Does Size Matter in Hair Transplant Cases?

Large volume hair transplant cases present both obstacle and opportunity for the hair transplant surgeon. On the one hand, there are unique challenges inherent to larger cases, especially when follicular unit extraction (FUE) techniques are employed, including the potential to over harvest the donor site. This can leave patchy bald spots on the back of the head—the dreaded “moth eaten look” that every patient naturally wants to avoid. As well, in cases where more hairs are extracted, the grafts are typically outside the body for a longer period of time, which may have an effect on viability.

Follicular unit transplant (FUT) approaches may offer a more facile path for doing larger cases; however, for patients interested in wearing shorter hair styles who do not want a linear scar, FUE is a far better option. The downside, of course, is that FUE procedures require precise and consistent extraction of follicles, from the first hair to the last. Thus, although there is really no set definition for what constitutes a “large” versus a “moderate” or “small” hair transplant case, most surgeons have a cutoff for how many follicles they will extract in a single session—for most that number is around 1,500 to 2,000 grafts. One prominent reason for doing multiple harvest sessions is that if manual techniques are used, fatigue can set in, with attendant risk for decline in harvest quality.

Large hair transplant cases, though, also offer the potential to help patients transform their appearance and confidence. Ultimately, hair transplant procedures can empower patients to feel better about themselves, often giving them a new outlook and optimism. In my experience, men with larger patterns of baldness are eager to find a solution, and when we can offer them the same kind of excellent results we are able to achieve in smaller volume cases, it is truly a win for the patient.

Over the course of my career, I have continually looked for technology that can help me help patients achieve their aesthetic and cosmetic goals. I strongly believe that FUE procedures offer greater flexibility and precision for hair transplantation, but previously, there may have been a limitation on how many follicles we could safely extract in a single session.

The introduction of the ARTAS Robotic Hair Restoration System, however, has changed that paradigm. Now, because I am able to rely on the robot to assist in the most critical aspect of the FUE procedure, harvesting the donor, I can focus my attention where I feel it is best applied: using my skill and training to design a customized pattern and distribution for the placement of the grafts to restore their hair with a completely natural appearance.

ARTAS in Cases Involving Large Volume Extraction

I decided to adopt the ARTAS system in 2011 because I knew that automating certain aspects of the FUE procedure would allow me to maintain consistency of the harvest across a larger volume extraction. To my knowledge, during the early experience and clinical testing with the device, there were no cases where more than 2,000 grafts were harvested in a single session. However, it was not long before I performed procedures greater than 2,000, then 2,500, and finally over 3,000. The largest case I have performed to date is 8,000 grafts over 3 sessions.

As mentioned above, the greatest benefit of the ARTAS for hair transplant cases is that it helps mitigate physician fatigue during harvesting. The ARTAS uses a three-dimensional optical system to locate and harvest follicular units directly from the donor area; meanwhile, an intuitive graft selection algorithm analyzes the scalp with micron-level precision to select follicular units for harvesting based on the number of hairs they contain, producing greater hair density while leaving fewer scars in the donor area. ARTAS utilizes a two-cut technique in which a sharp punch scores the surface of the skin and then a dull punch dissects deeper into the tissue, thus avoiding transection of follicles. With these capabilities, and due to other relevant upgrades, the recently released 9x ARTAS system is capable of harvesting up to 1,300 grafts per hour without sacrificing safety or risking over harvesting.

The ARTAS is also fully controllable, allowing the surgeon to immediately adjust important procedural parameters including puncture depth, coring depth, and angle at the harvest site. This has obvious advantages in cases where the robot is used for the entire extraction; I have also found that it has great benefit in situations where I am performing a combination of robot and manual FUE. In some situations, particularly when targeting a large volume of extraction, I may choose to feather or go lower in the donor zone toward the neck where it is harder for the robot to reach compared to manual techniques. In those kinds of cases, I can let the robot do the bulk of the work and focus on the more delicate work myself.

Any time we can offer the patient fewer surgeries with more dramatic aesthetic change is a good thing, and the ARTAS gives us a new way of doing just that. It still may be necessary to use multiple grafting sessions for a given case, but with ARTAS, there is potential to reduce the number of sessions, which gets patients to the goal they want with less inconvenience and discomfort.

