R o b o t i c H a i r Re s t o r a t i o n

Paul T. Rose, MD, JD*, Bernard Nusbaum, MD

KEYWORDS
 Follicular unit extraction  Follicular isolation technique  Robotic hair transplantation
 Follicular units  Transection  Strip harvesting

KEY POINTS
 The robotic system of hair restoration is an important addition to the techniques used for hair resto-
ration surgery.
 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.
 The advantages and disadvantages associated with the robotic device are similar to those of
manual or mechanized FUE/FIT harvesting.
 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 approved for use only in men for the purpose of

hair transplantation.
The use of robotic mechanisms that assist in sur- FUE/FIT is a form of follicular unit grafting1 and is
gery have been available for more than two a technique for removing hair grafts based on ob-
decades. The most prominent system is the Da taining intact follicular units2 or intact parts of a
Vinci system (Intuitive, Sunnyvale, CA) whereby a follicular unit from the donor area of a patient’s
physician directs the movement of the robotic scalp and then implanting the grafts into appro-
apparatus in various surgical procedures. priate recipient sites (Figs. 1 and 2). The technique
An advantage of a robotic system is that it can is essentially the old fashioned punch-graft proce-
perform repetitive maneuvers with great precision. dure3 but performed with small punches, usually
This ability to perform repetitive movement lends 0.7 to 1.2 mm in size. Whereas the 4- or 5-mm
itself particularly well to the performance of hair punches used in the older punch technique har-
restoration procedures when follicular unit extrac- vested multiple follicular units, which may or may
tion/follicular isolation technique (FUE/FIT) is used. not have been totally intact, the FUE/FIT process
The robot assumes some of the tasks that would is designed to remove single follicular units or
require several assistants if a strip harvesting pro- intact parts of a follicular unit.4–6
cedure is undertaken. The system also requires The primary attraction for patients who seek
less time to be proficient with FUE/FIT compared FUE/FIT is that it is considered to be a less
with learning to do manual FUE/FIT surgery. invasive or minimally invasive procedure com-
The ARTAS system (Restoration Robotics, Sun- pared with strip harvesting and most importantly,
nyvale, CA) is a robotic device developed specif- a linear scar is avoided. The patient may be able
ically for the FUE/FIT procedure. It is cleared by to wear his hair shorter than if a strip harvest was
the Food and Drug Administration (FDA) and performed but there is a limitation to this, because
derm.theclinics.com

Disclosures: Dr Rose has been a consultant to Restoration Robotics; Dr Rose owns stock in Restoration Robotics;
Drs Rose and Nusbaum have an ARTAS system in their office.
Hair Transplant Institute Miami, 4425 Ponce de Leon Boulevard, Suite 230, Coral Gables, FL 33146, USA
* Corresponding author.
E-mail address: [email protected]

Dermatol Clin 32 (2014) 97–107

http://dx.doi.org/10.1016/j.det.2013.09.008
0733-8635/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
98 Rose & Nusbaum

could be a possible concern. Thus, the FUE tech-

nique 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.8
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-
Fig. 1. Normal appearance of hairs in the scalp. It is encapsulated bupivicaine (Exparel; Pacira Phar-
important to notice that the hairs generally occur in maceuticals, Parsippany, NJ) postoperative pain
groupings, referred to as “follicular units.” is less commonly an issue with strip harvesting.
The liposomal-encapsulated bupivicaine lasts up
the wounds from FUE can be visible if the head is to 72 hours.
closely shaved. The appearance of the scar from For the physician, an advantage to performing
strip harvesting depends on multiple factors, FUE is that fewer personnel are required
such as donor density, strip width, tension on compared with strip harvesting. This is because
closure, scalp laxity, surgical technique, and the large strip harvest cases require several assistants
patient’s healing characteristics. to dissect the follicular unit grafts from the har-
Some advocates of FUE/FIT believe that the vested donor strip tissue. With FUE, the procedure
recovery time is shorter and patients can assume can be done with only one or two additional assis-
strenuous activities sooner.7 They also suggest tants whose role is to simply clean the grafts and
that the procedure is less painful than with strip har- sort them into follicular unit groups containing
vesting. The wounds from FUE do tend to appear one, two, or three or more hairs.
closed in 4 to 5 days, whereas a strip harvest pa- The manual technique involves using a biopsy
tient has sutures or staples in place for 7 to 14 days. punch of some type and manually harvesting the
The FUE/FIT procedure is considered well follicular unit grafts. Many physicians use a sharp
suited for a young patient who is uncertain as to punch, whereas some use a combination of a
whether he will ever want to shave his scalp or pro- sharp punch to enter the epidermis and then a
ceed with additional hair transplants. If he were to dull punch to go into the dermis and fat.6,9
have a strip harvest, concealing the resultant scar Some physicians use a motorized drill with a
punch attachment for this type of harvesting.10
There are several variations of a motorized drill
on the market (Fig. 3). The use of a motorized drill

