Robotic Follicular Unit Extraction in Hair Transplantation
Marc R. Avram, MD,* and Shannon A. Watkins, MD†
BACKGROUND In recent years, there has been a shift toward minimally invasive procedures. In hair trans- plantation surgery, this trend has manifested with the emergence of follicular unit extraction (FUE). Recently, a robot has been introduced for FUE procedures.
OBJECTIVE- To determine the transection rate of a robotic FUE device. In the attached article, the authors discuss the procedure, technical requirements, optimal candidates, advantages, and disadvantages of robotic FUE compared with the standard ellipse.
RESULTS- Optimal candidates for robotic FUE are those with dark hair color who can sit for 45 to 120 minutes and are willing to shave a large area for donor harvesting. The main advantages of robotic FUE compared with the standard ellipse are its minimally invasive nature and the lack of a linear scar.
CONCLUSION- The robot is a new and innovative method for FUE hair transplantation of which hair transplant surgeons should be aware.page1image10600 page1image10760
In the 1990s, hair transplant surgery underwent a revolution in the graft size used for transplantation. From the 1960s into the mid 1990s, 2 to 4 mm grafts containing 10 to 20 hair follicles were the standard graft used in the procedure. In spite of its scientific success, they were often a cosmetic failure because they resulted in a “pluggy” unnatural appearance. In the 1990s, there was a shift toward smaller graft sizes. Currently, the follicular unit, which contains 1 to 4 hair follicles, is the standard graft size used in transplant surgery.1,2 This shift in graft size has allowed patients to consistently grow naturally appearing transplanted hair, as it mimics the natural size of follicular groupings on the scalp1 (Figure 1). In addition, the use of follicular groupings eliminates textural changes and scarring in the recipient area. Large grafts containing 10 to 20 hair follicles required larger recipient sites, which resulted in unnatural “cobblestone” scarring on the scalp. Recipient sites for follicular groupings are less than
In the era of follicular unit transplantation, the only visible scar on the scalp is the linear scar left from the donor ellipse. For the majority of men and women, a linear scar has no short or long- term practical effect. Their existing donor hair will camouflage the scar. A linear scar can create an issue, however, for some patients who wear their hair shorter or want the option of a shorter hairstyle in the future. In addition, there has been an inexorable trend in all surgical procedures toward minimally invasive procedures, which result in less scarring and quicker recovery times.
Donor Harvesting Techniques
Over the past several years, the focus of discussion in the field has begun to shift away from the size of the graft used to transplant hair toward the harvesting method used to obtain the donor grafts. For decades, 2 to 4 mm punch trephines were used to obtain donor hair from the posterior scalp. Typically, the grafts were removed and wounds were allowed to heal by secondary intention. This resulted in widespread “hon- eycomb” scarring (Figure 2). In 1994, the concept of elliptical donor harvesting, also known as strip har- vesting, was introduced and has been the standard method for obtaining donor grafts.3 It is based on the same dermatologic surgery techniques used in removing nevi, skin carcinomas, and cysts. It allows efficient harvesting of hundreds to thousands of fol- licular groupings. As with any cutaneous excision, there is a scar created from removing the donor ellipse. For the majority of patients, this is neither a medical nor a cosmetic issue. For a minority of patients, medical and cosmetic challenges may arise. A small percentage of patients will develop hyper- trophic or broad scars. Others feel limited in the hair styling options because of the donor scar. For these
Follicular Unit Extraction Versus Elliptical Donor Harvesting
The concept of follicular unit extraction (FUE) was introduced in the early 21st century and refined over the past decade.4–6 Follicular unit extraction used the same concept of using a steel trephine to harvest donor hair, but instead of being 2 to 4 mm in diameter as was used in the past, the FUE punches range from 0.8 mm to 1.2 mm. This technique is a natural extension of the concept of follicular unit hair transplantation—the utilization of individual follicular groupings in the recipient and donor sites.
Challenges of this technique include the following: increased risk of transection of hair follicles, operator fatigue when harvesting hundreds of follicular groupings, and appropriate spacing of harvested grafts to yield the maximum amount of donor hair without creating the appearance of a depleted donor density.6 Throughout the posterior scalp, the angle of hair growth varies, which presents a challenge to surgeons. Magnification and excellent lighting reduce but do not eliminate the risk of transecting follicles. Compounding this challenge is the need to remove dozens to many hundreds of follicular groupings for each case. Harvesting larger numbers of grafts can result in increased operator fatigue and a higher rate of transected hair follicles. Some experienced sur- geons are able to harvest large numbers of follicular groupings with minimal transections, but others are unable to do so.
To improve the accuracy and efficiency of FUE, numerous FUE devices have been developed; of which some are motorized, some are suction assisted, and some are single user-directed robotic system. The NeoGraftautomatedhairtransplantsystem,7–9 SAFE (surgically advanced follicular extraction) system,10 and ARTAS Robotic System (Restoration Robotics, Inc, San Jose, CA) are a few of the more well-known FUE devices on the market. In this article, the authors discuss about robotic follicular unit extraction with the robot.
Robotic Follicular Unit Extraction

