The New Hair Institute has added the Artas® Hair Restoration Robot to its practice offerings (pictured above). Now, in addition to the strip surgeries for traditional Follicular Unit Transplantation, our Follicular Unit Extraction Surgeries (FUE) will include: (1) The Artas® Hair Restoration Robot, (2) the Manual FUE performed by Dr. Pak (we joke by calling him the Pak Robot using techniques we have used for the past 19 years), and (3) the Long Hair FUE, done with our own specialized manual instruments (we have generally limited LH-FUE to about 1000 grafts).
A LITTLE BIT OF HISTORY: In 1998, Dr. Pak (who was working with me as an engineer at the time) and I invented the concept of a robot which would use a special optical sighting system to align the hairs exiting the scalp for an automated and efficient Follicular Unit Extraction System. At the time we came up with this technology, we were using Follicular Unit Extraction (FUE) for about 2 years. We submitted the patents for two appropriate technologies, one would address the siting system U.S. Patent # 6,572,625, and the second would facilitate stabilization of the scalp with a tension apparatus Patent #US20040049206 (both of these are now used in Restoration Robotics’ Artas® System). We also submitted patents for some future steps in automation which include graft implantation techniques (US#5817120 which has cartridge storage for holding a large number of grafts and used in a graft placement apparatus), though these have not made it into the market today. Although Restoration Robotics’ Artas® robot only performs FUE today, the company will eventually incorporate the full hair transplantation process into the robot. The additional steps needed will: (a) move the grafts from the scalp into a storage mechanism while out of the body and (b) provide graft placement which will most likely use our patented technology. This makes the Artas®, a very appealing technology for our practice both now and in the future. Below are figures taken from the two patents incorporated into the Artas® Robot today.
We are problem solvers and we recognized that although we performed the FUE well, after pioneering it in the mid-1990s and writing the first scientific FUE article in 2002, doctors in the hair transplant field initially failed to perform the FUE procedure with consistency, efficiency and with minimal transection damage to the grafts, so results were generally poor despite proclamations by many doctors to the contrary. The market demand for FUE started to rise and more and more doctors wanted to offer the technique, but failures plagued the field. What was needed was the robotic technology we envisioned (like the Artas®) but that would be a very expensive engineering project, so most doctors tried to master the manual techniques with a wide variety of instruments developed, at times, by the doctors themselves. Some instruments were good (Dr. Jim Harris produced the Safe System) and many were terrible. The patients became victims of the failures which were all too common. Many of these patients found their way to our office. In 2006, Restoration Robotics was formed with a mission to build a robot for hair transplantation. Finally, in 2011 (just 9 years after we published our breakthrough article on FUE and five years after the engineering project was started), Restoration Robotics introduced the Artas® robot which fully addressed the frequent failures seen with the manual FUE process.
