Baldness and hair thinning is an extremely common problem, for some more than others, and at different ages and stages of life. Finding a more permanent solution than wearing a wig or painting on hair has been hard to come by but the ARTAS Hair Transplantation system is changing everything. At the recent ASCD 2018 Symposium I was able to catch up with Dr Mark Bishara from Restoration Robotics who have developed a solution that involves using your own hair. This is an amazing new treatment you’ve got to hear to believe.
Trish: Hey listeners, so I’m here today with Dr. Mark Bishara, and Dr. Bishara is a plastic surgeon and he practises in North Texas. Today he’s representing Restoration Robotics, and we’re going to have a chat about the ARTAS Hair Transportation System, which is, well new to Australia. I saw it a couple of months ago and I got really, really excited by it, so I’m sure that you all will as well. Today we’re going to have a bit of an up close and personal about the hair restoration system and what it’s about, and he’s going to answer all of our questions. So, welcome.
Dr. Mark B: Well thank you, we appreciate the opportunity to come in and talk to you today about hair restoration and tell you a little bit about what’s happening in the field and how the advancements over really the last eight to 10 years have brought robotics into hair restoration, and what that means for the field. Thanks for having us.
Trish: Thank you so much. I didn’t even know that hair restoration in good quality was actually really out there. I remember the old plugs from years ago, because my uncle had them done, and I was like, “Whoa.” But, this is just something else, so I’m pretty excited. Tell us can you explain how the ARTAS Hair Transplantation System works. That’s a mouthful, but can you tell us how it works?
Dr. Mark B: Absolutely. We’ve been performing this procedure for about nine years now, well eight, almost nine years. It’s funny that you mentioned seeing these patients that had a pluggy look or machine gun hair, or sort of corn rolls. There were all kinds of different adjectives that people would use to describe these just horrible looking hair transplants. For some reason when we see them, we always see them in the airports. I don’t know why that is, but we always see them in airports. But, that’s not the hair restoration procedures that are being performed today. Now, what we’re doing is we’re using a robot and we’re looking at the hairs in the back of the head.
The robot allows us to really measure the distribution of the follicles in the back of the head. It looks at the angles, the density, and a lot of different metrics. It will measure a angle of approach and actually go in and dissect out an individual hair and bring that hair to the surface, where we can then take it with a forcep and look at it under a microscope for quality control metrics. We measure a lot of different things during the transplant. Then, what we do is we turn the patient around, we create recipient sites using the robot as well too, and then we go back in and we take those grafts that we’ve harvested with robots and we place them in the holes. It’s a pretty amazing process.
In the interim what we’ve done also is we’ve taken iPads and some of the more portable technology today to take pictures. We used to take five pictures, now it’s a single picture. We can take a picture of somebody’s head, draw a hairline on that patient, discuss that with the patient. We can create parts from a right to left, or we might create different directional changes of the hair. Decide on a hairline for that patient, and then show them what would 1000 hairs look like, or what would 2000 or 3. Kind of give them an idea of a small, medium, and a large hair transplant that they would undergo.
It’s been a great not only patient education tool to use that imaging, but it’s also a really cool physician preoperative planning tool to then go and then harvest out the number of grafts that you need, and be able to plant them exactly where you want them.
Trish: Basically if I want, because I know it’s probably just the guys at the moment so I’ll talk guys first and then I’ll talk about girls. If I was a guy and I wanted to, like right, I need a little bit more hair but rather than just take a random approach and just fill it up with hair, you can kind of take a bit of a snapshot of what your head is now, where those hairs will be placed and what they will look like, and then actually create that for them.
Dr. Mark B: Absolutely.
Trish: They might want more or less, or they might be happy with less because it looks okay, or they might think, “No, I need a little bit more than that.”
