Robot-assisted hair restoration LA Times Article

[gillenator]

Guys, trust me, the difference between 1 mm and .95 mm is not that much in the right hands. A manual extraction with a .95 mm punch however can potentially show more scarring, and do more collateral damage than a 1mm robotic punch precisely placed.

The real issue IMHO is that the potential collateral damage done with manual extractions far exceed the potential damage of robotic extractions which IMHO are today now far more accurate. Why? You have more control over the torsion, traction, and compression issues that vary quite a bit between the proficiencies of various docs' skill levels when they manually extract.

Yet I do still agree that more refinements and experience have a ways to go and yet we must not forget the element of potential transection of the grafts and why the open-ended risk of manual extraction skills varies throughout the industry between the doctors.

That is why the yields with manual FUE still vary to this day.

[John P. Cole, MD]

if you have poor hands, you should use a robot or just not do surgery. if you have great hands, this robot cannot match the results of that physician. One day, they may improve it so that it meets the quality of care that i would expect from FUE, but today, it is far below the capacity of a quality FUE surgeon.

This robot is cutting grafts with a 1.2 mm punch.

There are very few results with this robot.

The robot has a transection rate of 8% probably from the sweet spot of the donor area.

In general, the IAHRS is supposed to recommend only the best physicians. This robot is far below the quality of work you can expect from a top notch physician with far better equipment.

[Follicle Death Row]

1.2mm diameter? I thought it was supposed to 1mm. Am I missing something doc?

[topcat]

Gillenator I agree with you there is not much difference between a .95mm and 1.0mm punch. But I don’t think that anyone who has done any proper research would let anyone come near their head with a .95mm punch. Now if you want to compare .75mm and 1.0mm there is not only a difference the difference is drastic. I knew that a .75mm punch was critical 7 years ago along with many others.

Let me ask you a question. Would you be willing to let this robot extract fue’s from your face with a .95mm punch. If not why would you expect a patient to accept having it used on their head. If it advances to smaller punches and the transaction rate is as low as a skilled surgeon that that is completely different. Until that time you have a moral obligation to fully educate the patient of the different methods and punch sizes.

Patients misunderstand press releases and can easily be influenced. No different than the recent caller that couldn’t wait to jump into the chair yet knew absolutely nothing about the specifics.

I suggest patients choose any doctor they like but make sure he/she is skilled with a hand punch and that punch is .75-.85 it has a proven track record in skilled hands. If you want to use a robot than wait until it is proven over years and evaluate the donor areas.

[topcat]

Somebody please tell me that the patient that will be having the upcoming Youtube ARTAS procedure has been fully informed of punch sizes and the possible consequences of using a larger punch in regards to visible scarring. Speaking from my own personal experiences over the years I would say that if there is one thing I could focus on that pisses me off the most it is the fact that those that were in a superior position of knowledge failed to share that knowledge with me as it was to their advantage not to and to be quite honest I have hardly even complained much about these doctors. I have just licked my wounds and have moved on. But I will do whatever I can to prevent it from happening to others.

This patient deserves the courtesy of being fully informed. If he then chooses to have the procedure knowing all the information it is better for everyone involved. This does not only apply to this robot but to all procedures.

[topcat]

After listening to a caller phone into a recent broadcast I was really surprised to hear how enthusiastic the person sounded about getting into the chair and having a robot perform fue on him. The patient clearly does not understand the concept of punch sizes and how diameter numbers are so deceiving. It is my understanding that the robot is using a diameter that is slightly larger than 1 mm but for this example I will use the 1 mm figure. Now when you hear the number .75 mm it does sound smaller but in one’s mind it doesn’t sound like much of a difference.

I knew for a fact it makes a huge difference and that was at least 7 years ago. But I do find it amazing that so many really don’t seem to understand. Maybe because outside of working in the night club business I have plenty of trade experience thanks to my dad putting me to work in the factory at 14. But something happened recently to me that might make the point much clearer for those that still do not understand. I know punches have been presented on the forums but they do not really provide a good example.

I bid on a job recently that required a catch basin to be tuck pointed. For those of you who do not know what that is it is basically a sewer where all the kitchen waste water goes to keep the grease out of the main sewer line. So yes I was going to get into a sewer, some of us do real work….lol….Anyway the sewer opening was not standard and the diameter was only slightly smaller, but this had a huge affect on the overall size and I realized I could not get inside and if I did I could end up trapped, so I had to refuse the job. It also gave me this idea of showing others what does a hole that is 75% the size of what we will consider hole at 100% looks like on a larger scale. When viewed this way one can easily understand why using a 1mm punch is not a good idea when smaller punches are available to those skilled at using them.