Why were we so late in incorporating the Artas® technology into our practice? A very reasonable question which I was ask last week by one of my patients since the Artas® has been available now for 4 years and has about 120 installations world-wide. The five primary considerations for our purchase decision were: (1) We are very efficient at doing FUE (without the robot) as we have been doing the FUE surgery longer than any medical group in the world (since the mid-1990s) with a focus on perfecting the procedure and developing instrument iterations which we pioneered along the way (16 issued patent to-date), (2) We are faster than the robot in doing FUE and faster than most doctors world-wide because we have been doing FUE, in some form, for 19 years, so we hesitated to make the purchase decision. Performing manual FUE efficiently is very difficult and only a small handful of doctors can match our overall speed, quality, and efficiency with manual instruments, so we hesitated to make the purchase decision, (3) The Robot delivers unquestionable quality and consistency, so having one was always appealing to us and the future expansion of the robot’s capabilities, such as in placing grafts, finally made the decision to purchase an Artas® a good business decision for our future practice. We are looking forward to the continued technical expansion of the Artas®’s functionality into this realm, (4) It solved two of our ongoing problems, (a) by eliminating the eye strain and the physical fatigue for the surgeon when performing the repetitive motions for FUE. Eye fatigue, a real known problem previously identified by me in lectures and publications, is worse for any surgeon approaching the age of 50 as their ability to focus and coordinate eye movement becomes a problem of aging in almost all people (fortunately for NHI, Dr. Pak is 42 years old and has none of these changes yet) and (b) repetitive hand motions stress the surgeon’s hand and wrist and can produce health problems like carpel-tunnel syndrome. Dr. Pak who does all of our Manual FUE procedures, tells me that on some days, he feels wrist pain, and (5) There were some initial concerns that there may be a legal problem in using a robot for hair transplantation. The Medical Boards of the Various States, like California, had not ruled on the legality of a robot performing this type of hair transplant surgery. I wanted an approval from the medical board so that if we purchased an Artas® system for Robot Hair Transplantation, they would not ‘ding us’ with regard to our license for improper conduct or rule against the legality of the robot for this purpose. Although the State of California still has not made such a ruling, its silence on this, we believe, has become a quasi-approval on the legality of using a robot for hair transplantation, so Dr. Pak and I concluded that it is worth taking this business purchase risk. The Artas® is not legally different from other robotic surgeries in medicine such as the da Vinci® Robotic Surgical System for Prostate Cancer Surgery and other similar robots which are routinely used in surgical procedures elsewhere in the body.
ARE THERE OTHER HAIR TRANSPLANT ROBOTS? Other hair transplant instrument companies have, unfortunately, falsely implied that their system is a robot, when in-fact it is not. Robots like the Artas®, uses real robotic technology that controls quality and obviates the errors associated with human operation when performing FUE (just like the robots used in the automotive industry to improve automotive quality manufacturing). The goal of a robot is to maintain human judgments while minimizing humans from performing the tedious components of the surgery and maximizing the robotic technology to obtain predictable quality products or services.
By calling an instrument a robot, however, some companies imply that their systems uses robotics so that they can sell them more easily to naive doctors who may think that they are buying a robot. Such doctors follow their purchase with ‘rent-a-tech‘ services to help them offer hair transplant to their patients, even if he/she was never trained in hair transplantation. Many patients asked me during a consultation about one such company, Neograft, (which heavily markets their technology). These patients ask: “is this a robot?” I have had a Neograft system in our office on two occasions (to try it out) and used it so I believe that we are qualified to answer this question. I also watched the Neograft in action in a hotel ballroom in San Francisco where a patient was transplanted in the hands of a technician (not a doctor) performing the service. It worked well both in my office and in the ballroom. The technician seemed to know what he was doing. What I saw, however, was an instrument that looked like a dental drill with a hollow drill-bit used to core grafts from the back of the head and suck them out into a liquid filled small jar (nothing robotic about it). The drill-bit was aligned by the eye in the hand of the operator, not by any optical site system, so the limitations of the human eye were imposed on the effectiveness of this instrument. If the operator was good at it, had excellent eyesight and years of experience, like our manual FUE process, the results could be very good. Many doctors using such systems, however, may falsely believe that they are using a robot for marketing purposes and represent it as such. When people have it performed on them, they can’t really tell if it is or isn’t a doctor doing it because the FUE is performed behind their head (they can’t see who the operator is).
All doctors want to improve their finances in this difficult world of ‘insurance driven medicine’. They are vulnerable to a sales pitch ‘that asks those not in the hair transplant business if they would like to add a few thousand dollars to their daily medical practice?’ This is a persuasive sales technique. Neograft’s sales strategy selling to doctors who are not formally trained in the field is so successful with this technique, that Neograft has become the dominant systems sold to doctors worldwide today. That is why you should always probe the doctor’s training and experience before you ‘buy into’ any doctor offering you this type of service as experience and track record are clearly the most important part of the decision-to-buy process.