Technical Aspect
The robotic system was approved by the Food and Drug Administration for hair transplantation in 2011.  This robotic device is used to harvest follicular units from the donor region (Figure 3). A 1-mm punch is attached to the robotic arm consisting of a “needle- within-needle”; there is a sharp inner punch sur- rounded by a blunt outer punch. The sharp inner punch creates a shallow 1-mm incision, subsequently, the blunt outer punch spinning at 400 to 800 rpm dissects deeper and separates the follicular units from surrounding tissue. A suction system attached near the punch elevates the follicular unit from the surrounding skin allowing for easier extraction of the graft. A combination of stereoscopic cameras managed by image processing software allows the sharp and blunt punches to identify the precise angle and direction of hair growth. This continuous imaging feedback allows the robot to precisely harvest each follicular grouping. Because of the high level of automation, the robot is able to remove 400 to 600 grafts per hour.11–13 The software requires a minimum distance of 1.6 mm between extracted follicular groupings to minimize risk of overharvesting donor hair. In Table 1, the authors compare strip harvesting with robotic FUE donor harvesting.
See the attached article for more information.

Like good health and youth, most of us take a thick head of hair for granted — that is, until it is gone. For many people, hair transplant procedures can help bring back the appearance of a full — or at least a fuller — head of hair.

Overview of Robotic Hair Transplant Procedures

Robotic hair transplant surgery is a logical advance in the technology of Follicular Unit Extraction (FUE). The potential advantages of Robotic FUE (R-FUE) over traditional FUE procedures include:

  • Increased accuracy of harvesting grafts to minimize damage to follicles
  • Ability to use FUE in a wider variety of patients
  • Reduced harvesting time
  • Increased graft survival

Follicular Unit Extraction is a harvesting procedure where hair is removed directly from the donor region of the scalp as individual, naturally-occurring groups of 1-4 hairs. The technique consists of two main steps: 1) Separation of the follicular units from the surrounding skin, and 2) Extraction (removal) of the follicular units from the scalp.
Step one, the separation of the follicular units from the surrounding donor tissue, is a highly repetitive and labor intensive process that requires great precision. This step requires the centering of the punch over the follicular unit and the alignment of the dissecting instrument with the follicles to prevent damage. This step, which must be repeated manually hundreds to thousands of times in a typical FUE procedure, subjects the patient to significant human variability and error.
The problem associated with the initial step of separating follicular units from the surrounding tissue has been a major challenge for FUE practitioners. A significant advance towards minimizing trauma to follicular units in this first step was to divide it into two parts; sharp, followed by blunt dissection. This additional step reduces the chance of injury to the lower part of the follicles during dissection. The current robotic system is based on this concept.


Risks and Costs of Treatment

The cost of hair transplantation will depend largely on the amount of hair to be transplanted, but it generally ranges from $4,000 to $15,000. The procedure is rarely covered by insurance.
As with any surgical procedure, hair transplantation carries risks, including bleeding and infection. Other risks that can occur with hair transplants include scarring and unnatural-looking new hair growth.
Around the time new hair growth starts, some people experience inflammation or infection of the hair follicles, called folliculitis. This can be relieved with antibiotics and compresses. Another potential risk is the sudden loss of transplanted hair, called shock loss. Fortunately, this hair loss is rarely permanent.
If you are bothered by thinning hair or balding, hair transplantation can significantly improve your appearance and self-confidence. However, it is important to understand that hair transplantation is just that — transplantation of hair you already have to a place where it is more visible. It does not create new hair.
To minimize the risks and improve the success of surgery, it is important to undergo hair transplantation only if you are healthy. You should always discuss the potential risks and benefits of any surgery with your doctor.
This Information is brought to you courtesy of Dr. Bishara and The Paragon Plastic Surgery & Med Spa