Dr. Mark B: Absolutely, and I’ll go back to what you kind of let off and you were saying well I think it’s only for men right now, you’re absolutely correct. The FDA, the US FDA has clearance for Caucasian and Asian men. That doesn’t mean that we can’t use the robot for other ethnicities or other genders. As a matter of fact in our practise we use this with females, so I would say that nation wide in the United States we see about 37, 36% of the patients, our hair restoration patients using a robot are female. In our practise particularly we see about an 18% chance that they’ll use a robot, and a lot of that has to do with marketing. We’re really heavily marketed in the sports radius, so it’s a very high male based population, so kind of what you were assuming about it being present in men is very, very true, but that’s largely a result of some of the marketing efforts that we’ve made.
Trish: Yeah, totally.
Dr. Mark B: Yeah.
Trish: With what you mentioned before, you were saying that you can make it directional as well. You don’t just put the hair, so basically, actually I’ll go back one step. Basically what you’re doing is you’re taking a hair out of a different section of the head and implanting it in somewhere, a different, in another part of the head where the bald bit is.
Dr. Mark B: That is correct.
Trish: It will grow like normal and act like normal hair, and you can colour it and cut it?
Dr. Mark B: Absolutely. Just to kind of recapture a couple things, just to make it very simple to understand. For all practical purposes there’s two types of hairs that exist on the scalp, okay. Those that are sensitive to a hormone called dihydrotestosterone, which means in the presence of that hormone those hairs will miniaturise. They’ll become debilitated and small and vellus and then they’ll disappear, okay. There are other hairs that exist kind of like the hairs in the back of the head where you see people with progressive hair loss states, they still have this kind of friar tuck or whatever, a horseshoe.
Trish: There’s a name for it. It’s called a skirt.
Dr. Mark B: A skirt, exactly, is that what you call it here? Yeah, it’s a skirt right, so the skirt is the area of the hair that’s genetically resistant to DHT. What we do is we pull hair from those resistant areas and we place them into other areas where you’re either thinning or you’ve lost hairs that are sensitive to the DHT. Interestingly, you think, well if you’re pulling it out from place does it grow back in that area? It does, it grows back, but it grows back where you place it, okay. You’re not a starfish, you’re not a crab that if you pull of one arm it grows another arm back. You’re not Saint Augustine grafts where you’re going to continue to grow more and more hair.
You have a finite amount of hair to deal with, and so really it becomes more of an issue of borrowing from Peter to pay Paul, but interestingly you can take up to about 30 or even 40% of the hair in the back of the head where that genetically resistant DHT follicles are, and still not have a moth eaten look or thin that area out. You can take quite a bit of hair and still look like you have a full head of hair in the back.
Trish: Yeah, so when you take it you actually make sure that the hair that you take is not hair that’s going to go bald one day, is that what you mean?
Dr. Mark B: Well, yeah, and this brings up the issue of a concept called senescence, okay. Senescence just means that if you live long enough, if we all live long enough, all of the hair on our body will fall out, okay. I would say that, yes, it’s going to be more resistant to falling out if you’re taking it from the back and putting it up here. Eventually it will fall out, yeah.
Trish: Okay, I don’t want to get that old.
Dr. Mark B: Right.
Trish: Tell me, are the results of the ARTAS treatment permanent?
Dr. Mark B: Correct. We get this question a lot, right, are hair transplants permanent? Well, there’s a couple things going on when we deal with hair loss, the actual problem that we’re treating. On one hand we’re dealing with hair loss prevention, or slowing down that inevitable thing that’s going to happen. You’re going to continue to lose hair, hair loss is a life long problem so you want to slow that down. On the other hand, we’re looking at the definitive treatment of hair loss. Once you lose that hair follicle, once it goes through a process called apoptosis and it dies, you can’t get that hair follicle back. At least not in 2018.
