IN CONVERSATION WITH DRS SHENTHILKUMAR NAIDU AND DR CHOW YUEN HO ON THE ROBOTIC HAIR RESTORATION SYSTEM
Dr Chow: Follicular unit extraction is the method of harvesting individual hair follicle units, which occurs in groups of one to four hairs. A small circular incision is made around the follicle unit to separate it from the base in the scalp tissue, leaving a tiny hole of about 1 mm in size and this will heal naturally in about a week.
Dr Shenthilkumar: The manual process of FUE is highly repetitive and labour intensive, and requires great precision and skill, or the extracted hair follicle units may be damaged and rendered useless. This repetitive process includes locating the incision punch tool for hair follicle extraction and aligning it precisely to prevent damage to the follicle, and making the incision. This completely new technology using the latest in algorithms and precision tooling means that we can perform very precise and accurate processes speedily with predictable results. As a result robotic FUE has increased the graft survival rate and also allows for more patients to consider this option.
Dr Chow: For a start, compared with the motorised extraction methods, the robotic system is much more versatile in harvesting grafts especially from patients with different hair characteristics, ethnicity and from different parts of the scalp in a single session. We have also found that the robot is good in extracting grafts from the sides of the scalp where the hair tends to be flatter on the skin. Ultimately, both physicians and patients know that this technology is the key to improving quality and consistency in a very skilled and precise labour intensive procedure, which now can be made available to more patients.
Dr Shenthilkumar: That’s a great question. To perform the FUE well requires many years of experience, time which many surgeons don’t always have, when there are many other procedures they may be required to perfect alongside. So, that’s already a barrier of entry for many surgeons who want to do this procedure for patients but may not have the consistency of results. With the robotic system, it takes into account all the nuanced decisions in the orientation, angle etc. that the physician makes and with a week’s of training with the ARTAS system, we can produce grafts which expert surgeons in this field say took them eight to ten years to accomplish.
Dr Chow: Firstly, there are safety features built into the equipment; then there is also safety in that the equipment is used only in the hands of trained physicians. There are built-in force sensors that monitor the pressure exerted by the punches, and sensors around the casing of the system which automatically backs away from the patient. A motion detector is constantly monitoring the patient allowing for real time adaptation and pauses until the doctor can verify the patient is ready to proceed. So if the patient sneezes, the robot will just pull back and wait. The needles have depth markings and with “live” visual tracking of the procedure and site, the doctor can intervene at any time to fine-tune calibrations for better results.
Dr Shenthilkumar: Yes, exactly. So even though the actual extraction process is autonomous, the physician is always present, monitoring and making decisions – so in fact, this highly proficient robot is in many ways just assisting him. That’s why we refer to this as robotic- assisted FUE in some literature. Another aspect of safety has to do with the results or outcomes as we say; with the ARTAS system we get predictably good grafts and this allows us to provide quality surgery with minimal scarring, and great results with the follicle unit transplantation.
Dr Chow: Trained nurses and medical assistants in hair restoration work will find the new technology will broadly enhance and widen their scope of work, not make them redundant. In fact, it will allow them to focus and develop new skills in dissection and implantation, and in some cases, get trained in robotic control and manipulation of the equipment, replacing the disposable equipment, removing grafts and logging the hairs per graft, and so forth. So, in many ways, the robot has a very complementary function in our surgery.
Dr Shenthilkumar: Plastic surgeons are still very sensitive to the aspects of artistry and precision in the work we do, particularly because most of our patients want a natural and lasting result. So this type of assistive technology allows me to focus on those aspects, while remaining alert and fresh. Of course, the robot also draws on our experience as doctors, over and above the algorithms, processing, and video tracking systems to make accurate assessments quickly. At 50 frames per second, for instance, the robot is assessing what it detects at a much higher rate than we humans can. That’s a great help for surgery.
Dr Chow: Yes, the development for the robotic system took many cycles, and was located in two test sites in California and Denver with some of the most prominent hair restoration experts in the US. We tracked that, like any medical geek, perhaps, and when it obtained the FDA approval in April 2011, we wanted to see how sustainable the technology was. The first versions of the robot were not fully automatic. But improvements in the algorithms based on the data being collected, resulted in continual upgrades and improvements. This reflected the developer’s commitment to make a great device. Then of course there were all the practical gains by introducing this technology to Singapore.