The image in the market is that robotic FUE is superior to the manual FUE process. This is probably true in most cases when the system is Restoration Robotic’s Artas® system; however, when dental drills are referred to as a ‘robot’ or when a person without formal training performs the FUE manually with non-robotic instruments, one should question just what is being delivered. Both the doctors offering these services and the patients receiving them should fully understand what is happening and that there is no misrepresentation made with regard to the robotic or non-robotic technology being used. The results from any manual system is heavily dependent upon the skill of the person performing the surgery (eye and hand control), just like it has been in our hands over the past 19 years in providing FUE services. Many doctors can use manual systems, of many designs, competently including the Neograft system which is another manual system. The good news is that some of the experienced ‘rent a techs’, probably do a good job, but they are not doctors. Many of the inexperienced doctors employing these ‘rent-a-techs’ to perform a hair transplant surgery, knows little to nothing about hair transplant surgery and leaving the surgery to a technician has many clinical and legal problems associated with it.
AND WHO DOES THE SURGERY? If you buy into a surgeon who facilitates a hair transplant procedure and you think that you are getting an experienced doctor performing the surgery on you, it might be a fraudulent misrepresentation. The International Society of Hair Restoration Surgeons (ISHRS), believes that the practice of using technicians to perform a hair transplant surgery is ‘facilitating the practice of medicine without a license’ (see:https://www.ishrs.org/content/qualifications-scalp-surgery). These ‘rent a techs’ also make the surgical recipient sites, and at times, I have been told that they administer the anesthesia. These are illegal act. One death that I know of (in the hands of a doctor unskilled in the field, not a technician) occurred California probably from an anesthetic overdose of a simple, usually safe and commonly used anesthetic. Not that simple if it kills someone (the doctor lost his license and the patient’s two children lost their father). Criminal charges (i.e. manslaughter or murder) can be brought against any ‘rent a tech’ who administers anesthesia and by mistake, kills someone. In other words, an incision through the skin with any FUE instrument or an incision that makes recipient sites, or a technician administering anesthetics is illegal in most states and countries unless directly performed by a licensed physician. Anything that goes wrong in such surgeries would put the doctor at risk for ‘facilitating the practice of medicine without a license’, and it could cause the doctor to lose his license, be indicted and/or be criminally prosecuted for it and be personally exposed to a malpractice suit without the protection of his malpractice carrier (which does not cover illegal acts facilitated by a doctor).
Quality of anything we do, is what motivates us and sharing it with the medical profession is critical to our philosophies and our Hippocratic Oath which requires us to teach our colleagues any and all advances in medicine that we originate. When I first introduced the FUE to over 500 doctors at an ISHRS meeting in 2002, to teach FUE, I produced over 500 DVDs which I gave out to the doctors in the audience who never heard of FUE prior to that meeting. The DVD was, in effect, a limited tutorial for FUE. Unfortunately, some doctors used it as a marketing tool to instantly proclaim their expertise in FUE, harming far too many patients.
People always ask us: What Motivates Our Inventions?” My standard answer reflects the cliché that ‘necessity is the mother of invention’ and we personally believe that ‘there is always a better way to do something, always’. All you have to do is to “think out of the box” when confronting any problem. That is why the Artas® was invented, built and commercialized. The company Restoration Robotics created a masterful, technologically sophisticated robot that leveled the playing field for all those who use one. The training time is relatively short for the coring of the grafts, but all of the surrounding technology still remains manual. The Artas® FUE creates a very high standard of care for FUE. Although today’s Artas® does not offer all of the features and functions it will eventually offer, the doctors who use it must be experienced and have an experienced team of skilled technicians who have mastered the quality control systems that lead to great results. Only with a good team behind it, will the Artas® produce great FUE results. We will write more on the Artas®, robotics and the FUE procedure in a future post shortly that will shed more light on the actual surgery that is very pertinent to the decision on how to pick an FUE doctor. Those doctors who own an Artas®, should be in that consideration.