitations to physical activity post-op.
In FUE the resultant tiny white scars
are easily hidden; even with relatively
short hair. e lack of a linear incision
enables the active person to resume
most activities immediately after the
procedure.
History and Instrumentation in FUE
e use of direct extraction to
harvest follicular units was initially
conceived by Dr. Ray Woods in Austra-
lia and called the “Woods Technique,
but he did not disclose the details of
his procedure. e technique was rst
described in the medical literature
by Drs. Rassman and Bernstein in
their  publication, “Follicular Unit
Extraction: Minimally Invasive Surgery
for Hair Transplantation.” is paper
gave the procedure its current name
and described the FOX test that is used
to identify patient variability in har-
vesting, an issue that continues to be a
signicant challenge for doctors today.
Follicular Unit Extraction is an
instrument-dependent procedure.
erefore, the type of tool that is used
signicantly aects the results. e
earliest methods of extraction consisted
of a small, round cutting instrument,
called a “punch,” to separate the follicu-
lar units from the surrounding tissue.
Dr. Jim Harris advanced a signicant
renement in the procedure when
he added an extra step using a blunt
instrument for the part that penetrates
deeper into the skin. is extra step of
blunt dissection substantially reduced
transection (damage) to the hair
follicles.
FUE instrumentation continues to
evolve as more physicians gain experi-
ence with the technique. Currently,
there are a wide variety of instruments
used in FUE. ese instruments include
punches of dierent diameters and
sharpness and instruments that are
rotated by hand or are motor driven.
Some techniques require the separated
grafts to be removed from the skin with
forceps and others use suction. Some
surgeons utilize the single step method
and others the two-step technique.
However, no method was able to avoid
the human error and fatigue associ-
ated with removing the hundreds to
thousands of individual follicular units
needed for a single hair restoration
procedure.
Robotic FUE
Follicular Unit Extraction consists of
two main steps: Separation of the fol-
licular units from the surrounding skin,
and extraction (removal) of the fol-
licular units from the scalp. Step one is
a highly repetitive and labor-intensive
process that requires great precision.
is step requires the centering of the
punch over the follicular unit and the
alignment of the dissecting instrument
with the follicles to prevent damage.
Since this process must be repeated
hundreds to thousands of times in a
typical FUE hair transplant, the patient
is subjected to signicant human
variability and error on the part of the
physician.
A major advance in FUE came in the
Fall of  with the introduction of
the rst robotically controlled extrac-
tion device that automates this crucial
rst step of FUE. e robotic system
increases the accuracy of graft harvest-
ing, which in turn minimizes damage
to hair follicles and reduces harvesting
time. Each of these factors potentially
contributes to increased graft survival.
e new technology also enables FUE
to be performed on a wider variety of
patients.
e current robotic technology
is based on the two-step method of
extraction. It uses a sharp punch to
penetrate the skin and a dull rotating
punch to separate the deeper part of
the follicular unit from the surrounding
tissue. e main dierence from the
older devices is that it uses a very pre-
cise, image-guided robotic arm to oper-
ate the dual-needle punch mechanism,
ensuring a high degree of accuracy and
precision.
Compared to manual systems, the
robot is also more versatile in its ability
to harvest grafts from patients with
dierent hair characteristics, patients
Robotic Hair
Transplants
by: Robert M. Bernstein MD, FAAD, ABHRS
6 The Link Issue 5, 2013
The Link The Voice of the AHLC
from various ethnic backgrounds and
hair from dierent parts of the scalp. It
is particularly useful in extracting grafts
from the sides of the scalp, where the
hair lies atter on the skin.
Introduction of the Robotic system
into a physician’s practice can present
a formidable challenge. Besides the
expense of the technology, the robot
requires an operating room larger than
those that exist in many doctors’ oces
and requires that the room be dedicated
to this purpose. In addition to special
training required to operate the system,
the FUE procedure itself should be
modied so that grafts are kept out of
the body for as short a time as possible
and kept in an environment that will
ensure maximum growth. is can be
accomplished by making recipient sites
prior to the robotic harvesting and by
using special biologic solutions to hold
the grafts.
Indications for Robotic FUE
Since FUE does not leave a linear
scar, it is useful for patients who want
to wear their hair very short. It is also
advantageous, when compared to FUT,
for those, such as professional athletes,
who are involved in very strenuous
activities and who must resume these
activities very soon after their proce-
dure. e technique is also useful for
patients who have healed poorly from
traditional strip harvesting or who
have a very tight scalp and so are not
indicated for a strip procedure.
Another application of FUE is the
camouaging of a linear donor scar
from a prior hair transplant procedure.