Fig. 2. Follicular unit grafts are depicted. Typically the

grafts contain one hair, two hairs, or three hairs. On Fig. 3. Different types of punches used to harvest FUE/
occasion follicular units with greater numbers of hairs FIT grafts. A motorized drill with a punch is also
in the unit occur. shown.
 Robotic Hair Restoration 99

can help skilled physicians harvest quickly and transection as a graft where none of the hairs
maintain low transections rates, with some physi- were obtained.
cians attaining harvest rates in excess of 400
grafts per hour with transection rates below THE ROBOTIC SYSTEM
10%. It can be difficult, however, for some clini-
cians to develop the necessary skill set to attain The robotic system is FDA approved for male pa-
low transection rates and adequate speed to tients with brown or black hair. It consists of a pro-
perform the procedure efficiently. Additionally, prietary imaging technology, computer interface
FUE can be a tedious and tiring procedure for terminal, multiple video cameras, video display,
physician and patient. the robotic arm device, a suction system to lift
At times transection rates can be quite high. In up the harvested grafts, and an ergonomic chair
one FDA study the transection rate of manual that positions the patient in the proper orientation
FUE was noted to be about 26%, whereas the ro- for the robot. The chair is adjustable for height,
botic procedure was rated to be 8%.7,11 The au- rotation, and head position (Fig. 4).
thors have found lower transection rates with The robot scans and digitizes the visual charac-
their approach to FUE/FIT and believe that physi- teristics of the donor area and characterizes each
cians can develop the skill to accomplish lower follicular unit. Based on a mathematical algorithm
transection rates with the manual process than that can be adjusted to some extent, the machine
that reported by the FDA. In the authors’ own randomly harvests follicular units.12–14 Spacing is
experience the transection rate for the robot can such that the harvested grafts are adequately
exceed 8%. spaced apart so as to decrease the chance that
As a side note, it is important to make sure that the graft sites would be visible if the patient
the definition of transection rate is agreed on by wears his hair quite short. The computer program
all surgeons performing FUE. The author defines also calculates follicular unit density and hair
transection as a graft where any of the target angulation.
hairs are severed. If the surgeon attempts to The robotic arm has a dual-bore needle appa-
obtain a three-hair graft and harvests only two ratus that includes a sharp needle tip to enter the
of the hairs while the third hair is damaged, then skin and a surrounding coring blunt needle that
a transection has occurred. Some define a then goes deeper into the tissue to limit the chance

Fig. 4. The Restoration Robotics ARTAS

system includes the robotic arm, ergo-
nomic chair, and video monitors. (Cour-
tesy of Restoration Robotics, Inc, San
Jose, CA; with permission.)
100 Rose & Nusbaum

