Proceed with caution #1. Robot FUE depletion with no growth.

[Dr. Lindsey]

So today we saw 2 poor results that get talked about frequently.

First up. Robot FUE with virtually zero growth and donor depletion. This medical professional came in for a visit today with a history of 2500 robotic FUE's done in 3 hours. He has VERY wispy hairs...to the point that I would personally have not offered FUE due to the weak fragile roots...like plants in the attached video.

He ask that I not photo the front but allowed me to photograph the donor area which is depleted. I offered him a strip repair. He's a bit gunshy...as is appropriate and hopefully will get back to us.

Its easy for naysayers to believe some of us just don't want to do FUE. Its not that at all....its just the consumer (YOU) need to understand that 1. Robots aren't foolproof 2. FUE never works as well as strip, particularly in fine hair and 3. Even doctors get fooled by marketing.

The video showing FUE and plants to discuss root stress is:

http://www.youtube.com/watch?v=lAq7sWpdxmU

Dr. Lindsey

[gillenator]

Regardless of the method employed, it really comes down to the skill of the surgeon. That's the bottom line.

[HTsoon]

Regardless of the method employed, it really comes down to the skill of the surgeon. That's the bottom line.

Except that with Artas or robotic FUE there is no surgical skill that is required, that's why I advise against any form of Robotic FUE to inconsistent.

[J_B_Davis]

No disrespect Dr. Linsey, but that donor looks a hell of a lot better than most FUE donors I've seen on these sites. You can barley see any scaring. Perhaps the doctor concentrated too much in certain areas, but the scaring looks great. Seems as good if not better than most strips. Just my opinion.
@HTsoon, I would assume the artas robot is much more consistent than doing FUE by hand. I'm not saying it's always constantly good, I think that depends on the clinic and how the robot is used, but looking at some of the more recent artas pictures posted by doctors on this site, I have feeling that some of the doctors out there are a little nervous that they might be losing an edge to technology some day.I think gillenater is correct in saying no matter the method it all comes down to the skill and judgment of the doctor and the people who work for him.

[JoeTillman]

Hi Dr. Lindsey,

I appreciate your post but there are a few points I feel compelled to address.

1. You said the donor is depleted. Maybe it is visible in person but the donor zone looks anything but depleted. In fact, aside from what appears to be slightly below average density the donor appears to be pristine and devoid of obvious concentrations of extraction points nor the scarring that would be associated.




2. 2500 grafts were done in three hours? Does this refer to the extraction alone or does it include the incision sites and placement? I suspect the former but even then I find it hard to believe that 2500 extractions were made in three hours. To extract so many would require blatant disregard for the patient in that all of the grafts would have to be taken from one area of the donor zone, most likely the posterior donor. With the ARTAS there is a grid placed over the donor zone and this grid must be adjusted and moved to the bilateral donor zone before it can continue. This takes time and would effectively make it impossible to remove so many grafts in only three hours. The only way this would be true is if all 2500 were taken from one area thus depleting the donor supply so much that the problem would stick out like sore thumb. Based on the photos and my first question, this does not appear to be the case.

The growth cannot be commented on for obvious reasons but I would highly suspect that the grafts were not examined carefully, much less with stereoscopic microscopes, to verify integrity.

1. Robots aren't foolproof 2. FUE never works as well as strip, particularly in fine hair and 3. Even doctors get fooled by marketing.

1. I think robots are foolproof. It's the programming that is not as is the case for those that write the software. This is a basic tenant of computing in general in that the machine is only as foolproof as the man that created it. Machines do EXACTLY what they are programmed to do short of any physical obstacle that may materialize. The shortfalls you refer to are mainly based in the programming. I would not lay down for an ARTAS today but it is getting progressively better. I don't think anyone can deny this if they are looking at the information available.

