Episode 14:
What Is The Difference Between Robotic & No-Shave FUE?

The Difference Between a Robotic Hair Transplant and No-Shave FUE

The following is a transcript of Episode 14 of the Hair Restoration With Dr. Daniel A. Danyo podcast.

All episodes of the podcast can be found at Apple PodcastsGoogle Podcast, and Spotify.

Dr. Danyo: Nothing can replace touch and feel while you’re doing FUE or follicular unit excision because the characteristics can change per graft. And sometimes the punch breaks through the skin really easy and the graft can just come right out, it’s released. In other times, it’s difficult. So without that minute feel of the skin and actually visualization, I watch the skin come up into the punch under loupe magnification, and if it comes up into the punch and I’m not pushing, it’s almost 100% that I have a fully intact graft. And so it takes a lot of concentration, a lot of feel, graft after graft, after graft to get it done right.

Clark: That was the voice of Daniel A. Danyo, M.D., founder and physician at North Atlanta Hair Restoration, a boutique medical practice solely dedicated to the diagnosis and treatment of male and female hair loss. And you’re listening to “Hair Restoration with Dr. Daniel A. Danyo.” I’m your host, Clark. And all season long, we’re speaking with Dr. Danyo about how he and his team at North Atlanta Hair Restoration are helping his patients transform their everyday lives for the better. In this episode, Dr. Danyo and I discuss the differences between robotic hair transplants and his own process of no-shave FUE treatments. He explains some of the disadvantages of working with a robot and shared some of the factors that set his work apart in both the patient experience and the quality of results. There’s so much to talk about, so let’s dive right in. Dr. Danyo, how are you?

Dr. Danyo: I’m doing great. How are you, Clark?

Clark: I’m great. I’ve been looking forward to another great conversation with you. I’m always learning so much. So I’ve been hearing about robotic hair transplants. And I really wanted to understand first just what that is. And I wanna hear, like, what that is compared to what you do. Because what you do is all by hand. It’s all very different. But what in the world is a robotic hair transplant? I just want to dive straight into that.

Dr. Danyo: Sure. Well, you’ve heard of robots doing surgeries before, and it’s the same concept. The robot is programmed to grab follicles. And essentially, all it does is it has a punch that creates a circular incision around the follicle, and then it goes to another follicle, and then to another. Now, it does not suck the follicle out. The actual follicles have to be hand-pulled because you’re really in a very static position. You know those massage chairs where you sit in the chair and you get them at the mall?

Clark: Right.

Dr. Danyo: Yeah, it’s something similar to that. Your head is, kind of, fastened into a skin tensioner. And then the computer maps things out and then, you know, starts coring. So that’s one of the main functions that the robot does, it’s just core grafts. It does not pull them. They actually have to be hand-pulled. And there are newer versions of the robot that do some placing, you know, and also surgical slits where it’ll go in and then do some small holes that you would later, you know, place the grafts into.

Clark: For some reason, when I’m hearing you describe this, it sounds like it could either be painful or really uncomfortable. You know, how does it measure up to maybe the time in the chair where overall, you know, these are…Do you know people who’ve done this? What do they say about it?

Dr. Danyo: Well, I mean, one of the biggest complaints is just being in that massage chair position where you’re kinda kneeling, your knees are flexed, and you cannot move, and your head is in the tensioner. I’ve had a couple of people say it was almost excruciating being in that position for that long. You know, and with me, if somebody said, “Do you mind if I move my shoulder or my neck,” or, “Can I sit up for a second,” no problem. And, you know, If they need to change position, I guess they can, but they’d have to be taken out of the tensioner and, you know, have the robot kinda get setup again.

You know, my opinion on the robot…because I’ll be honest, Clark, I have people ask me every week. You know, I do a lotta online consults and people say, “Are you doing the robot?” And I say, “No, that’s not what I do. And it’s something that I’ve worked hard to be better than the robot.” I’d like to talk about some of the pros and cons of the robot, and kinda reflect on how it really differs from what I do.

Clark: Yeah, I would love to hear a pro/con list.

Dr. Danyo: Sure. Well, I think the biggest…

Clark: Do you call it the robot, is that really just the…?

Dr. Danyo: Well, I mean the trade name is called ARTAS, A-R-T-A-S. The ARTAS robot is the main and then pretty much the only one doing a hair transplant robotically. I’ll be honest, I think the major pro for ARTAS goes to the doctor because the doctor’s not doing the case and the doctor can be doing something else. So, you know, if you’re the type of patient that wants doctor involvement, the robot method may not be the best because the doctors kinda not part of it, unless they’re part of the programming, you know, of the computer for each patient. But the actual extraction of grafts, they’re pretty much out of the mix.