In this technique, a small amount of
hair is extracted from the area around
a linear donor scar. It is then placed
directly into the scar, making it less
visible as the transplanted hair grows in
the scar tissue. FUE potentially allows
the surgeon to remove hair from parts
of the body other than the donor scalp,
such as the beard or trunk, although
there are many limitations with this
process.
Some patients desire FUE simply
because they have heard that it is non-
surgical. e reality is that FUT and
FUE both involve surgery and in both
cases the depth of the incisions (i.e.
into the fat layer right below the hair
follicles) is the same. e dierence is in
the type of incision made.
Limitations of FUE
Follicular Unit Extraction harvesting
requires a much larger area compared
to strip harvesting (approximately x
the area for the same number of grafts).
is has two implications. e rst is
that, in order to perform large sessions
of FUE, the entire donor area must be
shaved. is can present a signicant
short-term cosmetic problem for many
patients. In contrast, with FUT using
strip harvesting, the donor incision
can immediately be covered with hair
– even in hair transplants that require
very large sessions.
A second issue with the larger har-
vesting area in FUE is that with large
sessions the doctor must often push
the limit of what is actually “permanent”
in order to get the desired number of
grafts. is may present a long-term
problem when transplanting a younger
person in whom the extent of the per-
manent donor area cannot be precisely
determined.
e method of graft harvesting also
aects the quality of grafts and the full-
ness that may ultimately be achieved in
the hair transplant. In FUT, follicular
unit grafts are isolated with the aid of
dissecting microscopes – a very precise
method for preserving the integrity of
follicular units. Although the Robotic
FUE system appears to be the most
accurate of the extraction devices, it is
still not as accurate in generating intact
follicular units as a surgical team that
is skilled in the microscopic dissection
process used in FUT.
Because the dierences between FUE
and FUT are signicant and because
there are distinct advantages and disad-
vantages to each, the needs of each per-
son must be carefully considered when
deciding which procedure to choose.
The Future of Robotic Hair
Transplants
With the trend toward less invasive
surgery and the preference of men for
shorter hairstyles, the popularity of
FUE will continue to increase. Although
only a small number of cases of FUE
were performed in the United States
prior to , FUE is rapidly becoming
a mainstream procedure in many hair
transplant surgeons’ practices. ere
were three FUE Robots in the hands of
physicians at the end of , twenty-
two by the end of  and there will
be an estimated seventy in operation
worldwide by the end of . e rapid
adoption of robotic hair transplants
speaks to the increasing interest in
FUE by patients and the realization, by
physicians, that this technology holds
the key to improving the quality and
consistency of a very demanding, labor
intensive hair transplant procedure.
Dr. Bernstein performing Robotic FUE
The Link Issue 5, 2013 7
The Link The Voice of the AHLC
... This system includes a 7-axis KUKA robotic arm and multi-camera based stereoscopic vision system. Studies are carried out on the performance and accuracy of this system in [18]- [20]. The system used in Artas aims to perform FUE based hair transplantation in a semi-automatic way without in-depth analysis of whole head. ...
Article
Full-text available
Robots and artificial intelligence technologies have become very important in the health applications as in many other fields. The proposed system in this work aims to provide detailed analysis of pre-op and post-op stage of FUE hair transplant procedures to enable surgeon to plan and assess success of the operations. In order to achieve this target, a robotic and vision-based system imaging and AI based analysis approach is developed. The proposed system performs analyses in three main stages: initialization, scanning, and analysis. At the initialization stage, 3D model of the patient’s head generated at first by locating a depth camera in various positions around the patient by the help of a collaborative robot. At the second stage, where high resolution image capturing is performed in a loop with the usage of the 3D model, raw images are processed by a deep learning based object detection algorithm where follicles in pre-op and extracted follicle positions (i.e. holes) and placed grafts in post-op is detected. At the last stage, thickness of each hair is computed at the detected hair follicle positions using another deep learning-based segmentation approach. These data are combined to obtain objective evaluation criteria to generate patient report. Experimental results show that the developed system can be used successfully in hair transplantation operations.
Article
Early surgical hair restoration (SHR) techniques were fraught with limitations. Major advancements and refinements have taken place yielding minimally invasive, relatively scar-free, and natural-looking hair transplantations. Our aim was to review the origins and advancements of SHR and to discuss future directions for the field. Searches were performed using: Pubmed, Scopus, and the International Society of Hair Restoration Surgery's Hair Transplant Forum International for articles related to SHR. Reference sections of articles obtained were reviewed. Relevant textbooks obtained were reviewed. SHR techniques originated as macro-level graft transplantations and excision of scalp tissue. They progressed toward micro-level graft transplantations performed with extreme caution and precision. However, all SHR techniques are limited by their reliance on existing donor hair to fill balding areas. Further advancements in hair follicle cell cloning and regeneration of growth may offer a solution to this overarching limitation. © 2014 Canadian Dermatology Association.
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