2. "Works" is subjective but with all due respect, comparing an experienced FUSS surgeon with a travel tech wielding a Neograft handle is not a fair comparison. I would pit some of my favourite FUE surgeons against ANY FUSS surgeon all day long and would challenge anyone to show a quantifiable difference between results.

3. Agreed.

[J_B_Davis]

All I can say is that this is the best advertising for the Artas robot that I've seen, If that's the way the donor looks like after 2500 FUE removed, then sign me up! Joe Tillman's description of the donor looking pristine is correct. I have never seen a strip look like that and I have never seen regular FUE look that good either. Like he was never touched. The skin looks completely healthy with practically zero white marks. Thank you for enlarging the pictures Joe, you can really see the detail.

[HTsoon]

2. "Works" is subjective but with all due respect, comparing an experienced FUSS surgeon with a travel tech wielding a Neograft handle is not a fair comparison. I would pit some of my favourite FUE surgeons against ANY FUSS surgeon all day long and would challenge anyone to show a quantifiable difference between results.

I can definitely agree with this, the only thing though is the best FUE surgeons don't use the Artas machine. I've really only seen FUSS surgeons and hairmills use the Artas.

[Dr. Lindsey]

First off....I've admitted for years I'm no photographer. IF this guy comes in and I can get pics in the procedure room lighting rather than a "quick snapshot" in the consultation room...maybe you'll see what I see in person.

Secondly, he has NO GROWTH. Well, maybe 300-500. He's a super specialized surgeon who got nothing. If he can get over being gun-shy and proceed..we'll have a nice trimmed down view of both donor and recipient areas. The recipient area showing nothing, in and of itself is warning enough. And on top of that, whether you can see it or not, his donor area is depleted and scarred.

IF this is the best ad for those machines...they are in trouble.

Lastly, I do agree with Gillinator. You can put a knife or a machine, or a football in the hands of anyone. But relatively few can get consistent good results or make the pros.

Dr. Lindsey

[JoeTillman]

I can definitely agree with this, the only thing though is the best FUE surgeons don't use the Artas machine. I've really only seen FUSS surgeons and hairmills use the Artas.

I think there are two points being discussed here. I agree, most of the recognized top FUE clinics are not using the robot but I also don't believe anyone is saying that the robot is equal to, much less better than, the current crop of top clinics. I know I'm not. I think the point of the robot at this stage is that if used properly it has the potential to make a stronger starting point for those that are not as experienced with FUE. It shortens the learning curve and helps to create a consistency that might not be possible earlier in one's FUE career.

When performing FUE we are looking for two factors to determine if it is worth continuing for the patient.

1. Punch size. When FUE doctors are starting a procedure they will usually do a few tests to see how small of a punch they can get away with while maintaining graft quality. With ARTAS the punch size, in the past, was prohibitively large and caused obvious issues that defeated the purpose of FUE to begin with. Today the software is much improved and the punch size has dramatically reduced to sub 1mm diameters. Once you get below 1mm then the problem of visible donor scarring becomes much less of an issue.


2. Graft quality. When the grafts are extracted they should obviously be inspected and sometimes even modified or refined before they are placed. If the doctor sees that the quality of the grafts are sub-standard then the procedure should be halted and the idea of surgery re-visited.

If one or both of these factors are not satisfactory then the surgery will potentially be considered a failure so it is up to the doctor to stay on top of these issues to make sure the end result is worthwhile. This is necessary regardless of which tool is being used, including all forms of manual extraction, motorized extraction, or ARTAS.

The ARTAS, as it stands, is a tool only and it is up to the doctor to use it properly or not. The ARTAS is not automatically going to deplete a donor zone by virtue of being an ARTAS. A donor zone will be depleted because someone used the ARTAS to take too much hair. The ARTAS is also not going to be responsible for poor growth because if the doctor was doing his job and making sure the grafts looked good then there should be no reason why a patient would have poor growth.

Keep in mind, Dr. Lindsey did not qualify his initial point #2 as being ARTAS specific...