And you throw in, they’re doing surgical slits now, it takes a lot of the artistry out. And the doctor, again, I guess can see other patients and make more income that way. But that’s one of the main pros, but that goes to the doctor. From a patient standpoint, compared to what skilled physicians do, you know, with more manual techniques, I don’t know if there are any advantages to the patient. FUE, or follicular unit excision, which is what the ARTAS robot does and what I do, is very hard. And it is something that there are just so many factors that go into it. The skin depth, the skin tension, is there curl, is there splay? And all of this comes into play when you’re extracting.

And after doing, myself, over 2 million extractions, I’ve been through every scenario. And sometimes I have to apply a little tension, sometimes I don’t. And in general, the more tension that you apply to the scalp, the firmer the hair it gets. And if you have a straight, you know, a punch going through, sharp punch, you know, it can get transections. And really, if you look at the rates of transection, I think they’re much higher with the robot than what I have, even as high as 20% that I’ve heard.

Clark: So what is that word again?

Dr. Danyo: Transection means that you cut the graft. It could be anywhere in the graft. For my patients, we do occasionally get them. If they’re long enough, we’ll put them in, but we don’t count them. I really strive to get my transection rate as close to 1% or below as possible. And it involves my full participation, you know, coring, pulling the grafts, looking at the grafts, going to the next one. It takes hundreds of grafts, and so I really have a comfort level. But I never have a comfort level because as you go around the scalp, the dimensions of the scalp change, the elasticity and tightness change. And you have to do different things manually to get the grafts out successfully, but you have to have feedback immediately to determine that. Does that make sense?

Clark: Right. There’s just a lot of data points that a machine is just not gonna be able to understand.

Dr. Danyo: Well, I mean, a machine that is…you know, you’re laying in one position, there’s a tensioner on, and then the machine is just coring. And the question is…

Clark: What’s coring again?

Dr. Danyo: Where you’re creating a circular incision around the graft. So for me, when I do that, I’m not that far ahead of my assistants that are behind me pulling the grafts. And if we have issues with transections, they will stop me. And sometimes, you know, motion to me to go in the room and say, “You know, we have a little bit more than usual,” you know, or let’s say if we’re going for three grafts and you only get one follicle instead of all three, that in my mind is unacceptable. So, you know, the robot doesn’t have that feedback loop. And it’s just going through and just coring. And then, you know, the tensioner’s taken down and then the technicians go through and core and pull the grafts. And you could be, you know, hundreds of grafts into it and realize that you’ve got a lot of transections. And for me, it’s just not acceptable.

Clark: No. That sounds really, you know, potentially scary of a set-it-and-forget-it, kind of, visual I have in my mind where a doctor has set this machine up and they might be doing something else, you know? They make more money by…

Dr. Danyo: Yeah. You know, if you look at the true leaders in our field of hair transplant, many of them started out with an ARTAS when it came out. I remember early in my training, you know, back in, like, 2012, you know, just being like, “Oh, my gosh, this is, like, the newest, you know, best thing.” And so a lot of, you know, the big names got the robots, but they don’t use them now. And, you know, they don’t use them because of what I just talked about. And the fact is that you have to be involved in the case and you have to monitor what’s going on with the grafts, not let things kinda perpetuate because you’re in a hurry to just graft, graft, graft.

I guess when it comes down to it, I mean, we’re managing somebody’s bank account. And for me, you know, if somebody was skimping dollars off of my bank account, I wouldn’t take that very well, you know? And I have such a high level of OCD when I do this. I can’t see the ARTAS, you know, really doing that because it’s taking that OCD, that physician, you know, determination to do good out of the equation.

Clark: Well, you were talking just a moment ago about some of the things that a machine or a robot may not be able to see. And you use that word, like, you know, kinda artist. So you’re talking about different things like the way a hair curls or how you position a hair. Is there anything else, like, any other examples of [crosstalk 00:12:02] even think about all the things that you’re thinking about after you’ve done, like, you said over 2 million of these?

Dr. Danyo: Yeah. Well, I mean, you look at, you know, one extreme, which would be African-American hair, which has, you know, either a J curve or possibly a total C curve under the skin. And it’s something that you have to have minimal tension on the skin, if none, and kinda slightly core the skin and literally have the punch sit there and have the skin work itself so that the graft works itself into the punch. And, you know, again, this is something that I’ve developed this finesse for, which is in stark contrast to having a scalp that is fully tensioned, and then you’re taking a sharp device and cutting through. So sure, you can kinda straighten out some of the C curve if there’s a big curve, but it can also tension that hair so that there’s no gives that you have a sharp punch going through and cutting it. So, you know, when you graft around the ear, it’s different than just above, you know, kind of in the middle part of the scalp, which is a lot more fleshy. There are just so many nuances.

