Robotic, AI-Assisted follicular unit excision and implantation for
hair restoration with ARTAS iX
David Berman, MD; Gabe Zingaretti, Dott Ing; Eric Selvik, MS, MBA
Berman Skin Institute; Restoration Robotics
Introduction
Medical robotic systems are assisting an increasing number of
surgical procedures across multiple medical specialties. In 2011, the
first robotic platform for hair transplantation was introduced to assist
in follicular unit excision of hair grafts (ARTAS, Restoration Robotics,
San Jose, CA). Many papers have studied the use of the robotic
platform for harvesting of follicular units.
Recently, a new robotic system was developed that, in addition to
harvesting follicular units, also creates recipient sites and implants
grafts. (ARTAS iX, Restoration Robotics, San Jose, CA).
Objectives
The objective of this case study was to evaluate the use of the new
robotic ARTAS iX System to assist in both harvesting and
implantation of follicular units in hair transplantation surgery.
Methods
A 50 y/o male with black straight hair presented with androgenic
alopecia, Norwood Grade 5, and elected to undergo an FUE hair
transplantation procedure. The patient was treated using the ARTAS
iX System (Fig1).
The patient was prepped and given the standard anesthesia protocol.
The physician created the 3-D preoperative plan design using ARTAS
graphical user interface. For the procedure, the patient was seated in
the ARTAS procedure chair, leaning forward, with his head supported
by the head rest column (Fig 2).
During the harvesting procedure, a tensioner is placed on the scalp to
provide uniform skin tension and fiducial guidance for the robot. Using
machine vision image guidance, the system excised individual
follicular units with a combination of an 1.0mm needle and rotating
coring punch (Fig 3). The grafts were harvested, counted, trimmed,
and placed in linear cartridges of 25 grafts each. The cartridges were
loaded individually into the implantation mechanism of the system
(Fig 4). Temporary fiducial markers were applied around the recipient
area of the scalp spaced 2-3cm apart. Using a 0.9mm implantation
needle and “stick and place” technique, the ARTAS iX implanted the
grafts by simultaneously creating a recipient site and inserting a graft
from the cartridge according to the digital plan prescribed by the
physician. The remainder of the grafts were implanted manually into
sites made manually. After the treatment, the patient was discharged
under standard protocol, and returned home.
Fig 1 Fig 2
Fig 3 Fig 4
Results
1042 follicular unit grafts were harvested at an average harvesting
speed of 1093 grafts/hr, with peaks as high as 1318 grafts/hr. 796
grafts were implanted robotically at an average rate of 468
grafts/hr., with peak rates at 794 grafts/hr. The remainder of the
grafts were implanted manually into sites made manually per
physician preference. Average number of terminal hairs/graft was
2.0. No adverse events or post operative complications were
reported.
Discussion
Manual FUE is a widely-used and clinically proven technique,
however the cases are long and require thousands of precise
repetitive motions to accurately excise and implant individual grafts.
Fatigue can cause pain and discomfort for the clinician , and
2
potentially lead to human error and higher transection rates 1,
particularly towards the end of long cases. Furthermore, manual
implantation requires a significant amount of graft handling at the
bulb of the hair follicle which is avoided with the use of the robotic
implanter. Use of an image-guided robotic system such as the
ARTAS iX to assist in the procedure can address many of the
physical limitations of human vision, physical fatigue, and motor
skills precision.
Minimizing the amount of operative time is of interest to both the
patient and the physician. This case study demonstrates that the
ARTAS iX can provide clinically efficient surgical workflows that are
consistent with manual techniques, with potential to reduce total
case time for FUE procedures.
Conclusion
The ARTAS iX System is a novel robotic hair restoration platform
that provides safe, effective, and clinically efficient follicular unit
harvesting and implantation functionality. More studies
demonstrating larger case sizes and increased clinical efficiency
are recommended to further evaluate the benefits of robotic
assisted hair transplantation.
References
1. Avram MR, Watkins SA, Robotic follicular unit extraction in hair
transplantation. Dermatol Surg 2014;40:1319-1327
2. Williams, KL et al, Ergonomics in hair restoration surgeons. Journal of
Cosmetic Dermatology 2015; 0: 1-6