Masters of Beauty Ep. 6: A Conversation with ARTAS Restoration Robotics

Dr. Shah:

I'm Dr. Anil Shah today. I'm going to be treating two guests. Uh, we have Oggie Petrovich, uh, and he's been with restoration robotics for over 10 years. And, uh, he seen artists evolve, uh, from harvesting 40 graphs in one case to now doing over 4,000, uh, in one case, uh, his current role is the director of research and development. Is that right? Yes. Got it. And, uh, you've worked all over the place, including Motorola, Intel, IBM, and all these products. So, uh, your background is in technology and robotics and all that cool futuristic stuff that, uh, uh, all of us guys, uh, dream and drool about. Yeah. Thanks. Thank you. That's fine. And also we have Eric, uh, Eric, uh, uh, is the director of product management at restoration robotics. Uh, he's worked in this technology and device space for about almost 20 years. Although you look, uh, young enough to maybe be a son of mine. So I don't know how that's possible. So maybe you started when you were like one or two.

Speaker 4:

Yeah. The gummies started real early.

Dr. Shah:

And, um, and, and, and do prior to working restoration robotics, you worked at intuitive surgical, uh, which is also kind of in that robotics space as well. So it's been kind of something it's been in your DNA, so to speak that's right.

Speaker 4:

Actually, you know, I was trained as an engineer and the first job I had out of college was designing robots for the semiconductor history. And, uh, since then I've moved on to medical devices and more in, in roles, in, um, uh, marketing and stuff. So I've, I've kind of come full circle. I've married my, my love and passion for medical devices, with my passion for robotics,

Dr. Shah:

Uh, which is interesting. Now I think the robots I see, I have a six year old, the robots I see my six year old are purely for destruction. Did you ever do any of those types of robots and robot wars and all those aspects are mostly to help humanity? Well,

Speaker 4:

For my part, I it's always been sorted and stuff. I know argument I've done some phone robot war type stuff with them,

Dr. Shah:

But, uh, yeah, no, no destruction, no destruction save that for my six year old and his robot wars. So, which is fun stuff. And you see, that's interesting because robots are being taught more and more to our youth as kind of a part of where we think the world is going, where the future's going. Um, and, uh, it's interesting to see how that's evolved. Um, so artists, um, if I'm not mistaken, it's the only robot in the aesthetic space and the only robot in the airspace.

Speaker 4:

That's correct. That's correct. Uh, this technology is quite unique in, in the aesthetic medicine spaces, the first robotic solution. And in terms of, you know, when you compare it to other hair, uh, transplantation, hair, restoration technology, it is far and away the most advanced piece of equipment that you'll find.

Dr. Shah:

Um, so when you talk about the roots of artists, like where artists came from, um, and, and, uh, both of you probably are, I've been with restaurants, robotics to know about this. So where did this start? Like when the product, when it was first and sexualized, uh, where did it start and how did it come along?

Speaker 5:

Yeah, so this started more than 10 years ago, probably about 15 years ago. Um, our founder was part of a company called Accuray and they do radiosurgery with Roberts and, um, they were looking for another medical application that, uh, tedious difficult, uh, to do where accuracy is required. And, uh, one of the doctors mentioned, Hey, there is this very, uh, proceeded. There is hair transplant procedure, which is, uh, meets all these requirements. You should check this out and try it. And, um, our founder got a robotic arm and started a company basically in the garage, just like, uh, many other Silicon valley startups. That's how, that's, how it all started. And, uh,

Speaker 4:

Some of the best work in the, in the value is done in people's garages here, as you can see,

Dr. Shah:

Well, I've worked for Steve jobs, so it's not, uh,

Speaker 4:

And Hewlett and Packard and everybody else. Right. Yeah.