And the key for me is that, you know, if I’m gonna do 2,000 grafts, I’m gonna be very close to 2,000 attempts with minimal transections and very good looking grafts that are not fractured. You know, if we’re going for three or four follicles in a graft, we’re getting all of the follicles, not one or two. Now, I’m saying this without having personal experience, you know, using the ARTAS. But you know, in reading, talking with other physicians, and really my general concept that the doctor has got to be involved, like, you have to have skin in the game to make this experience work. Because really, that the patient has a golden opportunity during the case to have it done right. And so it’s gotta be done right.

Clark: If it’s not done right…Has someone ever come to you and said, “Hey, this other person,” maybe it was a robot, maybe it was not, some other place they went, do they ever come to you and say, “Hey, can you help me fix this?”

Dr. Danyo: Sure, I’ve had many patients.

Clark: What goes wrong, “Hey, can you help me fix this?”

Dr. Danyo: Just poor growth. You know, I did have a patient that had a robotic procedure, pretty large. And it was very thin hair that was left. There just wasn’t a lot of definition. And I showed them pictures of what my patients look after 2,000 grafts, and he was blown away. So we ended up doing another 1,500. And I mean, he’s super happy. In fact, he’s got a great review on Google describing it. But, you know, I’ve seen that. And it is so important that the physician is involved. And more and more states with hair transplants, I know Florida has got some stricter laws, the doctor has to be involved. It can’t be technician run.

And, you know, a lot of these companies, they don’t market it to experienced hair transplant physicians. They market to people that are, say, you know, dermatologists, plastic surgeons, family practice. They’re looking to do more cosmetics in their practice. And then the problem here, transplant provided by a robot or whatever, is not just a procedure, it’s actually a field of medicine. So you have to have the knowledge base to deal with all aspects of, you know, the evaluation, the actual execution during the hair transplant extraction, and placement to make this thing work, or it just doesn’t. And it can be devastating.

Clark: That would be really bad, because already someone is going to a solution because, you know, it’s really important to them. It’s an investment, it’s something that they’re really trying to do. And so if it’s not done right, that is quite tragic. And you know, I always love talking with you because I love hearing the passion that you bring to this work. And when you think about these other folks out there, if they’re offering it, it’s likely because they’re doing a bunch of other things. It’s not a specialty ton of focus, this is something that you’re also doing all of this. You’re not handing it over to a technician to replace you, you’re…this is a boutique practice, it is you, right? For better or worse, I mean, you’re the one doing everything. And it takes a lot of time as I’ve learned.

Dr. Danyo: Well, I mean, it just takes intensity. And, you know, intensity doesn’t necessarily have to be a bad thing. I mean, intensity can be fun. When you’re grafting, and things are going really fast and you’re getting great grafts, I mean, it’s an exciting, you know, thing to be part of. But then on the flip side, I’ve had extremely tough cases. Last week, I had some very hard cases, in fact, at my oldest patient ever at age 80.Clark: What? I never even knew…is there an age…?

Dr. Danyo: No. He’s otherwise healthy, and has a young wife, and wanted hair. So who am I to say no?

Clark: And age.

Dr. Danyo: But, you know, even with the tough cases, it’s not a race. I mean, sometimes, I just have to slow down and we have to change gears. And it takes that physician mindset to determine, you know, what needs to be done. And that can be whether it’s patient comfort, anesthesia, bleeding control. But ultimately, it comes down to results. And you have to get out the grafts properly. And you have to put them in properly, in context with everything that’s in association with why they actually have hair loss in the first place.

Clark: That is a good point because you’re not just gonna see someone and then they’re leaving. You’re having that consultation, you’re having that deep dive with them to understand maybe why this is happening. And that’s gotta be different for different people.

Dr. Danyo: Sure. You know, there’s one thing that people assume that the latest technology is the best thing. And it’s just not there with hair, from what I can tell. And the fact of the matter is that there are too many variabilities with patients with skin type, hair type, we talked about that, but also from graft to graft, it changes. And so it takes intense knowledge, intense feel to determine, how am I gonna get this follicle out? Because sometimes, they’re tethered more from one follicle to the next. You can have five that come out easy, and the next five are really tough to get out. And so I think if you take this approach, you know, one-size-fits-all, it doesn’t.

And particularly, you know, some other issues, I mean, ARTAS does great with black hair and white skin. It doesn’t do as well with darker-skinned individuals because there’s not as much of a depth of field in contrast between the hairs where it can count twos, threes, and fours. It doesn’t do well with blonde, especially gray hair, it has to be shaved. Most of the grafting is, you know, they’re like little kind of bony ridges that are round on the backs and sides of your head. Because, you know, straight up from there, kinda like goalposts, it can graft there. But, you know, we do a lotta excellent grafting from just in front of the ear and up from there, it doesn’t really do well there. So we’re able to use more of the donor site. We’re able to do shaveless or no-shave procedures that it can’t. And we’re able to do these on people with curly hair, dark skin, gray hair, blonde hair where it may possibly struggle.