of transection of hairs and allow for easier removal loss is confirmed by appropriate examination.
of the selected follicular units. The sharp needle In some cases the diagnosis of a hair loss condi-
has graduated markings to allow the physician to tion apart from male-pattern hair loss may also
assess the depth of penetration. be suitable for hair transplantation. Depending
The system is designed for use by a physician on physician preference, laboratory work, such
in conjunction with an assistant working at a as complete blood count, complete metabolic
computer terminal. Together the physician and profile, prothrombin time and partial thrombo-
assistant can continually make adjustments as plastin time, and hepatitis and HIV status, may
needed to facilitate harvesting. be obtained before surgery.
The robotic system has pressure sensors that
assess forces generated to penetrate tissue. The Preoperative Photographs and Marking
system ceases operation and requires a resetting At the time of the surgery, photographs are taken
of the parameters if the threshold of force needed of the patient’s scalp from the front, sides, back,
to penetrate the tissue is exceeded. The device and top of the head. Appropriate informed consent
has several other safety features. The safety sys- is provided.
tem of the robot prohibits the robotic arm from The recipient area is designed and marked and
touching other parts of the robotic arm that might then the area to be harvested is marked out and
hinder advancement of the needle apparatus or shaved to a length of approximately 2 mm. Photo-
cause damage to the robotic arm. The robot is de- graphs are once again taken to demonstrate the
signed to prevent any possible injury to the patient recipient area design and the marked donor area.
by restricting the movement of the arm if neces- In most patients the proposed donor area con-
sary. It is noted that more than 350 patients were forms to the safe area of hairs that are expected
treated in the clinical trials and there were no to survive throughout the patient’s life.16 In some
safety-related issues.15 The physician and assis- instances the physician may decide to harvest
tant have emergency stop buttons to cease oper- outside of the recognized safe area if he or she be-
ation of the machine. The emergency stop button lieves that the patient’s hair loss will be limited and
is located on the “pendant” handpiece that the allow removal of grafts from beyond the safe zone.
physician uses to control the various functional The authors often divide the donor area into
parameters of the device (Fig. 5). sections. Usually four sections are marked out,
Patient movements are monitored by the robotic two central portions and two lateral portions. The
system allowing the machine to move to some area to be harvested is anesthetized in sections
extent with the patient. If movement is excessive so that the smallest amount of anesthetic agent
the robot indicates that it cannot adequately recog- is used at any one time throughout the course of
nize the follicular units and ceases harvesting. the surgery. The authors use 1% lidocaine with
epinephrine 1:100,000 for this purpose.
THE ROBOTIC PROCEDURE
Medical and Surgical History Anesthetic
As with other surgical procedures the patient’s The patient is typically provided some form of
medical and surgical history are obtained before sedation, such as diazepam or similar medication.
the procedure. A diagnosis of male-pattern hair Pain medication may also be given. Some

Fig. 5. The “pendant” that is held by

the physician provides an ability to
adjust the various harvesting parame-
ters of the robotic device. There is an
emergency stop button should the
physician need to stop the machine
while in motion.
 Robotic Hair Restoration 101

physicians elect to give preoperative antibiotics

routinely, whereas some give antibiotics depend-
ing on the patient’s health status. Some physicians
use intravenous sedation, which allows for easier
maneuverability of the patient and limits ill-timed
patient movements that slow down the use of the
robotic device.

