The Birth and Development of Robotic Assisted Hair Restoration Surgery (ARTAS) – Dr. Arthur Tykocinski

The below article was written by Dr. Arthur Tykocinski who is a member of the Coalition of Independent Hair Restoration Physicians.  You can also view his website by clicking here.  You are also encouraged to click here for a free consult with Dr. Tykocinski.

Whenever I imagined a robot working with humans, I thought of that friendly maid on the Jetsons and also on that robotic treadmill she entered every morning and exited showered, dressed and styled. Later my reference began to be those intelligent and friendly robots in the “Star Wars” series, performing complex tasks and with artificial intelligence. Well, mine, for now, is not that smart.

And as all ARTAS must have a name, to facilitate communication within the company, mine is called R-2, in homage of R-2-D-2, the friendly cybernetic hero of Star Wars. Since the beginning I knew that the robotics technology was still evolving and that in the beginning its operation had been rather inconsistent and with several failures. That was what was heard by word of mouth in congresses.

It was also clear there was tremendous financial interest in this exponential follicular unit extraction (FUE) market: companies wanting to sell equipment and physicians wanting to get in on that, still reserved, market. In addition, the FUE procedure may be very attractive to the doctor, because the sessions, though smaller and more costly, require smaller teams, thus providing a higher operating margin.

It happened as it did and the FUE exploded worldwide. As the learning curve is steep and procedure requires greater physical preparation and to be performed by the surgeon, there was an initial resistance to migration, especially in the case of the Americans, accustomed to delegate their teams positions.

This scenario offered, in a certain way, a reserved market those who initiated and a great opportunity to ascend to a new status, which in fact occurred. As they created this whole glorification of the FUE, they tried to bury a team of excellent surgeons, the world over, ditching the common. Thus create a new class of gods and a new focus to hair transplant.

It worked to a certain extent. Then came the entrepreneurs offering a dangerous business idea: sell a product, which includes not only a marketing plan, but also trained technicians who operate the equipment for the surgeon, allowing doctors extraneous to the area to offer hair transplant instantly.

Of course this model could not only collapse the FUE practice, but hir transplant as a whole. The ISHRS, attentive, took measures to curb this dangerous practice, discouraging such practice and moving away from these companies. The US Robotics proposal, however, seems to be different: to develop a tool that facilitates and in certain part automates the FUE, making the withdrawal easier and more consistent.

But to say that it does everything alone, would not only be a tremendous exaggeration: it would be inaccurate. The robot is just a tool, although highly sophisticated, which follows the pre-established parameters and with assisted and controlled autonomy. Therefore, whoever operates it should know what he is doing. The entire surgical planning, correct indication and the surgical act, is done by the surgeon.

But the robot has certain autonomy to perform the FUE incisions within a restricted area and defined by the tensioner that is positioned by the surgeon on the scalp. The robot recognizes its edges and limits and in this restricted area that it performs a sequence of incisions, determines the hair angle, the depth of the incision and dissection

During this process, the surgeon can adjust these three parameters defining criteria on the systems automatic adjustments. But the adjustments are likely to be minimal, especially regarding capillary angle, after all a sophisticated system by images is more accurate than the human eyes.

What varies most is the depth of the incision and dissection, but even then, only small adjustments when changing areas. Even so, we must be vigilant during the entire process. This idea that it does everything alone, for now is not reality. But the system impresses by the consistent quality of the follicles, ease of extraction and centralization of the hair in the graft removed.

The centralization is really consistent, ranging little, when compared to those performed by human hand. Not that this is the only determinant of quality, but it shows the potential of a robotic system. There is a learning curve, but much shorter than the FUE manual/motorized. Those who already do or have some experience with the FUE “human”, will find it very easy to adjust and the process as a whole.

I have my doubts about the inexperienced,  if they would not degrade the procedure as a whole. What determined my decision to acquire a robot was the fact that the FUE came to stay and without it the activity spectrum of hair transplant, today, would be limited. Also because the new generation of ARTAS showed consistent results and to be “ready to use”.

In addition, I wasn’t attracted by the smaller FUE sessions and found the larger very tiring, even so, smaller than the FUT. I saw some of the best in the world operating the FUE, and I realized that even they may have inconsistent results and fatigue. I think it’s inevitable that a robot can do a better job with something so technical and repetitive as the FUE.

At the moment it is already better than the majority of surgeons. Yet it’s not as fast as a  highly capacitated swift human being, the cream of the FUE. But I believe it to be a matter of time. The way that the technological advances have been quick, I think that in a few years it will be better than the best of the best. If not this company that we have today, a future one. But there’s still a long road ahead. Nothing guarantees that it will be soon.

My Training: training includes theoretical part, which is fast and the practical part, which is made in a growing: We started with a case of 400 grafts, after 600 grafts, 1000 grafts and closed the training with a session of more than 2000 grafts.

Positive: – I received a visit from an international engineer and another location which guided the preparation for the installation and then received the equipment and performed the complete installation and tests. They’re impecable. – During the week of training, we relied on the company’s international engineer, an international training coordinator, two surgical assistants and support of the national representative.

Four of my teams assistants and I received training. All extremely helpful and polite. They tried not to interfere with my routine. Had a very positive attitude. – Dealing with a robot is interesting. It uses a sophisticated algorithm to determine the parameters and will automatically adjust according to the location and the result of their incisions, that shoots pictures of each one.

Graft quality, compared with the punch cutting edges that I also use, has more protection, in general, all around the follicular units – easy to remove the grafts. Few times more adherent withdrawals are necessary. In general are well loose. – Different from the human eye, it sees in infrared and can see through a little blood.

Negative – what I thought was worst, was the systems graphical interface. It is not intuitive, it’s confusing and has badly drawn icons. Maybe for being a Mac/iPhone user, I was getting used to a self explanatory interface. But nothing has changed since the beginning. I would recommend starting from scratch and building everything again.

Only 1mm is featured in Brazil. We hope to approve the 0.9mm. – If you only use the Arta there will be some spaces between the “grids” and the edges. A manual wrap/motorized “human” finish is recommended. – If you start and find that it’s not working, you have to pay royalties anyway. –

The robot sometimes returns to places already incised and must be stopped. A failure to be repaired. – In skin with a lot of textural variations he gets very slow in these stretches, with rates of larger transection. In these cases the robot shows its limitation. Having returned to the little FUE Workshop in Istanbul, it is clear that he is not better than the best in the world. But what about the subject? The whole world gets amazing results with FUE? Always?

Well, in the workshop, two surgeons had difficulties in one of their cases, with greater transection than usual. I suspect that many that relate to obtain minimum transection, if they were audited continuously, would show higher numbers. We tend to “forget” worse results and any one can have a difficult day. And remember they are the best in the world. And the other mortals?

For now, the robotic surgery is a secure beginning to the FUE, and well less tiring but much more expensive. Is it worth it? I still wonder…. we’re yet see the final results; the quality healing in comparison with the technical manual/ motorized in same cases; the company’s support, maintenance costs (sometimes hidden) and the directions of technology/Company

Thus, as in technology, the example of the laser, that in certain areas of medicine dominated, but in other was banned, the robotic surgery has yet to have its role defined. Only time will tell.

I believe that technology will evolve much in coming years, after all, it’s a technical movement, precise, variable and repetitive, based on many numeric parameters, technicial, where a machine has everything to adapt better and be consistent. Perfect for automation.

Different from capillary art, where the sensitivity and the human touch make all the difference. Apparently, we’ll be needed for some time…

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Bill, Managing Publisher