Artas ixi Hair transplant

INTRODUCTION

Modern hair transplantation has evolved from Punch Hair Transplantation into more advanced treatment options.1 Currently, the most common hair restoration techniques for commercial use are Follicular Unit Transplantation (FUT) and Follicular Unit Excision (FUE).2 FUT is an invasive surgical procedure where a long strip of scalp with hair follicles is excised in order to get donor hair grafts or follicular units. A scalpel is used to cut and remove a part of the skin, while stapling and suturing are used for closure.3 In contrast, FUE utilizes small punches to detach demarcated hair grafts (follicular units) from the scalp.4 FUE requires hair grafts to be harvested individually in a two-step method – sharp punch placed into the scalp and forceps to manually separate grafts—which can be very laborious and tedious due to volumes of up to 2000 to 3000 grafts that need to be sorted and handled very carefully to avoid damaging donor hair.4 FUE is also not a straightforward procedure, because there is a high learning curve for surgeons. Also, the procedure requires physical stamina, patience, and hand-eye coordination3 to repeatedly harvest and punch hundreds or thousands of times during same session while ensuring the correct angle is used to match the angle of each hair follicle during harvesting.4 Moreover, the viability of grafts is contingent upon the surgeon’s technique or skill in this process, as hair grafts growing at an angle from the vertical are more diffi cult to harvest without damaging the follicle.1 If such measures (density, size, angle and orientation of grafts) are not considered before implantation, the viability of harvested grafts decreases significantly.5

Implantation of harvested hair, on the other hand, has traditionally been performed by trained surgeons or transplant technicians using forceps to manually implant grafts into premade sites in the recipient area; however, in the hands of new or inexperienced physicians, who may lack the accuracy and reproducibility during implantation—means that damage to grafts can be prevalent. With many of the issues and challenges with harvesting and implantation discussed above, advancements in Artifi cial Intelligence (AI), machine learning and vision have allowed for mitigation of many of the challenges faced with FUE procedures.

The first robotic platform to contribute to the evolution of hair restoration and address its challenges in hair transplantation is the ARTAS® Robotic Hair Restoration System, developed by Venus Concept Inc. (San Jose, CA). This device focuses on AI assisted robotic FUE. It harnesses the power of mechanical imaging, AI, and the robotic execution capabilities of the system to harvest follicular units and create recipient sites. The most recent version, ARTAS® iX Robotic Hair Restoration System virtually robotizes the entire hair transplantation process by adding implantation capabilities.

The first robotic platform to contribute

ARTAS® iX from Venus Concept is a robotic medical device that off ers precise, accurate, and reproducible harvesting with simultaneous recipient site-making and implantation functionalities in a single, compact platform. The ARTAS® iX system contains AI integration, a high-defi nition multi-camera stereoscopic vision system, and state-of-the-art medical grade hardware that contributes to hair transplantation technology. ARTAS® iX’s AI machine learning recognizes and digitally maps past, current, and future grafts on the scalp (Fig. 1). The AI can intelligently analyze, monitor, and track each hair follicle’s characteristics, such as the position, angle, size and orientation for optimal harvesting, site making, and implantation, delivering repeatability and precision. Moreover, this robotic system contains an interactive graphical user interface (GUI) that allows for the ease of visualization, and state-of-the-art KUKA robotic arm. Furthermore, our proprietary ARTAS® iX Ultra Punch has a multi-faceted tip with variable coring speed up to 5000 rpm, resulting in dissection with less potential trauma to follicular structure and yielding robust grafts for implantation (Fig. 2). The latest system also includes an improved XTensioner tool to help enhance graft quality by keeping the scalp taut and uniformed across the donor area during harvesting (Fig. 3).

Fig. 1 Digital mapping and tracking
Fig. 1 Digital mapping and tracking of past, current, and future grafts.
Fig. 2 ARTAS® iX Ultra
Fig. 2 ARTAS® iX Ultra Punch yields robust grafts for implantation.
Fig. 3 ARTAS® XTensioner helps
Fig. 3 ARTAS® XTensioner helps to enhance graft quality by increasing tension on the scalp.

The ARTAS® iX system begins harvesting hair follicles from the donor area under the discretion of a physician who sets the initial testing parameters. These include the number of grafts to be harvested and the desired targeted hair density, all of which are set prior to acquiring potential harvest site. All of this is done with a press of a button in the GUI and the device automatically harvests individual grafts in groupings of 1-4 hairs using a sharp punch that makes a circular incision of 0.9-1.0 mm (19 gauge or 18 gauge respectively) at the donor area in a random pattern. The operator has full control of the automation and can override any processes during the procedure. This can result in higher quality grafts compared to those harvested manually through the FUE techniques. With the ARTAS® iX system, users can achieve a harvesting rate of around 1100 grafts/hour.