Robotic Technique
 After the patient is positioned in the chair, in a
semiprone orientation, the surgeon applies a
tensioner to the initial area selected to be har-
vested. The tensioner measures approxi-
mately 10 to 11 cm2 and it is crucial that the Fig. 7. The tensioner is positioned onto the skin for
skin be stretched before application of the donor harvesting. The fiducial markings are seen
tensioner and that the tensioner be placed along the periphery of the tensioner. These marking
securely on the desired area (Fig. 6). allow for orientation of the robot by the imaging
 To increase the rigidity of the tissue in the system.
area, fluid, such as saline or saline with
epinephrine 1:100,000, is injected into the
follicles and a suitable angle for the robotic
dermis to provide a firmer surface so that
needle to approach the follicular unit. The sur-
the robot can incise into the skin more easily.
geon can control the machine by a “pendant”
 The physician works with an assistant sta-
that has various buttons controlling the har-
tioned at a computer terminal. The robot is
vesting parameters (see Fig. 5). The person
then directed to identify borders of the
operating the computer terminal, which can
tensioner (Fig. 7). The tensioner has fiducial
be the physician or an assistant, also has the
markings that allow the robot to track patient
ability to control some aspects of the harvest-
movement and ensure proper alignment for
ing process. In the course of harvesting the
the robot to recognize the area and the grafts
physician has the ability to select or skip units
in the enclosed space. With the tensioner in
chosen by the robot.
place the robot then scans the image of the
 The robotic arm has at its end a sharp 1-mm
enclosed donor area. The robotic cameras
needle that initially penetrates or “scores”
then send the image to the computer to
the skin, just entering the epidermis. This
recognize the follicular units, angle of hairs,
portion of the needle has clearly visible grada-
and the follicular unit density within the
tion markings on the monitor to allow the
tensioner area (Fig. 8).
physician to control the depth of penetration.
 After the follicular units are identified the robot
A second blunt punch then enters the skin to
can then begin to select units for harvesting.
a greater depth to core out the graft. The
The robot determines the angle of the hair
depth of the needle penetration and the depth
of the coring blunt punch can be adjusted as
needed by the physician. Additionally, the
speed of the drill tip can be adjusted. The
vacuum assist helps to raise the grafts up
facilitating harvesting and also allows visuali-
zation of the harvested grafts below their
epidermal surface to adjust parameters and
optimize graft quality.
 After several grafts have been incised, the
physician assesses from the video screen
the quality of the graft harvesting (Fig. 9).
Several grafts can also be examined by
collecting them from the tensioner enclosed
area. If the physician is satisfied with the grafts
the robot can be placed on automatic mode
Fig. 6. The tensioner and the tool used to place the and the machine will harvest at speeds gener-
tensioner onto the donor skin. ally ranging from 300 to 500 grafts per hour.
102 Rose & Nusbaum

Fig. 8. View of the video screen as observed by the physician. The screen shows parameters that are considered to
harvest the tissue. CD, coring depth of the outer blunt needle; PD, punch depth of the needle. The speed of rota-
tion can be adjusted (RPM) and the angle of attack can also be observed on the video screen. (Courtesy of Resto-
ration Robotics, Inc, San Jose, CA; with permission.)

Graft harvest speeds in excess of these An average Norwood type V or VI patient is able to
numbers are reported. have 1500 to 2000 grafts harvested in a single ses-
 After the initial tensioner area is harvested the sion. Some physicians have reported harvesting in
tensioner is removed and the grafts are excess of 3000 grafts from some patients. In such
collected, examined, and trimmed under a mi- instances the patient may have a particularly high
croscope if necessary. The tensioner is then follicular unit density, large head, and therefore
moved to an adjacent area and the same pro- an extended surface area of harvesting available.
cess discussed previously is repeated. Logis- It may be that the surgeon has decided to exceed
tically, it may be helpful to harvest several the safe donor zone and/or grafts are cut down to
grids and collect the grafts while another smaller sizes.
grid is operated on. At times the suction It is noted that graft harvest speed is not directly
component may not be able to elevate the correlated to the time it takes to complete the
incised grafts. Such grafts are often tethered procedure. Graft harvest speeds apply only to
to underlying tissue and it may be necessary the rate the robot is incising grafts at the time it
to free up the graft. Using a 19-gauge needle is in the automatic mode. Time is added by having
can be helpful in releasing the graft. to manually collect the grafts, reposition the ten-
sioner, make recipient sites, and place grafts.
Therefore, if 1500 grafts could actually be har-
vested in 3 hours there would still be several addi-
tional hours needed to place all the grafts in the
recipient site. A 1500-graft case might take 5 to
6 hours to complete.

Recipient Site
After the grafts are collected they are placed into
recipients sites. This step is performed in the iden-
tical fashion as when follicular unit transplantation
grafts are obtained from strip harvesting. The recip-
Fig. 9. Typical grafts harvested by the robotic device. ient sites are made for one-, two-, three-, and
 Robotic Hair Restoration 103

