FUE: Surgical Skills and Robots (Part 3 of 4)

So far, we’ve looked at the history of FUE in part 1 and graft quality/survival in part 2…

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FUE Today:

The FUE market may reflect as much as 40% of the total hair transplant market today. I believe that 20% of the doctors offering FUE, are skilled in the process; however, a majority of the doctors who offer FUE today are not skilled in the process. With such a large gap between skilled and unskilled doctors doing FUE, one would ask what the doctors are doing about it, because no doctor wants to be second class. The doctor must get the expertise that they need… somehow.

Some doctors try one of the various instruments that promise great success with the FUE process. Some instrument entrepreneurs try to convince the doctors that if they purchase a particular instrument, great success will befall them and every new doctor purchasing these system, want to believe it. I admire Dr. Jim Harris, who pioneered a special instrument because he offers training on human volunteers to physicians who want to master his unique approach. I have participated in his course and own one of his instruments. There are instruments that:

(a) drill out the follicular unit with a slow variable drill
(b) that vibrate and/or rotate when they drill the hair graft
(c) have variable depth control to minimize damage to the deep portions of the graft
(d) claim that their punches are sharper than all other drills or punches on the market
(e) are made dull intentionally to minimize transection, etc..

Drilling is the most popular way of performing the FUE and most doctors seem to favor the drill. Prices for these drills (the doctor’s costs) run as low as $1200 to as high as $220,000 plus $1/graft. Each vendor claims some advantage over the other.

With the discrepancy between $1200 and $220,000, let’s see what value comes with each package.

ARTAS:

The ARTAS system made by Restoration Robotics is the $220,000 unit for FUE harvesting. The sole function of the ARTAS system today is to core grafts from the scalp, leaving them in the scalp until they are manually removed. Their ARTAS system does the coring with a high degree of accuracy. It does this with robotic efficiency using optical siting technology (initially designed and patented by Rassman and Pak — Patent 6,572,625). The ARTAS uses a sharp punch to score the skin and then a dull punch (designed and patented by Dr. Jim Harris) measuring 1.2mm each. The hair shaft lies mostly below the scalp surface and the angle of ‘attack’ by the robotic punching system is calculated by knowing both the angle of the hair stubble above the skin and an estimate of the bend in the hair follicle found below the skin. The hair is left with stubble when the scalp is shaved so the part of the hair shaft that is exposed allows the optical siting system to establish the needed alignment for the extraction. The bend below the skin is consistent in adjacent grafts, but vary in different parts of the head and constant adjustment is needed as the instrument moves from one area to another. The robot can not ‘feel’ the graft, so the extraction is done by science and math, while all of the other instruments on the market allow for the ‘feel’ of the graft as the instrument plunges into the scalp.

A skin stabilizer (invented and patented by Rassman) is used to stabilize the skin for the extraction that follows. The ARTAS leaves the graft in the scalp and moves from one location to another until the entire drilling process is complete (speed of drilling is about 300-400 grafts per hour). About one graft is excised out of every 5 in a single field of view and this variable can be dialed into the ARTAS controls. The robot is very efficient in making the calculations to remove 20% (or 25%….) of the follicular units in any one field of view. The coring is where the automation ends. Once the grafts are cored out, the rest of the process, including the removal of the grafts is a hand process.The ARTAS damage to the follicular units from the drilling part may range in the 5-10% in each patient. The variations by the team or with the patient dictates most of the variables and most damage occurs when the grafts are transected or ripped out after the drilling process.

Restoration Robotics intends to automate the entire hair transplant process some time in the future. They are estimating that the complete automation may be accomplished in 2-4 years. When they complete the automation for implantation, the art of the hairline has to be dealt with and I am interested in seeing how they go about the rest of the automation process. The ARTAS system requires the least training for the mechanical extraction of any instrument available today. In fact, once the diagnosis is complete and the plan is laid out, the surgeon becomes superfluous to the process. As the doctor pays $220,000 for today ARTAS and $1/graft, these costs must be put into the final price for the consumer making the ARTAS FUE possibly the most expensive technology for the consumer today.

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The final part of this series will be posted tomorrow, where we’ll discuss Neograft and manual processes for FUE.