In the picture below the circle to the right is exactly 75% of the one to its left, quite a difference.

[Follicle Death Row]

Good example. A 1.00mm diameter punch is almost 78% bigger than a 0.75mm diameter punch in terms of area. Maybe if they gave the punch area instead of the diameter people would understand better what we're dealing with.

[gillenator]

topcat,

Thanks for your comments. My previous point was to simply distinuish the fact that using a smaller size punch in itself does not mean less invasiveness nor less collateral damage. We need to be just as concerned as to what is happening below the surface and to the neighboring FUs adjoining the extraction sites. Clearly I am not advocating the primary use of 1mm plus size punches for the record.

The industry as a whole has made some progress in the number of HT surgeons learning and developing their proficiencies (skill and instrumentation) with FUE whether by manual or robotic methods. And there are more doctors performing manual FUE with decent results using a combination of punch sizes. You just can't extract every FU with the same punch. One size does not fit all. Let's not forget that the FUs vary in size and spacing between patients. In addition, some patients with a high degree of coarseness have multiple hair bearing FUs over 2 hairs. They may have 3, 4, or even 5 hair bearing FUs that cannot be extracted with a .75 size punch without transection no matter how skilled the surgeon is in manual extraction.

It is not necessarily immoral to use a 1mm size punch if avoiding transection. For example, african-american patients can have such tight curl to their hair which many times protrudes into the dermis layer. Transection can be even more prevelant in situations involving tight curl characteristics. However if the entire procedure is being done with 1mm plus sizes, then it better be justfied in that particular case. Again to imply that .75 is the proper punch size for every case and every patient is irrational IMHO, no offense.

Sure, either method will have its drawbacks whether robotic or manual. And I also agree with the statement that anyone that does not have good hands should not be doing FUE. I will take it a step farther and state not doing any cosmetic surgery at all.

And no I don't think that robotics have arrived to its fullest potential yet and ready for everyone. IMHO, it has opened an entirely new method of harvesting hair that we did not have even 5 years ago.

And yes I do agree that we have a responsibility to inform patients of both benefits and risks. All patients need to be aware of 100% of their options including non-surgical methods, and at the same time they need to take responsibility to inform themselves adequately whether it involves surgical hair restoration or breast implants.

And no offense but I do not think that it's fair to compare a facial scar to one hidden by hair in the back of our heads. It's because guys like myself are willing to hide a scar in the back of our head to have hair in a high visual impact area, namely our hairlines. I know myself like many men have accepted the fact that we may never be able to shave our heads again. I am okay with that to have my hairline back.

You would be shocked at the number of times that I personally have sent patients back to their homework who clearly are not ready to make an informed decision.

One last statement. We do not have enough yield results yet from either side of FUE, both manual and robotic methods. Time will tell. At least there are responsible reputable surgeons at the robotic helm. If a patient does not make a good candidate for this type of surgery, we simply need to tell them and then inform them of the other options available.

Thanks for all of your contributions and insight!

[topcat]

I think it’s fairly well known that the ideal punch seems to be in the .75-.85 range. A four hair graft can be removed using a .75 punch from all the evidence I have seen over the years. The problem is the majority of doctors trying to perform the procedure with these small punches fail miserably. And so we get into a case of semantics and all this talk about high transections rates when in fact all that is true for the majority of doctors. But I am specifically speaking of the minority of doctors, big difference.

You stated we don’t have enough results from fue manual or robotic. It’s hard for me to take that statement seriously. There are plenty of results out there by doctors that know exactly how to perform the procedure using a small manual punch and it is long tedious work. Where exactly are you looking? I can’t even believe that you wrote that statement.

Your comment about comparing beard fue and strip scars I don’t quite get. I am speaking specifically about fue. If someone chooses to have a strip procedure to harvest larger numbers I see nothing wrong with it.

I think if you go back and look over the history and the results you will find a substantial amount of postings with substance but if you prefer I can copy and paste a few to this thread.

Don’t take this personally because it is not meant to be a personal attack. What I see happening in this industry often angers me and I make a point of doing my best to help change it. I enjoy this forum and listen to the show.

Something I feel very strongly about regardless of the industry is that those teaching, advising, or professing to others actually walk the walk as opposed to just talking the talk. I mean some of these clinics remind me of an obese man trying to teach me about fitness or a homeless person teaching me how to acquire wealth. It means nothing to me as I want to see the proof. There are only a few experts in the ht industry performing fue. I have read their writings, listened to them speak and most importantly I have seen the proof.