four-hair follicular units. Many physicians make a linear scar. In a young patient who is uncertain
recipient sites with custom-cut blades ranging as to whether he may want to have multiple hair
from 0.7 to 1.5 mm in size. Others use premade transplant procedures or simply shave the scalp
blades or use needles, such as a 19-gauge, to in the future, the robotic technique provides an
make recipient sites. The same aesthetic consider- ability to be more flexible in decision making. The
ations are followed as with any other hair restora- patient can have a procedure and perhaps later
tion procedure. decide not to have any more procedures, yet still
Some physicians elect to make some or all of be able to wear his hair quite short without evi-
the recipient sites the day before the procedure dence of a surgical procedure in the donor area.
to shorten the operative time on the subsequent The patient would probably be reluctant to shave
operative day. This means that the surgeon has his head because the remnants of the punch
predetermined to a large extent the number of wounds might be evident as hypopigmented dots.
one-, two-, and three-hair grafts and what size The wounds with FUE seem to heal more quickly
the recipient sites will be before knowing for compared with strip harvesting where the donor
certain what the sizes of the harvested follicular site is sutured. There may be less postoperative
units are at the actual time of surgery. pain in the first 24 hours but this may be a moot
issue with the author’s use of liposomal marcaine
Postoperative in strip surgery.
With strip harvesting there can be a period of
Postoperatively patients apply antibiotic ointment
tightness and paresthesia in the donor area,
and alternate with a water-soluble lubricating jelly
whereas a sense of tightness generally does not
to the donor area. After 1 week we suggest the
occur with the robotic procedure or FUE/FIT. In
use of a product such as Mederma (Merz Pharma-
general, there may be a lower incidence of postop-
ceutical, Greensboro, NC).
erative parasthesias but these seem to be of little
consequence in strip harvesting because the
Advantages
parasthesias are infrequent and resolve quickly.
The use of a robotic device to perform FUE can be Because no sutures are used with robotic harvest-
advantageous for various reasons. The procedure ing or FUE/FIT there is no suture removal discom-
done manually requires significant skill that can fort and one less visit to the clinic.
take a substantial time to learn because the sur- For the patient with a naturally occurring very
geon must account for hair direction, exit angle, tight scalp or tightness because of previous sur-
density of skin, and selection of grafts. The pro- gery, FUE/FIT is often the preferred way to harvest
cess itself can be physically taxing for the physi- grafts and ensure avoiding a wide scar yet still
cian. These issues are resolved with the use of harvest a significant number of grafts. Similarly,
the robot because it excels at such repetitive ac- some patients have natural thinning in the supra-
tions. The robot obviously does not experience fa- auricular area. That could allow a linear scar to
tigue and it has sufficient accuracy to ensure be conspicuous. The FUE/FIT technique may
acceptable transection rates. The learning curve allow harvesting without the possible appearance
for proper use of the robotic device is significantly of linear scarring.
shorter than that for learning manual FUE/FIT.
For a physician entering the field of hair
Disadvantages
restoration an important advantage of the robotic
procedure is that fewer personnel are needed As with any procedure there are advantages and
compared with a strip harvest.11 An assistant is disadvantages. The disadvantages of the robotic
used to help manipulate the robot by a computer procedure are few but the physician needs to be
terminal. At the same time the physician directs aware of them. The robotic system relies on the
the device and is able to control the various param- machinery being able to adjust to patient move-
eters for harvesting.14 The grafts recovered have a ment and the ability to harvest along a curved sur-
small amount of tissue on them so that further trim- face, the skull. If the patient is moving to a great
ming is minimal, if needed at all. The placement of extent the robotic system will have difficulty prop-
the grafts can be done by the surgeon and the as- erly aligning and a considerable time can be
sistant or in most instances two assistants place expended before the harvesting can occur. The
the harvested grafts. sweet spot for manual FUE is generally believed
From a patient point of view the robotic device to be the center occipital area and this is also
advantages are akin to FUE/FIT whether manual true for robotic harvesting. As the harvesting
or robotic. It is a procedure that is ideal for a pa- moves to the lateral areas, particularly supra-
tient who is averse to an incision and the idea of auricular areas, the angle of hair growth can be
104 Rose & Nusbaum

