The Push Towards Automation in Surgical Hair Restoration


One Surgeon’s Assessment of the Current Role, and The Application to Other Plastic Surgery Disciplines

Jeffrey Epstein, MD, FACS

For 18 years, I have specialized in surgical hair restoration, which makes up approximately 75% of my rather busy facial plastic surgery practice.  This translates into performing over 750 hair procedures annually, the majority performed for male and female pattern hair loss, but also for a variety of more specialized indications.  This includes eyebrow and beard restoration, hairline advancement (both with hair grafting as well as the surgical hairline advancement procedure), and many reparative procedures.  Since 1999, follicular unit grafting (FUG) has constituted the primary technique utilized in my practice for obtaining the grafts that are subsequently transplanted into the scalp as well as the other areas restored with hair.  The FUG technique is labor intensive, requiring the individual microscopic dissection then transplanting of as many as 3000 or more grafts in a single procedure.  Each of these grafts consist of a single follicular unit of one to three, occasionally four hairs.   To carry out these procedures, I employ a full-time team of 19 hair transplant technicians. 
The role of these technicians is primarily one of repetitive but delicate work, assisting in the donor strip removal, dissecting each graft, and then placing each graft one at a time into the specific recipient sites.  Because of the aesthetic importance in determining the distribution, pattern, and angulation of growth, I make every recipient site, after which my designated planters (each of whom average, like my full surgical team, over 8 years of working with me) fill each recipient site with a graft, carrying out the arrangement of one-, two-, and three hair grafts that I have personally determined to achieve the look I want.  Another invaluable role all these technicians play is that of hostess/host, greeting then entertaining and befriending the patient who is often at first nervous, then held “captive” for the 5 to 8 hours it may take to complete the procedure.
As an alternative to FUG, the follicular unit extraction (FUE) technique avoids the making of a single donor site incision.  Instead, each graft, consisting of a single follicular unit like with FUG, is harvested one at a time using tiny punches, in my practice usually 0.8 mm, sometimes 1.0 mm in diameter.  Once extracted, these grafts can be trimmed of excess tissue under the microscope, and then placed into recipient sites, once again much like with FUG.  The donor sites, which can number as many as 2000 or more in a single procedure, are allowed to heal secondarily, where they usually result in essentially undetectable dots that can permit patients to shave the head. 
While it is beyond the purpose of this paper to delve into the advantages and disadvantages of FUE versus FUG, since 2008 the FUE technique has been a regular part of my practice, currently constituting approximately 25% of the hair procedures I perform.  It is particularly indicated in male patients who are relatively young (less than 28 years or so in whom there is a higher risk of donor scar widening), African American, and/or who wish to be able to shave the head.  While a matter of debate, there seems to be a consensus amongst my more experienced peers that FUE grafts, at least given current techniques, have a lower percentage of regrowth (75 to 80% versus 90% plus with FUG), despite efforts to increase that percentage.  In addition, FUE procedures require shaving of the back and/or sides of the head, can take longer to perform, and seem to ultimately provide a lower number of total grafts available for transplanting over the course of a patient’s lifetime.  Despite these challenges, FUE is still a wonderful procedure for the right indications, and with developments in automation, these challenges may be further reduced.
Over the past 15 years, a variety of devices designed to automate the hair transplant procedure have been introduced.  The first generation of these from the late 1990s/early 200s included a “whacker” that cut hundreds of grafts in minutes using a guillotine-like device, a carousel implanter, and a pneumatic graft handler and placer-  all three intended for application to FUG, attempting to both reduce surgical time and to replace the need for hair technicians.
The automation devices introduced the past five years have been designed for the FUE procedure, the earlier ones consisting of hand-held drills to help with the extraction of grafts, the more recent ones more complicated, consisting primarily of the NeoGraft® and the just released ARTAS® System.  While thought of by many as similar, they have differences in what they are designed to do.  What they both have in common is that they cannot provide artistic know-how nor clinical judgment, two key components of successful aesthetic surgery.
The ARTAS ® is a computer assisted system that utilizes image-guidance to determine which grafts to extract, which it then does using a two-step process.  Quite a bit of research and work has and continues to be put into the device, assuring the collection of objective clinical data that physicians can access.   Once extracted by the ARTAS® System, the grafts then get transplanted by the surgeon and his technicians, no different than with any other technique of hair transplantation.  Currently there are few surgeons experienced with the ARTAS®, but this number is sure to grow.  The business plan for growth is similar to that of laser vision correction, where the new robotic technology will encourage more patient to undergo a procedure, essentially creating vertical growth for FUE hair transplants (meaning an expansion of the total market for hair transplantation)
While I have less first-hand experience with NeoGraft®, this device, under the control of the surgeon or technician, extracts then places grafts into recipient sites utilizing pneumatic pressure, a process that can speed up the process of FUE.  While originally promoted to hair transplant surgeons, the NeoGraft® is now marketed directly to plastic surgeons, dermatologists, and other cosmetic doctors.  To facilitate incorporating the basic knowledge necessary for performing a hair transplant, technicians can be included as part of the NeoGraft® device, who can perform the great majority of the procedure, controlling not only the extracting, but also the transplanting of these grafts. 
These two devices are commendable for their advanced automation and technical aspects, and have the potential to advance the field of hair transplantation.  They are particularly useful, at this time, for doctors who do not have a team of surgical assistants, for they reduce the manpower needs to properly perform the procedure.  As it is, the FUE procedure requires typically a smaller number of assistants, to help with the extraction process and to then implant the grafts. 
We must keep in mind that these devices do not replace the role of the surgeon in the treatment of hair loss.  First, they do not make clinical judgments, nor evaluate the patient for the candidacy and appropriateness for the procedure.  Much like when addressing any other cosmetic concern, this knowledge comes through study, training, and experience.  Age, etiology of hair loss, medical treatment, future permanence of donor hairs, sex-  these factors all impact the best mode of treatment, and not only determine how, but whether even if, the procedure should be performed.  Second, these automated devices do not replace aesthetic decision making.  Hairline position, design, and pattern; graft angulation and density; density of graft placement; distribution of grafts and which areas to restore-   these are all critical steps in the hair transplant process for those surgeons seeking excellence and the most natural appearing results.  As a facial plastic surgeon, I view surgical hair restoration as a truly aesthetic procedure, and can be as rewarding as any other cosmetic surgery for both patient and doctor.  I hope, in order to maintain the public’s ever-increasing positive perception of hair transplants, that the highest aesthetic standards be applied by all those performing this procedure.
I am excited to see how automation can assist surgeons in all areas of plastic surgery, not just for the treatment of hair loss.  As the practitioners of our craft, we have the opportunity to benefit from these advancements, but at the same time have a responsibility to our patients and our reputations to be sure that these advancements are embraced for the proper reasons, and continue to help us, not replace us.

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Miami Facial Plastic Surgeon