Once the desired number of grafts is harvested, each graft is sorted by hair groupings then stored in a pool of ATP plasma solution in a controlled temperature environment around 4°C (~39°F). After this step, the ARTAS® iX system is loaded with reloadable cartridges that can each house 25 hair graft units and is now ready for implantation. The physician can utilize the 3D Pre-operative Planning feature to help achieve cosmetic proportionality and a naturallooking hairline at the site of implantation based on the patient’s balding pattern and preferences. This is accomplished by adjusting the angles and spacing of implanted follicles. With the ARTAS® iX’s AI image guidance capabilities, the system sets the implantation angles to match the direction of natural growth of existing hair. Upon determining the appropriate angle of insertion, ARTAS® iX creates recipient sites and inserts the grafts, following overall digital plan created by the physician. Because the system performs these tasks simultaneously, it reduces physician fatigue and shortens the procedure time versus one done by hand.
I have found that the ARTAS® iX system signifi cantly improves the process of transplantation, reducing staff bandwidth and training time — handling of harvested grafts, site-making and implantation. In the past, hair implantation required multiple trained staff to utilize multiple dull and sharp tools to manually implant grafts into premade sites at recipient areas with the use of forceps. Most of the devices developed on the market require manual operation for harvesting and implanters to be loaded individually, which can be time consuming and can potentially damage grafts with the force and manipulation required while holding grafts in place and implanting them. The ARTAS® iX system is the fi rst system in the implantation fi eld that allows for minimal handling of the grafts, eff ectively addressing this issue. The only manual handling occurs during sorting and loading grafts into cartridges. Once the cartridges are loaded, they are stored in chilled saline solution ready for implantation and do not require much further staff support. Thereafter, the Robot handles the site-making at recipient area and implantation simultaneously (Fig. 4). All in all, the system helps to reduce the physician’s workload associated with implantation of grafts manually with forceps and with an implanter.

ARTAS® iX system is easy to use for implantation and not labor intensive due to the ability to adjust settings in the GUI for depth control and implanting. For instance, the system can be pre-set initially with the target hair density and direction and adjusted during implantation using the same touch screen GUI. This feature allows the physician to address areas of the head that may need more attention than others. In addition, the ARTAS® iX GUI system allows for the surgeon to adjust the time and distance in between recently implanted sites to minimize the popping of the grafts during implantation. The GUI system allows for real-time changes during the implantation by toggling the parameters even while the procedure is ongoing. Moreover, the ARTAS® iX’s unique abilities to make sites and implant simultaneously allows the speed of graft insertion to be at a rate of 800-900 grafts per hour. With the ease and versatility of the ARTAS® iX system, it is an excellent option to help physicians increase repeatability, precision, and control when implanting graft.

ARTAS® iX system is easy to use

Other intrinsic advantages of the ARTAS® iX robotic system include a relatively quick and easy learning curve for the support staff to achieve good speed in graft loading. In my practice, we have used both dull and sharp manual implanters. This process process usually takes 1 to 2 months for an experienced technician to obtain suffi cient speed to become effi cient in loading sharp implanters. In contrast, the learning curve to load ARTAS® iX cartridges is much shorter and typically takes 1-2 days. The maintenance of cartridges is minimal. Cartridges are reusable per patient per procedure, and are disposed when the case is complete, while sharp implanters require detailed cleaning and sterilization after each procedure. In summary, the ARTAS® iX implantation system helps to increase the bandwidth of implantation, provide better estimation of qualifi ed staff time to perform procedure, achieve natural-looking results for patients, and improve graft survival rates. ARTAS® iX creates recipient sites and inserts the grafts while following the overall digital plan created by the physician. Because the system performs these tasks robotically, it reduces physician fatigue and shortens the procedure time versus one done manually.

ARTAS® iX – Results

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Photograph of 5 different patients before (left) and 9-12 months after (right) a hair transplant procedure using the ARTAS iX Robotic System.

ARTAS® iX - Challenges & Improvements

While the ARTAS® iX robotic system is a fantastic step forward for implantation, it has some challenges. For example, in the clinical setting for both manual and automatic implantation, it has been observed that there is occasional popping of previously placed grafts following insertion into adjacent areas due to variability in patient scalp elasticity. As well, implantation of the swirl of the crown with the robot is still under development. The newest Robot, the ARTAS® iX system, contains an update that addresses the swirl of the crown during implantation and a sharper needle implanter to help with the issue of variability in patient scalp elasticity to prevent popping. The latest system also includes faster imaging cameras (100 Hz) that will improve centering over and locking of the robot onto grafts during harvesting, plus a pink light feature that combines white/red lights for better contrast for darker skin types (Fig. 5). This pink light feature also increases the visibility of follicles covered in blood during the procedure. All these features aim to increase effi ciency and help to improve the versatility of he ARTAS® iX technology

The first robotic platform to contribute
Venus ARTAS black RBG

Conclusion

In summary, the ARTAS® iX system is a novel one-stop shop for harvesting, site-making, and implantation that provides predictable safe, eff ective, consistent and reproducible clinical results in hair restoration. The system is very effi cient as it helps reduce staff and surgeons’ time, which indirectly reduces fatigue and resources required to complete a full procedure. I look forward to more improvements in the speed and versatility of the ARTAS® iX system by Venus Concept.

References