difficult for the robot to align with and transection

rates tend to be somewhat higher. Areas of varying
hair direction can be a problem for the robot and
working in the softer tissue of the nape yields
reduced numbers of viable grafts, as is also true
with manual FUE.
With continued harvesting (often multiple ses-
sions) one notices with FUE and probably with ro-
botic surgery that it becomes increasingly arduous
to harvest large amounts of hair and higher tran-
section rates may result from hair angle changes
that result from adjacent scar tissue.
With manual FUE the surgeon can pick out
particular grafts or particular types of grafts, such
as two- or three-hair follicular units. This is much Fig. 10. After harvesting of FUE/FIT graft whether
more difficult to do with the robot; however, recent manually or with a drill or robotic device the donor
changes to the software may allow this to be wound scars may hypopigment leaving a buckshot
appearance to the donor area.
accomplished.
As with manual FUE/FIT, it is more difficult to
harvest curly and particularly kinky hair as seen with 80 follicular units per square centimeter den-
in blacks. In such situations or in situations where sity, scar length of 12.5 cm, and a scar width of
transection rates are unacceptable the surgeon 2 mm, the total area would be 2.5 cm. Thus, the
may need to abandon the procedure and possibly total area of scar created with FUE is generally
perform strip harvesting if the patient has so greater than with strip harvesting given the same
consented. amount of grafts harvested.
Because the robot is a complex and sophisti- As with other forms of FUE, if there is continued
cated device with a computer interface there is a harvesting in successive sessions the donor area
potential for mechanical, software, or hardware becomes thin and less dense. There can be a
breakdown. If this should occur the surgeon needs “step off” from the harvested donor safe area to
to stop the procedure and have the patient return the zone above that has not been harvested and
when the problem is fixed or have the patient is at least temporarily denser. For this reason it
consider manual FUE or even a strip procedure. may be wise to perform low-density harvesting
Because studies for the robotic system were into the more superior areas to blend the den-
done on males the FDA has approved its use to sities of the safe donor area with the more supe-
only male patients. Also, because the robotic sys- rior hair.
tem relies on the contrast between hair and the When multiple sessions or excessive harvesting
skin to identify hair clusters the system is only takes place, the donor area can have a moth-eaten
approved for use in patients with brown or black appearance. Again, this is not a problem associ-
hair. If the patient has white or very blond hair ated with the robotic device but rather the FUE
this issue can be overcome by dyeing the patient’s approach, because nothing is being put back in
hair. place of the hairs taken out of the donor area.
Although FUE/FIT is often advertised as a no The author has used suction applied to the
scar or minimal scar procedure the mathematics wounds to further improve healing of FUE/FIT
prove otherwise.17,18 The wounds created by wounds and decrease the size of the scars.
FUE whether robotic or from manual FUE produce An issue inherent to FUE is that fewer grafts
round scars where little or no hair grows. These can generally be harvested in a single session
spots are often hypopigmented and larger than compared with strip harvesting. This is because,
the punch diameter used. If the patient wears his to allow for adequate spacing between extraction
hair quite short or shaved, the scalp has an appear- sites, the surgeon can only remove approximately
ance of having been struck by buckshot (Fig. 10). 12% to 20% of the grafts available in the first har-
Although a 1-mm punch may be used for har- vest session without the human eye detecting the
vesting the resultant scar is often greater than pattern of wounds if the hair is cut very short.17
1 mm and may approach 2 mm or more. If one With subsequent sessions the percentage that
takes 1000 grafts and calculates the area of scar can be harvested decreases further. There have
even with 1-mm circles the area is 1000  pi  been reports from several doctors using the ro-
radius squared. This equals 7.85 cm2. For the botic system of cases in excess of 3000 grafts in
same number of grafts a linear scar in a patient one session. It seems that the surgeon is going
 Robotic Hair Restoration 105