Most people are a candidate for hair transplant surgery. However, in order to properly determine your candidacy for the procedure, an ARTAS physician will need to consider various factors, including age, family history of hair loss, current and projected future hair loss pattern (area of baldness), donor characteristics (laxity and density), and whether or not the goals of the patient can realistically be met.
The best way to find out if you are a candidate for a hair restoration procedure is to go to a surgeon that specializes in hair restoration. The answer will depend on the cause of your hair loss, your age, the stability of your donor supply, how extensive you hair loss is, your expectations and a number of other important factors that will be taken into account.
It’s important to have realistic expectations before undergoing a hair transplant procedure.
Remember there is a finite amount of donor hair that can be moved to the thinning areas of the scalp. If that hair isn’t used in an efficient manner the outcome of the procedure might not meet your expectations.  Every patient is examined on a case-by-case basis, but here are some general types of patients that are great candidates for hair transplants:

Technology Makes a Difference Click Here to download the brochure

The best candidates for hair restoration surgery are:

  • Men who have been losing their hair due to Male Pattern Baldness for more than five years or who have progressed to a Norwood class 3 or above.
  • Men with realistic expectations and who understand that their hair loss might continue to progress even if they are taking prescription medication to stop the progression.
  • Men who have been balding for many years and who’s pattern has stabilized and are interested in just adding some hair to provide a more youthful appearance.
  • Men and women who have lost hair due to trauma or burns
  • Men and women who have lost hair due to other cosmetic procedures such as face-lifts.

Some women are candidates for hair restoration surgery. They are:

  • Women who have suffered hair loss due to mechanical or traction alopecia (non-hormonal).
  • Women who have had previous cosmetic or plastic surgery and are concerned about hair loss around the incision sites.
  • Women who have a distinct pattern of baldness, similar to that of male pattern baldness. This includes hairline recession, vertex thinning (on the crown or top of the scalp), and a donor area that is not affected by androgenetic alopecia.
  • Women who suffer hair loss due to trauma, including burn victims, scarring from accidents, and chemical burns.
  • Women with alopecia marginalis, a condition that looks very similar to traction alopecia.

Hair Restoration is available for many areas, not just the head, although that is the most common place.  We also do hair restoration for eyelashes, eyebrows and beards.
Please visit the website of Dr. Bishara, who specializes in Hair RestorationRobotic Hair Transplants and Plastic Surgery at or call our office at (817) 473-2120.

LaserCap® in Elle Magazine

Small enough to hide under any Eugenia Kim beret, the diode-laced LaserCap delivers a low-level laser light proven to increase the cellular energy produced in mitochondria, enhancing growth. 
“It’s virtually identical to the treatments we used to give in the office using a $100,000 machine,” Bauman says of the effective (but pricey, at $3,000) chapeau.
After 30-minute sessions every other day, “Most people will have a 15 to 30 percent improvement in hair mass in the weaker zones within 90 days.”
Read More

ELLE’s annual roundup of age-defying breakthroughs will have you looking better than your #flashbackfriday from head to toe, but here, we’re focusing on hair products particularly. Because as too many of us know, it’s not just your skin that can age you, and it’s not just guys that have thinning hair problems. Below, our favorite shortcuts to thicker, longer hair, from serums to foams to laser treatments.
Turn Up the Volume
“It’s easier to hold on to hair than to regrow it, so I get patients into treatment as early as possible,” says dermatologist Nicole Rogers, MD. Minoxidil, the derm world’s favorite OTC hair-loss medication, can now be found in more than just Rogaine. “Major hair product companies are realizing how important minoxidil is to women,” says Rogers of the ingredient, which works by making the hair follicle wider and sparking regrowth within six months of use. Meanwhile, we can thank the car industry for a short-term fix. L’Oréal Paris Volume Filler Fiber Amplifying Concentrate contains a thickening agent inspired by the technology used to fix cracked windshields. The brand’s patented Filloxane molecule changes from a liquid to a solid, penetrating the hair fiber and immediately plumping it from within.
Platelet-rich-plasma (PRP) hair-growth treatments—during which a patient’s blood is processed via centrifuge to concentrate the plasma, then shallowly syringed into the scalp—are getting a boost with human placental tissue. Hair restoration specialists inject a patient’s own blood and removes the platelets and plasma. On average, 90 percent of patients with early-stage hair loss will experience a 20 percent increase in volume and coverage.
Light Show
Small enough to hide under any Eugenia Kim beret, the diode-laced LaserCap delivers a low-level laser light proven to increase the cellular energy produced in mitochondria, enhancing growth. “It’s virtually identical to the treatments we used to give in the office using a $100,000 machine,” Bauman says of the effective (but pricey, at $3,000) chapeau. After 30-minute sessions every other day, “Most people will have a 15 to 30 percent improvement in hair mass in the weaker zones within 90 days.”