Dr Shenthilkumar: We could now remove some of the technical barriers of entry to hair restoration work because the robot’s results were consistent and predictable. That’s a very significant quantum leap in medical technical expertise where results are concerned. So we have achieved that because we invested in this technology for our practice. I definitely believe it’s made a great difference.
Dr Chow: And as we were speaking, we felt that we are moving into the age where driver- less cars are going to become a norm, where automation and self-quantification is going to be an everyday experience. Investing in really great technology – the best in the world today – we hope will also inspire the new generation of students and educators to encourage science, technology, engineering and mathematics, and design to solve problems and make a positive difference to our lives.
Dr Shenthilkumar: Their hair is trimmed short, down to a millimeter and half. After all the preparation is done, the patient will be in a facedown prone position in a special chair that has many adjustments. It is similar to a massage chair in some spas with their face down in a pillow. They will be aware of the robot’s location nearby and behind their head, because they will hear and feel during the procedure. After their skin is numbed with local anaesthetics, we place what we call a “skin tensioner”, a small plastic apparatus, to the back of the scalp to keep that area stable and allows for the robot to note the “fiducial markings” which its program will recognise as the target area. The patient will hear me and my assistant issue commands to the robot and using a remote control I will instruct it to look for those “fiducials”. Once it has located the target area, it will analyse every single hair follicle and commence the assessment of the angles and directions. I give the command to proceed and the robot will begin the dissection process. The patient will hear some pneumatic sounds which is the mechanism doing the punches to the scalp to complete the dissection. There would be a slight sensation of pressure against the scalp and many patients get bored after a bit and some fall asleep. When we are done with the donor area, getting about 90 to 100 grafts per application, we might move the skin tension device to another location and repeat the process. So the patient is going to feel this is a very benign experience, perhaps for a couple of hours, and while seated leaning forwards in a massage chair with their face in a pillow.
Dr Shenthilkumar: The dot-like scars are very, very small, from the dissection or extraction. The robot does it in a very consistent and refined, precise way, and spaces out the selection of follicle units within the targeted area, so the result is a very naturally spaced look. You won’t have a concentrated area where the hair follicles are all extracted leaving another bald spot, for example. Now, those tiny dot-like scars are easily camouflaged by any new hair growth that is just a few millimetres long, so within a short space of time after the procedure, it will not be noticeable.
Dr Chow: We knew from the start that those with their iPods and IPhones will represent the cohort who will embrace this robotic technology. But whether our patients will let their preference decide, that depends. Vending machines and ATMS are the most basic robots and we do trust them with our money.
Dr Shenthilkumar: Advances in Lasik eye surgery and wound medicine are other examples. Some patients may still want and prefer the trusted hand of surgeon in some procedures. But this technology is adopted because it will produce the cosmetic results patients want; this new technology is not experimental technology anymore.
Dr Chow: We have itemised the structure of the procedure, so there’s no possibility of over- charging, with all the disposable items such as the dissecting tips, tubing and suction, skin tension device, and the number of grafts attempts being purchased by the patient. There is some premium involved because we have more staff involved in each application – at least three to four nursing and technical staff assisting the doctor. So patients will have to know what they are paying for, which is not a reduction of service as a result of the robotic system, but in fact a higher quality of service with predictable results. The fact that the robot is involved is therefore to improve on the outcomes, and that is what patients will be paying for.
Dr Shenthilkumar: That’s very true even with the patients we have seen during the past week, where some have had botched results from manual FUE done previously and are just looking for better, and improved technology that can produce consistent results.
Dr Shenthilkumar: That big red button on the machine, on the control panel and the same one on the remote in my hand are for my medical assistant and me to remind the robot that ultimately, it is the humans that are firmly in control…
Dr Chow: Yes, if the robot “says” anything unexpected and it’s not what we like, we just hit the “big red button” and everything stops.