[gillenator]

Listen my friend. You have not seen enough FUE cases to make those concrete judgements but we all are entitled to our opinions. I have seen patients that have such large hair groupings of 4, 5 hairs and FUs that a .75 -.85 mm punch would greatly damage.

Your point that .75mm is the order of the day implies that everyone has identical hair characteristics and that is simply not true and I wonder where and why you would make such a "general implication".

I do agree that there are few surgeons doing it compentently but there are more than you think, and the FUE field is growing rapidly. I know that because I see examples from an entire cross section of FUE work world-wide. It is not the norm, yet one of my stronger points was and still is that one size does not fit all situations. A "range of punch sizes" are required. Heck I'll be the first one to advocate the smaller punches "IF" they do not present higher transection risk to that "particuliar patient". I mean is it better to risk transection over punch size? Give me a break. You're talking too general in terms and grouping everyone togethor from observing your comments. And speaking of groups, I trust you are familiar with FUGS and/or MUGS? You are implying that a .75mm or even a .85mm punch can safely extract them? Excuse my expression but "ARE YOU NUTS?" Sorry if that was offensive, but I mean what can you be possibly be thinking? Have you seen these larger hair groupings in multiple patients? I have and that is why I am emphatic that one size does not fit all situations.

And I have seen hundreds of FUE cases over the past 8 years now and have seen plenty of patients with above average hair caliber and some do have FUGS and MUGS. Just how do you propose that these type of FU groupings are extracted with the smaller punches that do not even come close in periferral size to remove a FUG or MUG without damaging them or transecting them? Their diameter size (periferral) can exceed .75mm! and the punch does not even encompass the FU to extract it safely and intact.

Further, you do not ever mention the potential dangers of using smaller punches in those situations where transection potential is imminent unless you increase punch size for that larger FU, FUG or MUG. So is punch size then more important than transection considering we all have limited donor? If hair is transected than you have defeated the very reason that the patient got in the chair to begin with! The number one reason that FUE has poor yield is due to transection!

Because of that, you then are indirectly implying that every patient has identical FUs, identical coarseness, and you completely blew off my point about the patients with tight curl, high caliber hair characteristics! Why? Do you understand that the spacing between hair within a multiple hair bearing FU can vary? They are not all the same spacing either. Why do you not consider that in the equation and not comment about risk of transection?

Sorry friend, there is a huge difference between reading patient posts and the real world denoting the phisiological differences between individual patients. Yet I see it day in, day out. You are reading a very small sample. Yet you state that you base your opinions from what you read in the forums exclusively. Think about that for a moment and you will realize that you are getting a minority opinion.

And don't forget about the higher number of cases that you know nothing about simply because most patients don't post their HT story strip or FUE. That's just the reality of it.

And please don't think I am in favor of either method or specific sized punches. I am only interested in patient safety and satisfaction.

And how you do not understand my point about preferring the scar in the back of my head verses my face is beyond me. I prefer not short hair so the length in the back donor zone adequately hides my past strip scar. That's my preference as an individual patient, not yours.

We both have our opinions. Again I wish hair could be harvested without any scarring whatsoever, FUE or strip.

But I have to say as respectfully as I can, I have far far more expereince and exposure to HT surgery and the instrumentation used to base my opinions.

And again if all FUE could be done "safely" with a .50mm punch, I would be the first to say YES. But you and I know that it cannot be done safely. Yes, .75mm may work for a larger percent of FUs, I would agree with that statement but not that one size fits all extraction sites/situations.

Take care!

[topcat]

I am fairly certain if you ask the top fue doctors in the world of which there are less than a handful they would say that the .75-.85 would suffice in most cases. Sure I would agree with you regarding afro hair and coarse Asian hair, maybe I should have been a little more specific. I meant in the majority of cases which are not afro hair and for the most part of average thickness. But you make a good point and hopefully clinics are letting these patients with extremely curly or coarse hair know they are not good candidates as a larger punch would be needed and personally I would advise against it.

I gave a range of .75-.85 but preferably the smaller punch would be used unless it was necessary to move up in size, again maybe I should be more specific. I tend to write fast and should slow it down as sometimes my message might be confusing.

I do not agree with you that there are more competent fue doctors in the world than I have stated, just my opinion.