2. FUE never works as well as strip, particularly in fine hair...

I disagree with this statement simply because I've seen too many FUE results to think otherwise. FUE certainly has taken a long time to get up to speed, to the point that it can be considered worthwhile, but my own thinking changed in 2013 when I got out of my little corner of the world here in Vancouver and started going to conferences again. This is when I started to see the bigger picture. I do agree that many cases of FUE are not as good as strip because of the curve of adoption. It is cheaper and easier to get into the field of FUE than to start out with FUSS and because of this lower threshold of entry into the market it has attracted a large participation with a lower skills set, not to mention a lower ethic. I predicted this would happen and I'm being proven correct as the overall FUE market is continuing to explode. I feel the majority of this explosion has to do exclusively with greed. 2015 alone saw Turkey reaching the 1 Billion dollar revenue mark from hair transplant surgery and it is all FUE. 2014 saw FUE reach parity with FUSS as far as overall usage and I'm positive that this year, when the 2015 numbers are revealed, we'll see it surpassing FUSS considerably.

I think it is a mistake to cast doubt on ARTAS being to blame, especially in the manner by which Dr. Lindsey has done. The blame for any problems lies with the doctor alone. We cannot determine what the problem is with the donor zone that Dr. Lindsey claims is so visible in person because the photos do not reflect the problem he references. I guess the same point about the ARTAS could be made about Dr. Lindsey's camera. The result is not the fault of the camera, but the operator (as Dr. Lindsey confessed ), just as would be the case of an ARTAS and the doctor controlling it.

[HTsoon]

I can agree with that Joe it makes sense, I guess Artas is better than an inexperienced surgeon, however, I've had only FUE and every FUE Doctor I've ever consulted with told me that if the Artas was better than them they'd buy 10 machines and be done with it, I still think both Manual punch and SAFE system is the gold standard for FUE. But no doubt like all things user error is usually at fault for poor results.

[JoeTillman]

I can agree with that Joe it makes sense, I guess Artas is better than an inexperienced surgeon, however, I've had only FUE and every FUE Doctor I've ever consulted with told me that if the Artas was better than them they'd buy 10 machines and be done with it, I still think both Manual punch and SAFE system is the gold standard for FUE. But no doubt like all things user error is usually at fault for poor results.

And that is the point, HTsoon. It is better than an inexperienced surgeon, which automatically improves the level of care. That alone makes it a viable option for some people and we can only hope those that wield this tool will do so judiciously and ethically. Some of that comes down to the training.

I think too many times people on the forums get caught up in the "who's the best" debates without realizing that they are talking about a 4 billion dollar industry. Realistically, I think that the vast majority of people that have hair transplant surgery have no idea who we're talking about in these debates and go to their local clinic. Patients will go to these clinics regardless and if they are inexperienced then I think having an ARTAS might help the patient to have a better level of care and better results than if the same inexperienced team tried to do the procedure via Neograft. Maybe it could be looked at being the lesser of two evils.

Another way to look at this, and this is for the benefit of anyone that reads this, is that if you reverse the scenario the outcome may be far worse. Look at what some "top clinics" use as their tools of choice. It may be the SAFE system. It may be a sharp manual punch. What would be the outcome if an inexperienced clinic used the VERY SAME TOOLS as is used by top clinics? Would the result be the same? Absolutely not. The ARTAS however is updated based on the success to failure ratio of each and every graft that is scored since it first started operating several years ago. This means that a hair transplant doctor, working on his first patient, at least has the experience of over a million extractions baked into the software of the machine so the experience level is immediately and quantifiably higher than had he just picked up his first punch and got to work. THAT is what makes ARTAS potentially a good tool to have on the market.

There was once a poster I used to get into regular debates with and he had this idea that doctors were obligated to tell their patients about better procedures if they were not offering it themselves. In other words, if a patient walked in to a clinic that used ARTAS and/or motorized punches he thought that it was unethical for them not to tell patients that manual punches are better. This showed me two things.