Photo: Courtesy of Companies 

  1. Alterna Caviar Clinical Daily Densifying Foam lessens daily strand loss ($36,
  2. Pantene Expert Hair Regrowth Treatment stimulates follicles with minoxidil ($23,
  3. Instantly amp up body with Oscar Blandi Hair Lift Serum ($30,
  4. Biologique Recherche Complexe Cegaba+Bioproline tonic works to boost hair density. (Price upon request,
  5. L’Oréal Paris Advanced Haircare Volume Filler Amplifying Concentrate is like Restylane for hair ($7,
  6. Renessence Follicle Forever Serum prevents loss with a patented peptide ($85,

This article appeared in the October issue of ELLE magazine.


Platelet Rich Plasma therapy — or PRP Available in the Office of dr. mark bishara

Nov 10, 2014, 11:05 AM ET
A new hair-loss treatment is giving hope to millions of people with thinning hair.
The treatment, called Platelet Rich Plasma therapy — or PRP — could help regrow and thicken hair without surgery, drugs or expensive treatments.
PRP relies on the patient’s own platelets. The patient’s blood is drawn and placed in a machine, where the plasma is separated from the blood and injected directly into that patient’s scalp.
The platelets contain growth factors that stimulate the regrowth and thickening of hair follicles.
Eyebrow Transplants Enhance Fullness in Thinning Brows
“This is the best kept secret in the world,” Dr. Jeffrey Rapaport, a New Jersey dermatologist, told ABC News.
Tanisha Jimenez has used PRP and she says it has worked for her.
Jimenez said that years of pulling her hair back caused her to lose some around her face. Just weeks after her first treatment, her hair started to regrow, she said.
“It’s amazing,” she said.
Rapaport noted, though, that this isn’t considered a cure for baldness.
“It’s a treatment … What we’re doing is increasing the diameter of the size of the hair follicle,” he said. “And we’re keeping the hairs that would stop growing in the growing phase.”
The best candidate for PRP is someone who has recently started losing hair, Rapaport said. It won’t work for those who are completely bald, and it won’t regrow all the lost hair, he said.
The entire process, including the injection, takes about 90 minutes.
Rapaport recommends one treatment per month for the first four months and then two maintenance treatments per year. Some doctors add other hair-growth medications to the mix

En Espanol
10 de noviembre 2014, 11:05 AM ETABC News a través de Good Morning America
Un nuevo tratamiento de pérdida de cabello está dando esperanza a millones de personas con el adelgazamiento del cabello.
El tratamiento, llamado terapia de plasma rico en plaquetas – o PRP – podría ayudar a crecer y engrosar el cabello sin cirugía, medicamentos o tratamientos costosos.
PRP se basa en las propias plaquetas del paciente. La sangre del paciente se extrae y se coloca en una máquina, en donde se separa el plasma de la sangre y se inyecta directamente en el cuero cabelludo de ese paciente.
Las plaquetas contienen factores de crecimiento que estimulan el nuevo crecimiento y engrosamiento de los folículos pilosos.
Cejas Trasplantes Mejorar Plenitud en Adelgazamiento cejas
“Este es el secreto mejor guardado del mundo”, el Dr. Jeffrey Rapaport, un dermatólogo de Nueva Jersey, dijo a ABC News.
Tanisha Jiménez ha utilizado PRP y ella dice que ha trabajado para ella.
Jiménez dijo que los años de tira de su pelo hacia atrás le hizo perder algo de alrededor de su cara. Apenas unas semanas después de su primer tratamiento, su cabello comenzó a crecer de nuevo, dijo.
“Es increíble”, dijo.
Rapaport señalar, sin embargo, que esto no se considera una cura para la calvicie.
“Es un tratamiento … Lo que estamos haciendo es aumentar el diámetro del tamaño del folículo piloso”, dijo. “Y estamos cumpliendo con los pelos que dejaría de crecer en la fase de crecimiento.”
El mejor candidato para PRP es alguien que ha comenzado recientemente la pérdida de cabello, dijo Rapaport. No funcionará para aquellos que son completamente calvo, y no va a volver a crecer todo el cabello perdido, dijo.
Todo el proceso, incluyendo la inyección, tarda unos 90 minutos.
Rapaport recomienda un tratamiento por mes durante los primeros cuatro meses y luego dos tratamientos de mantenimiento por año. Algunos médicos añaden otros medicamentos crecimiento del cabello a la mezcla