I am familiar with MUGS and FUGS and I have had the unfortunate experience of having multiple MUGS placed into my hairline. I don’t mean to offend here but acronyms to me are just a load of horsesh*t. They are used to make something sound more complicated than it really happens to be. No different that these multiple acronyms for FUE. Let’s see we have FIT, FUSE, SFET and whatever else anybody just decides to come up with. It’s just part of what makes this a horsesh*t industry in my opinion, just a little too much deception.

The number one reason why FUE has poor yield is too many doctors are trying to perform it but simply do not have the patience and skill. So they look for ways to speed it up or somehow make it easier. Most of the damage is being caused by these doctors trying to use motorized devices exactly the opposite of what you have stated but that is my opinion. It’s not a coincidence that all the top FUE doctors with the highest yield have one thing in common, manual extraction.

I’m not sure what your point is with the strip comment you lost me there. I asked if you would be willing to let the robot extract a fue from your face using a .95 punch to make a point. It’s too large and would likely leave a white dot no different than the scalp. So why use it on the scalp if a skilled doctor is available that can use a smaller punch lessening the chances of scarring.

Let me add that I do not work in this industry so I can understand since you make your living in it you have strong feelings. I have equally strong feelings as I have learned over 25 years just how corrupted it is with what can only be described as top heavy in greedy psychopaths. Those that are ethical in this business make up a very small percentage in my opinion.

I will continue to state my opinion as it helps to keep the industry honest. I received 1 pro bono offer by a clinic that I happened to have thought was the best in the world at FUE. I respect that they reached out and gave me a hand up because it is my personal philosophy. My words might sometimes seem harsh but I would be the first person to extend my own hand to help someone in need and if you read my story you would know that I gave up half my pro bono offer to 2 other patients in need as I couldn’t leave someone behind and I have paid for the additional procedures.

I am a person of modest means but I have every intention of getting the funds together that are equal to or greater in value of that first pro bono offer and somehow passing that on to another repair patient in need sometime in the future. That to me is helping patients and I would like to see others who work in the periphery of this industry do the same.

[topcat]

This an past BHR posting that someone recently revived on another forum. I believe it was another clinic but I will cut and paste it here as it might be helpful.

Follicular Unit Extraction/Donor Management & Punch Size



The safety zone for FUE can be measured and sectioned in to three areas; simply both sides and the back, then the total surface area calculated. The density is then measured in each area and an average overall density taken using a magnifying densometer; the natural FU groupings measured and an average taken including miniaturisation of hair in the donor safety zone.

The number of grafts available for extraction can then be calculated; taking into consideration not over harvesting and leaving the donor “moth eaten”. To ensure not to over harvest there must be a limit to the number of FU that can be removed per cm2; removing much more than 27% per cm2 will noticeably thin the donor area and potentially cause obvious visible scarring over a large area of the donor.

The punch size used will affect the number of FU that can be safely removed; incorrect punch can increase transection of the removed FU, damage surrounding FU cause larger and more visible scarring. With a small punch there is a risk of transecting the FU being removed if the group is too large to be encompassed by the diameter punch, therefore cutting the FU causing the loss of a hair from that FU and reduce the total hair numbers placed. When a large punch is used it has the possibility to cut into an adjacent FU if the density of FU is high. This either means taking two genetic groups at the same time or splitting and transecting one of them, for example two 2 hair FU or maybe a 3 hair and a 1 hair in the same punch OR maybe taking an intact 3 hair FU and dissecting another and a likely conclusion is killing a hair and traumatising the surrounding hairs.

Included in this problem is the pattern of extraction; to use a large punch and over harvest in an area will leave obvious thinning and density changes in the donor; this will result in the donor potentially being too thin for further extraction even from a relatively small number being removed; say 2000; this has been called “hairless areas” but simple is larger scarring be it obvious or not OR overharvested areas.

The larger the incision made into skin has the potential for greater scarring; obviously the skill of the incision will have an impact but simply a larger hole is made in the skin tissue and more fibrosis is caused and greater pigmentation alteration; thus making the scarring potentially more visible and larger. If the larger punch is used and the extraction pattern not monitored to approximately 27% the donor can visibly lose density, because a “moth eaten” look on the scalp and make it almost impossible to harvest any amount of grafts.


Below is a section of a report made with Dr Bisanga a few years ago discussing the FUE procedure and the pros and limitations; it shows the effect of a 1.1mm punch on the surrounding FU and smaller punch on larger FU groups; also that a .75 mm punch can surround a 4 hair FU without transection and thus cause less potential scarring.