1. How naive he was about what doctors feel may or may not be "better". Would it not stand to reason that if a doctor felt another procedure was so much better that would be worth mentioning to their patient that they would logically adopt this procedure into their own practice? In other words, why would a doctor use a procedure KNOWING it is inferior to another procedure? This never made sense to me.

2. How naive he was about how many hair transplants are performed every day, worldwide, and how few doctors do what he feels is best for the patient. Realistically, he was only trying to steer business to his favourite doctor but even if there were 100 doctors in the same league as his own doctor they would still be pitifully overwhelmed by the sheer volume of patients seeking hair restoration.

I digress, but in the end, while I personally would not lay down for an ARTAS procedure in it's current iteration, I feel that it has value. The question is, how are clinics being trained to use it? Are they being trained to know about donor depletion? Are they being trained to know what separates a viable graft from a compromised graft? I simply don't know but what I do know is that it is getting better. I'm seeing good results and I'm seeing smaller diameter punches. Mechanically, it can only get better still so the question will, as always, come down to the quality of the hand wielding this controversial tool.

[HTsoon]

I agree, I would rather have Artas than an inexperienced surgeon/team perform extractions on me, however for the benefit of anyone reading, I think it's better to research thoroughly before agreeing to have surgery, there's so many fantastic FUE surgeons that have put in the time to learn the skill of FUE and have a trained team that produce consistent results that mirror FUT surgeons.

[Arochahair]

It is our firm belief at Arocha Hair Restoration that the latest update to the ARTAS robot is a big improvement. The software is updated based on continuous unit feedback and so each update is a culmination of what has been learned EVERY day that the robot is used worldwide. This latest update is amazing and it is allowing for healthy grafts to be consistently extracted with .9mm punches.

There are two reasons why a donor would be depleted using an ARTAS.

1. The punches used were the older punches that had an inner cutting diameter of over 1mm.

2. The extraction pattern was too tight for the number of grafts removed thus causing a density imbalance.

In other words, if a patient had a depleted donor it is because the tool was not used properly and not because of the tool itself. This is not exclusive to the ARTAS and can and does happen regularly with manual punches and motorized punches.

[Dr. Lindsey]

This may have been discussed elsewhere but here it is again.

FUE is hard. Currently I do not see that mechanisms/robots/gadgets are better than a well trained human hand and human eyes. I do think, unlike some of my associates..., that eventually they will be better. I just don't think it will likely happen in the next 10 years, and I'm likely retiring in 12...so its not really a factor for me, but if say my son were to enter this field...I do think its an issue he will have to deal with.

BUT I am occasionally wrong on these things..acme hair harvester could come out tomorrow and put everyone out of business, or Johnny's hair clone Inc...I just don't see it in the near future.

I have talked with 6 artas doctors, and although any reader could say that I'm making this up....I'll tell you I heard the same thing from all 6. "We have to pay the company for each time the machine fires, whether we get a graft or not...and it costs the same for a singles as it does a multi. So we always shoot for multi hair grafts and have a cutter sliver them into the necessary singles. That is the most cost effective."

Now that could be that I've only talked to 6 greedy guys, or I'm making it up, or its true of a bunch of those folks.

You can sliver big hand extracted FUE's too...as I've seen personally from a practice less than 30 minutes from my office.

Again, this thread is not to condemn everyone or a specific technique. Its title is PROCEED with CAUTION. Whether machine, by hand, fue or strip...do your research.

Dr. Lindsey

[GNX]

so u see two poor results and now the ARTAS is inferior? lmao..... this is the second thread I've read from you in the last week where you make blanket statements cause uve seen a "Few" patient results and therefore everyone shud avoid it. the first one was concerning BHT which you don't even perform so its comical to hear u say it doesn't work.

and now I see this thread lol. so u see a couple patients that didn't have great results from ARTAS and now you make a thread on the world wide web that it shud be avoided cause again "YOU" don't use it?