Combined Manual and Robot FUE: A Positive Feedback Loop

The ARTAS Robotic Hair Restoration System is not intended to replace or substitute for the input of the skilled hair transplant surgeon. Rather, ARTAS is a tool that helps in performing our procedures with greater accuracy and consistency. There is no denying that quality results are achievable with all-manual FUE, even in cases where 2,000 or more follicles are extracted in a single session. At the same time, I find that the ARTAS enhances my ability to consistently extract quality grafts over the course of the procedure, sometimes in unexpected ways.

One of the benefits of having the ARTAS robot is that I can use feedback from the robot to better understand how I will approach harvesting by hand in combination procedures. As the robot scans the scalp to determine the best angle of approach for a cut, I can observe its actions to map out how I will similarly approach the scalp during the manual portion of the session.

Because the robot streamlines much of the procedure, incorporating specialized manual techniques and approaches to complete hair restoration becomes much more viable. For example, I can offer patients the potential to selectively “over harvest” a donor zone to achieve a greater graft yield and use micropigmentation to camouflage any white spots in the donor zone. Fundamentally, providing these kinds of choices gets us closer to offering truly customized hair restoration options for all of our patients.

There are subtler ways to increase graft yield with the ARTAS. When setting the parameters, the surgeon can opt to perform a second pass over a donor area, for instance, preferring multiple-hair follicles on the first pass then coming back over the same grid to capture the single-hair follicles. That kind of maneuver is much more difficult to perform by hand, and using the robot helps maintain safety as other parameters will help maintain adequate spacing between follicles.

My Protocol

In my clinic, success in large volume cases hinges on proper patient selection and patient preparation. Ideally, we only want to harvest between 15% and 25% of the zone in a given session, so you need considerably more square centimeters of donor area if an FUE procedure is being used.

Particularly in larger cases, I like to bring the patient into the clinic the afternoon before the session to prepare him for the procedure the next morning. During that encounter, I will map out where I am going to go with the recipient sites and I evaluate the donor zone. I also shave that area and, if necessary, dye the hair the night before—I find that doing this eliminates anxiety the next day. In larger cases, all the steps start to add up, and the longer the patient is under potential duress, the higher his anxiety can get.

Courtesy of Craig L. Ziering, DO

Left, Middle: Periprocedure images. Harvesting for what was eventually 8,098 grafts in three sessions: 3,736 in the first, 2,936 in the second, and 1,426 in the third. Right: Micropigmentation was used to help mask the appearance of white dots; 2 months after third session, the donor site is nearly indistinguishable from the rest of the scalp.

During the prep session, I may also make the incisions at the donor site for the majority of the grafts, which has a couple of benefits. First, it gives me insight into the actual number of grafts I will need to harvest. Second, as this step is typically completed after grafts have been removed and before they are placed, performing this step the day before reduces the out of body time for the grafts. Third, making the sites the night before may stimulate the release of growth and healing factors that ease the patient's recovery after the procedure.

If there is a downside to the prep day, it is that you have to numb the scalp twice, but in my opinion, it is worth the trade off in larger cases. We have found that recipient sites that have been prepped the day before often stay open slightly until accessed on procedure day, which to our eyes, reduces bleeding.

Conclusion

If I were teaching a completely uninitiated surgeon how to perform FUE hair transplant procedures, I think I would turn on the robot and let him or her watch what happens when you adjust various depths, angles, and spacing during a harvesting session. The robot truly does what the human hand can with greater precision, reproducibility, and consistency.

Getting assistance with important aspects of harvesting, however, is only one small part of how the ARTAS robot changes the approach to hair restoration. Indeed, because I can more or less delegate meticulous, energy-draining work to the robot, I am able to complement my approach to larger cases with use of manual techniques and approaches. Some patients appreciate that we are using the latest technology, and several of our patients have sought us out because we offer robot hair transplant procedures in our clinic. Yet, high technology really builds on the natural skills of the surgeon and expands the potential to customize the approach to hair restoration.

The statements, views, opinions and analysis concerning Restoration Robotics and its technology which are expressed in this article are solely the author's and are not intended to reflect the statements, view, opinions and analysis of Restoration Robotics.