Clark: We’ve talked about a procedure called no-shave FUE. So just the idea of having to shave parts of your head, that’s not good because part of what you’re doing is keeping this discrete. And someone coming in on a Friday and they can…you know, you’ve had patients that go in and work on Monday and no one…you know, they’re able to do that.

Dr. Danyo: Yes. Yeah. And, you know, we’ve perfected the no-shave. You know, we’ve got a couple podcasts about it. But the fact is 70% of my patients last year were no-shave when we looked at the numbers. And it’s because they don’t want a weird haircut. And the majority of the people that we did shave cases on are, like, a number two or less, you know? That’s how they wear their hair anyway. So it’s like, you know what, just shave it. It will be easier. But we do 100% of our women are no-shave. And that includes extremely long or possibly even, you know, more kinky hair, say with African-American females. And that, you know, increases the complexity. I mean, these are all, kind of, more super-level things that I just don’t see the robot ever being able to complete, and that’s really what people want.

Clark: Right. That makes sense. This has been really interesting. I appreciate you going to all the pros and the cons, and why you don’t engage with this. And I’m sure, you know, if you wanted to just have…you know, create an empire, you could get a bunch of these machines and go that route. But it sounds like you’ve really chosen a different path.

Dr. Danyo: Yeah. I mean, I’ll be honest, I looked into it, but it was a very, kind of, fleeting moment for me, just more of an interest. And I went to a conference and there was presentations, and then you see the sales things, and you think, “Am I being too callous about this?” But when I really talked to leaders in the field, one-on-one about it, they said, “This is something that you’re past that stage, you know what I mean, keep doing what you’re doing.” So they did not recommend it. And the other thing is, it is a very expensive tool, in the hundreds of thousands of dollars, plus the disposables per case are extremely high. So for me, it just didn’t work from a business standpoint or from, you know, just a principles standpoint.

Clark: Final question. These other leaders in the field that you mentioned, do you think if you and them maybe looked at a comparison, like you didn’t know you had this done by hand, or you had this done by the robot, would you be able to tell a difference?

Dr. Danyo: You know, the robot, for the most part, is just creating that circular incision around. You know, I think if you took maybe average people with darker hair and lighter skin, and without a lot of, you know, issues that we had talked before with curl, you know, it may be a very simple skin type, there may not be much of a difference. But the problem is that you have these devices being bought by people that have no training in hair restoration. So the robot does all this coring…

Clark: Just hook it up and see what happens.

Dr. Danyo: Then you’ve gotta handle the grafts, then you’ve gotta sort them out properly and then put them in properly. And we had talked about the individual that had some poor growth and I really think it was on the implantation side and possibly on the extraction side as well.

Clark: Interesting. Well, here’s a one potential way. This just came to mind. So Dr. Danyo, this quarantine time, I’ve been getting into plants and just learning about plants, and I got some plants, going to the store, buying plants, whatever. So I’m curious, you know, the leaves at the store, they might look green, they might look good, but you don’t know the roots underneath might not actually be healthy. You wanna export them.

Dr. Danyo: I’ve killed many ficus trees.

Clark: So I mean, the thing that’s coming to my mind is, you know, after a procedure, you might not be able to tell a difference. But what I’m hearing you say, there might be things beneath the surface, you know, that maybe the…you know, we’ve talked about how this is sorta comparable to like a tree. You know, you uproot the tree and replant it. But if it’s not planted well, that could be problematic.

Dr. Danyo: Yeah. I mean, you want results. And you can get caught up in the glitz of a robot and things like that. But you also have to do your due diligence on who’s actually, you know, doing the procedure, what are their credentials, and what do they do? I mean, there are a lot of, you know, respected hair restoration surgeons that use ARTAS, don’t get me wrong, and do great work. But at the same time, there’s so much hype about it. I hear it all the time with the consultations that, you know, the company wants to sell more machines. And then ultimately, they want the best results because that’ll probably generate more machines. But they want more cases because they have more disposables.

And there is a huge push to have people that are not really qualified to do hair transplant buy these machines thinking that they can use technicians or, you know, somebody that’s maybe trained in the ARTAS to come into the office, perform the extractions. But then again, it’s the full package. Because you gotta pull them and then you gotta place them, and you gotta put them in the right way to get the right texture, the right curl, the right hairline, you know, all that stuff comes into play.

Clark: Excellent. Thank you so much, as always, for taking the time. I always enjoy our conversations. Looking forward to the next one.

Dr. Danyo: Awesome. Have a great one.

Clark: Thanks for listening to “Hair Restoration with Dr. Daniel A. Danyo.” Book your consultation today with Dr. Danyo by simply calling 678-845-7521, or visit them online at nahairrestoration.com. And be sure to subscribe, rate, and review the podcast wherever you listen to your favorite podcasts.