Okay, we might be able to do some things down the road where we can get them to come back, but for right now the treatment for those areas, those bald areas, those shiny bald non-hair bearing scalp areas, are going to be to take hair and transplant them into that area. When we use the word permanent, we kind of shy away from it. We want to say things like definitive because what’s permanent in this world, nothing in the world is permanent, right, but this is going to give us a more, a 10 and 15 and 20 year solution to something that we’re dealing with.
Trish: Okay, that makes sense. I think I likened it before to my cosmetic tattooed eyebrows I have to get done every few years.
Dr. Mark B: Right.
Trish: They’re still dark, but you’ve still got to top it up.
Dr. Mark B: Absolutely, sure.
Trish: So tell me, is the Hair ARTAS Transplantation Treatment suitable for all patients. Like I know we spoke men and ladies but when I say all patients I mean like some women when they’re post menopausal, I’m not talking about myself here, or maybe I am. But, they might get a bit of hair loss in one area of their head where it’s just a bit sparse, so is it suitable for that, or is there anyone that you wouldn’t actually do the treatment on?
Dr. Mark B: You know, I think that, we have a very large experience with the specific tool, this robot. We have three of them and we’ve been doing them for almost 10 years now, and we’ve transplanted well over 1.2 million grafts worldwide, which I believe is the most in the world now. We used to fluctuate, we used to go back and forth between the top three producers, and what I’ll tell you about that answer is that if I want to give you the best results, in a patient who is a perimenopausal female who has some diffuse thinning, I might not opt to choose the robot right away.
It may be something that I want to use with you, but I may want to use platelet rich plasma injections where we take some blood particles from your blood, we spin it in a centrifuge, re-inject growth hormones into those areas first. Maybe treat you with light based therapies and some topicals. Or, maybe doing a combination of, some permeation of all three of those before transplanting you. While we can, sometimes we don’t need to just jump to the transplantation process. It’s more of a comprehensive approach to each individual patient.
Trish: Yeah, right. It’s kind of like, yeah-
Dr. Mark B: It’s a tool.
Trish: … it’s an individual thing and yeah, okay.
Dr. Mark B: Correct.
Trish: All right, got that. That was really interesting actually, but I’m not talking about me. Tell me, because it’s so new where can people find the ARTAS Hair Transplantation Treatment in Australia?
Dr. Mark B: Sure. You’re seeing more and more practises that are looking at this, and you have a couple of them. My understanding is that Sydney has a practise. There’s two or three devices now. You’re going to see that that number of devices increases very soon. There’s a lot of interest that is coming out, specifically now with IX. Now, IX is a different robot entirely. Leading up to today we’ve been using 7X, 8X, and then ultimately 9X. That is what’s sort of been evolving since 2011, April or so, when the robot was sort of introduced to the US market.
Changes have occurred in this last decade where we’ve got new hardware, there’s been new software updates. The user interface is different now. But now, just a few months ago I was in Las Vegas and giving a talk. A keynote that was there about robotics in surgery these days. We unveiled the IX robot, which is the latest and greatest. The differences in this robot and what has been rolled out before is now we have a robotic arm that is more streamlined. It is a medical robot arm. Before the arm that we were using was an automotive one. It was straight off the automotive industry, something you would see in Tesla, where they’re making Tesla cars or something like that.
Now, this is a specific biological robotic arm and it has more joints on it. It has better economy of motion. It’s faster. The other thing that this robot offers, has the ability to do that prior robot models weren’t, is to be able to take the graft and make a recipient site and plant it at the same time. Before, and so that’s combined two processes. Before what we had to do was let the robot make the site and then we had to go back in and put the grafts in afterwards. But now, we’re using the robots to harvest all of the grafts, and then turn around and plant that graft at the same time as we make the recipient site hole. It’s really streamlined it and it’s taken, you know, it’s probably about a 30 to 40% more efficient process at this point.
Trish: Onto the basic questions, and does it hurt?
Dr. Mark B: It doesn’t hurt me a bit.
Trish: Have you had it done?