Follicular Unit Extraction when the limitations are adhered to can be an excellent form of hair transplant. The limitations are the use of the correct punch size, not to extract a combination of FU in one punch; not to over harvest the donor to extract more FU and leave the donor thinned.

[gillenator]

Well now you're making more sense being more specific. And you know I do agree with most of whay you are stating.

Again, I see far more work than you do and one thing for certain is that you are dead wrong about there NOT being more and more doctors competently doing FUE. And the field is growing in North America unlike anything else that I have seen in the past.

Sure it's true that the best results right now are being done manually but SO ARE THE WORST RESULTS. You forgot to mention that or possibly I missed it in your past posts.

As I said before, robotics have not yet arrived to its fullest potential obviously and also why there are far more docs doing it manually. We need to give both methods more time for these surgeons to develop their proficiencies and potential.

And thanks for putting up the BHR post which confirms what I have been saying and also to some extent what you are saying. Actually you have made many valid points and some which I felt need some fine tuning.

Listen, FUGS and MUGS are not just some slick terms for FUE as you seem to be implying, they represent large FU "groupings" or multiple unit groupings.

And I do think where we all agree is that yes in most cases of FUE extractions, patients with average FU sizes and hair characteristics can have a very large percent of their FUs extracted with the smaller punches. And thank you for finally acknowledging that the best approach is to match punch size to the FU so not to transect or destroy the hair.

Let me say in conclusion that I very much respect and appreciate your giving up a pro bono to another patient. And you have been a very big help on these forums which I think that I have acknowledged before. If not, please allow me to do that now.

Lastly, no I am not "employed" in this field. Each doctor at my signature pays a nominal amount to me as an independent advocate to operate my office whic is open to any patient. But I don't get any paycheck for what I do, I don't earn any commissions, no bonuses, no other compensation whatsoever. I can faithfully and honestly tell you that I have never in 31years ever charged any patient one penny for my help. And there have been more than a few that I have put much effort and assistance in getting corrective resolve to their complex cases.

I am also a four time HT patient still battling hairloss myself. So please don't insinuate that I am in this for the money because I am not. I am here to help other hairloss sufferers just like myself and you topcat.

At the same time with my background and knowledge over the past three decades, don't you think that I could make lots more if I chose to do so? But I don't choose to start my own website and hairloss community, nor do I choose to work as a consultant, salesperson, whatever.

I am semi-retired and actually serving my community as a "volunteer" if you really want to know. I do not get paid for that either which takes up a fair amount of my time especially in hospice care. I am also a terminal lung cancer survivor living with one lung now. But my passion like you has always been people because people are what matter and I truly hope my posting history in these forums over the years prove that.

Anyway topcat, you're a good guy and hope you stay around! Again thanks for your insights and contributions my friend.

[fitness-man]

didnt have time to read this whole thread but I am going to speak on REAL WORLD EXPERIENCE.

I just got home from Dr. Harris office and he performed a test on my head to make sure I was a good candidate due to my mix nationality.

Thankfully I am good candidate

My head is still numb

[topcat]

Okay we can agree I do believe a punch range is best but I believe the punch range to be between .75-.85 If the situation calls for a larger punch then the patient should be advised and also have a clear understanding of the possible implications of using that larger punch.

As far more doctors performing fue at a very high level I would have to still disagree with you. I also believe results are not only technique related but also doctor related so of course I would believe there are plenty of doctors using a hand punch and are doing a tremendous amount of damage but that in my opinion is skill related.

I wasn’t trying to imply that MUGS and FUGS were slick terms for fue but simply that the use of acronyms can sometimes be used to confuse or simply make something sound more complicated than it happens to be and it’s not specific to the hair transplant industry.

As far as how much you make or can make from this industry I have no reason not to believe what you wrote. Speaking just for myself I can honestly say I have made zero nor do I care to make one penny from this industry. I understand that sometimes I might come across as very harsh in my opinions but we are all presenting what we know from our own unique experiences.

Gillenator you sound like a good guy so please do not take my comments as personal attacks because that is not their intention. I hope you have gotten past your health issues and if I can be of any help I would be more than happy to offer up what I know. Something I have learned in life as I have gotten older and we are probably close in age as I will be 50 soon. Diplomas, awards, designations etc does not necessarily make one and expert and this is not directed towards you. For me it’s more important to show the proof and let that do the talking.

We can disagree and state our opinions and I wouldn’t take it personally. It’s good for forum members to read and in the process everyone learns something.