beyond the traditional safe donor zone and may be make adjustments of the various parameters of
cutting down grafts to smaller sizes. the robotic system to remedy the problem should
The author has observed that the robotic system it occur.
does not seem to work well in patients with previ- Although most physicians would agree that tran-
ous strip harvesting. The area around the scar is section should be kept to a minimum, the question
often significantly less dense and the area of of what is an acceptable rate is crucial. Many who
fibrosis makes it difficult for the robot to penetrate perform manual FUE believe that transection rates
the skin. Also, the hair direction may be altered in less than 10% are reasonable.
the area adjacent to the scar and so transection
rates may increase. Thinning of the Donor Area Hair
When large numbers of grafts are needed, the
As a result of FUE harvesting, the wounds result in
robotic surgery can be tiring for the patient.
areas in which no hairs grow. If the patient elects to
Some patients feel a sense of claustrophobia in
wear his hair very short the resultant scars may be
the chair. There are patients who simply move
evident as an appearance of multiple dots with no
too much for harvesting to proceed at a reason-
hair, reminiscent of buckshot wounds. In some
able rate and acquire high-quality grafts. These
areas where the grafts have been harvested in
patients tend to be very anxious at the outset
close proximity in one or multiple sessions there
and such patients might be best suited for having
can be a visible thinning of the hair in the donor
the procedure performed with intravenous seda-
area and a step off of hair density from the higher
tion in an appropriate facility.
density above the harvest zone. There may also be
an impression of a moth-eaten appearance to the
ADVERSE REACTIONS AND COMPLICATIONS scalp in areas where concentrated harvesting has
occurred.
The complications associated with robotic sur-
gery are essentially the same as with any FUE
Hypopigmentation and Hyperpigmentation
process.18
The scars that occur with FUE whether by robotic
Buried Grafts device or manual harvesting are usually hypopig-
mented dots. These wounds, when they heal,
At times the use of a small-diameter punch inad-
might not induce activation and migration of
vertently pushes the incised tissue further into
melanocytes to restore normal skin color. This
the skin. The result is a graft that is buried in the
is most evident in patients with darker com-
adipose tissue. Oftentimes these grafts tend to
plexions. On rare occasions there may be
be pushed off to the side adjacent to the incision.
hyperpigmentation.
The surgeon can attempt to find the graft by prob-
ing the area with a mosquito hemostat or forceps. Folliculitis
Making an incision with a #11 blade into the space
created from attempting to remove the graft and Occasionally, a folliculitis may occur at the donor
pushing down on the surrounding tissue may force site. This may be secondary to hair spicules that
the graft upward and outward, allowing recovery are left behind in the skin or partially transected
of the graft. Sometimes injecting saline into the hairs trying to grow through the healed donor sites.
area may push the graft out. If one is unable to Treatment with warm soaks and opening of any
retrieve the graft, it is left alone. If the graft remains pustules can be helpful. On occasion the use of
buried there may be a subsequent foreign body re- suitable antibiotics may speed recovery. If an
action or possibly a cyst may form and may need infection is suspected in the area, a culture and
drainage or excision. sensitivity study may be appropriate.

Transection DISCUSSION
Transection results in damaged hair follicles and in The use of a robotic device to perform FUE-type
some instances entire follicular unit grafts that are hair transplantation is an important innovation
not usable. Some physicians argue that transec- in hair restoration. The machine is in itself a
tion may not be important but could be beneficial remarkable technical achievement combining
because some hair might regrow at the FUE a computer interface, imaging analysis, and a
wound site. This would serve to camouflage to robotic arm.
some extent the harvesting that has been per- For patients, the attraction to this type of a
formed. The surgeon should be aware of the de- procedure is severalfold. The process is consid-
gree of transection throughout the procedure and ered to be less invasive than strip harvesting
106 Rose & Nusbaum

and does not involve the creation of a linear scar. It is the authors’ opinion that it behooves the
There may be quicker healing and the patient physician to know how to perform manual FUE/
may have an earlier resumption of strenuous FIT and strip harvesting in the instance that there
activities compared with strip harvesting. is an intraoperative need to abandon the robotic
Compared with manual FUE, robotic harvesting procedure.
is often more consistent and generally more The authors urge anyone unfamiliar with
rapid while still maintaining acceptable levels of hair restoration, who desires to perform hair resto-
transection. ration surgery, to learn about the various aspect of
From the authors’ perspective, the ideal candi- hair loss diagnosis and treatment and seek appro-
dates for the robotic procedure or simply FUE/ priate training. The International Society of Hair
FIT include young patients who have not had prior Restoration Surgery (www.ishrs.org) is an excel-
harvesting and need a relatively small amount of lent source and the society offers numerous
grafts. Such patients can then have a greater courses around the world.
chance of wearing their hair quite short if they
decide not to proceed with further grafting. Other REFERENCES
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