Dr. Mark B: I actually have had it done, and so the last time, so I’ve had three very small procedures. Certainly when I was a student and a fellow. But, the last time that I had a robot procedure was actually September 4, 2014, and that was about four years ago, almost to the date now. Each procedure that I have had has been a very small procedure. I have a progressive hair loss state, and I have a family history that has a lot of hair loss both in my mother’s side and my father’s side. I’m what you call follically challenged, right, I don’t have a lot of follicles to borrow from, Peter to pay Paul, so the transplants that I have really done have been focused on the frontal tuft of my head.
We’ve done small transplants at a time. You know, looking forward to the future about this robot, what we can expect. We just gave a keynote talk a few moments ago at the meeting here, and the title was, Is the Future of Hair Restoration Robotics. I have to challenge that, I gave that talk, and I have to challenge that, and I would tell you that the past and the present and the future, because we’ve been doing it for eight years, right, is going to be robotic hair restoration services. I don’t think it’s something that is this futuristic idea of something, we’re doing it now. We’ve been doing it, and I’ve had mine four years ago.
Trish: It just gets better and more refined by the sound of it as times goes on.
Dr. Mark B: That’s correct, that’s correct, yes. Just like all things, yes.
Trish: Back to the does it hurt, so what’s the, can you tell me a little bit about the process, like the-
Dr. Mark B: When I went through it right, so when I went through it four years ago, I had absolutely no discomfort whatsoever, okay. Some of the initial injections where we’re using these very tiny little needles, we’re administering local anaesthetics, kind of like going to the dentist. Well I used, in my office we do a lot of Botox injections, we a lot of other things as well, but we use the same needles that we apply the Botox that we use, we use the same 32 gauge needle to apply the local anaesthetic. It’s very tolerable. What I usually tell my male patients that come in, in their 30s and 40s, is that on Wednesdays when we do our Botox
patients, and we have a lot of 70 year old ladies that come in for Botox injections. They keep flocking back in record numbers, they come in now four at a time. If those 70 year old ladies can do it, so can you.
Trish: Yeah, totally.
Dr. Mark B: Right?
Trish: Totally. Just for the process then, so basically I come in, the first thing you’ll do is you’ll put local, and what’s the process?
Dr. Mark B: Right, so a typical patient would come into the office first of all as a consult. Let’s look at them first, let’s figure out if they’re a candidate indeed for this procedure. Let’s say that they are a candidate, indeed they are. They’ll put on a schedule, they’d come in, we usually start in our office very early in the morning. We have multiple robots so we’re usually doing multiple robotic cases in a day, so we might start at 6 or 7:00 in the morning.
Patients will come in, all of their consent forms are digitized, so all of the questions are done beforehand so that right when they come in their blood pressure and heart rate is taken, they’re weights are taken, pictures taken. They’re brought into the operating room where they change into some appropriate attire for that day. We will trim, we’ll take pictures of course of them, we’ll trim some of the access points because we do have to get access to the back of the head, and so the robot needs the hair length in the back pretty short. Usually about one to one point three millimetres in length, so that’s trim. We don’t say shave, because we get some patients that come in that are halfway to Fabio, they’ve got long hair, and if we say shave they run out the door. We don’t want them to run out the door, so we say the word trim.
By trimming, for guys that are listening to this, we mean trimming. We mean not a one, not a two guard, this is taking a no guard and basically buzzing the back of the hair where we need access too. Not necessarily their whole head. If we’re transplanting the top of the head we don’t have to cut that, we can certainly plant between existing hairs in those areas.
Trish: It can be just like a thin little row that’s like a quarter of a centimetre.
Dr. Mark B: That is correct.
Trish: Because I saw the pictures, that’s how I know this, so a thin little row about a quarter of a centimetre, about maybe six inches long or something like, yeah.
Dr. Mark B: Correct. That’s absolutely correct. We’ll trim the hair, we’ll apply those nerve blocks that we spoke about. We will also, every patient in our practise undergoes platelet rich plasma injections. We will take blood, okay, we will take a whole blood, peripheral blood draw, and we will spin that in a centrifuge. With typically 3500 RPM for about 10 minutes. Well, when you take whole blood, okay, and you spin it fast enough for a long enough period of time, that blood will separate, okay, into red cells and white cells and platelets.
Well, we get rid of the red and white cells, we don’t want them. Some of the orthopods that use PRP they want the white cells for inflammatory response, but in hair we don’t want white cells. We just want the platelets, okay. Platelets are important to us, because they have growth factors in them. Mainly one called IGF1, which is growth hormone, okay. It’s your bodies own indigenously produced growth hormone. We take that and we inject it into the areas where we’re going to actually transplant. We’ve done the blocks, you don’t feel any of this. We inject the PRP. We go ahead and start making all the holes where we’re going to place all the grafts.
Trish: Mm-hmm (affirmative), and that’s done by the robot isn’t it, so that it’s all, yeah okay.
Dr. Mark B: That’s done by the robot, but this is the 9X technology that was done that way. Then, we put you into another position where we go in and we start taking out the grafts in the back of the head. Okay, and so that also we’ll put some platelet rich plasma in those areas to too propagate the healing process. Those grafts come out of the back of the head and they get subjected to some quality control measures. We look at them under microscopes under light boxes and we make sure that they’re of a quality nature that we can retransplant them. We’ll take those, we’ll take them back to the areas where we want to plant them, and we put the graft in the hole.
Trish: Okay, and how long does it take?
Dr. Mark B: Now, that depends. If you’re a small transplant, a 1000 grafts, that may take you three or four hours. 2000 grafts may be upwards of six or seven hours, and then of course if you’re doing a 3000 graft case, I mean that’s much more large in nature, maybe eight to 10 hours or so. But, all in one day.
Trish: Yeah, right, oh that’s good so you can get it all done in one day?
Dr. Mark B: Sure.
Trish: Well that sounds great. I actually saw this a while go on, oh what was it, I think it was Plastic Surgeons of Beverly Hills or something, I was like, “What, why.”
Dr. Mark B: You did. My good friend Dr. Craig Ziering. He is 90210. He also is one other leader and laureate in the field, and we go back and forth between number one and number two as far as numbers in the world.
Trish: Okay, and I was like why is this not available in Australia, why is this, you know like really this can be done, why don’t more people know about it.
Dr. Mark B: Well, this is also a function of politics and regulatory bodies. Australia’s been notorious in the past, not quite as bad as mainland China, but it takes a while for these things, for the FDA to look at these and then to clear them and to get them through the regulatory. Then, because it is a US based country, you’re using distributors that have to get the products and all that has to be worked out.
Trish: Because, it’s a bit like that with fashion as well, we’d be fine with that as well, but hey.
Dr. Mark B: Yes, indeed.
Trish: Well, that’s been really, really enlightening, thank you so much for joining us today.
Dr. Mark B: Oh, it’s my pleasure, it’s my pleasure, and thanks for having us. I know it was our first time in Australia, and we flew in from Dallas this morning and we have just been non-stop, we’ve got a couple more talks to give here, but we appreciate you inviting as and letting us spread the word about some of the things that we get to do on a daily basis to help people out.
Trish: Absolutely. Enjoy the beautiful weather here in Melbourne as well, we’re lucky because normally it’s quite cold here, so enjoy Australia.
Dr. Mark B: Well, thank you so much, we appreciate it.
Trish: Thank you so much.
Dr. Mark B: All right.
Trish: So listeners if you’re out there and this is something that you might be interested in, just feel free to drop us an email to email@example.com, and we will help to guide you in the right direction. We’ll have lots more information on this coming up on the web as well, so thank you so much.
Dr. Mark B: Thank you, thank you so much.
Dr. Mark B: Bye-bye.