Dr. Shah:

Okay. And so with the early robot, um, obviously there's different kind of challenges with that. Um, in the beginning stages, the robot first came out, I think it was in the market. Uh, is it 2011, 2011. So the first robot comes on the market. Um, what was it like when it first came on the market and what were some of the initial things you said, okay, we've got to change this a little bit. We've got to here's the, some of our challenges.

Speaker 5:

Yeah. So when we initially released the product, it was, it was able to do hair transplant. It was able to hire his hair and it was, uh, he was able to assist her, uh, surgeons to do that. And it was very, the number one thing that we got from the doctors is that it's very difficult to, uh, to use. So you can do a big case. You can do your, you know, 2000, 3000 grab case, but it took a lot of effort on part of the surgeon. They didn't have to actually make the incisions and do individual Harris by hand, but they had to tweak the robber angles. They had to tweak, uh, needle decks and they was quite a bit of a work different work, but it's still quite a bit of work. So that's when we, when we decided to invest more time on machine learning AI to help doctors, um, with those problems. So the, uh, the machine now is way more automated than it used to be in 2011.

Dr. Shah:

Um, and I think that's interesting was the initial robot, did it have the same dough and sharp, uh, punches, or was it a different, um, harvesting mechanism? I know there were larger punches in the beginning. I think they were like, uh, what were the size of the punches and how did it

Speaker 5:

With the 18 gauge? Uh, it's about a bit larger than one millimeter punch. It's the same concept needle in a needle needle, in a punch. And, uh, that, um, that particular technique has not changed that much. We did improve the punch over time, however, the whole clinical workflow and the software around it. And, um, the mechanism there body account has been improved tremendously over time.

Dr. Shah:

And is it the same, uh, arm in the 2011 robots, the same, uh, base robot, or is that changed in, uh, current iterations of it or is there a different robot, um, underlying, uh, robot?

Speaker 5:

Oh, no, we have moved to a much more modern, uh, robot last year. So, which has seven degrees of freedom. It has built in four sensor it's designed for medical applications. Our original robot was actually an arm that was used that's is also used for automation in factories, for example. And we had to do a lot of modifications to fit it in surgeons room. The current Robert is designed for medical applications.

Dr. Shah:

Okay. Um, and I think there's so many things to talk about, like, you know, design wise and technique wise about the robot and harvest team. Um, the thing I like about it is the fact that you have a cutting burn, a delver, and that really helps with the harvesting and preserving the hair follicle. Um, I'm guessing you model that off of, um, maybe it was like a Harris punch, is that, is that right? Um, the original one as the Dr. Harrison, Colorado is a similar type of, um, harvesting system because the sharp, you need to have something sharp when it's going through there. And if you'd have something doll, um, the doctors who do only sharp, and there are some devices on the market that do only sharp, they tend to transect the hairs. Uh, and the doctors who only do doll tend to like scoop up all the hairs around them. Um, so have you guys noticed anything as you've tweaked the device? Any, any comments on that?

Speaker 5:

Yeah, we work with Dr. Harris for many, many years. So he was our principal investigator, uh, when we were developing the harvesting system. And, um, he gave us a lot of good inputs. Um, you know, our, the sharper needle that we use only goes about a couple of millimeters in the skin. So that way we minimize a chance for transection. And then the dowel punch goes around the needle, of course, out of the polyp whatsoever, just as you mentioned, that that, uh, keeps the C-section rates down.

Dr. Shah:

And I think, um, I'm going to segue that to some of the suction based, uh, punches. And, um, I'm not going to talk, there's so many differences, but there's, that's the first question that sometimes think, okay, I'm talking, I'm not going to name a brand, but we know there's a couple of suction based product punches out there. Um, and one of the fundamental problems, I have a lot of problems with, uh, the way the, you know, the basic science works on this and how that aspect of it works. But one of my biggest problems is as simple as the punch, uh, how it works because it's only sharp. And if you do only sharp, you're going to have so many more transections, it's just effect. Um, and so I think that's one of my biggest issues with the suction based devices. Um, I have a whole list of issues I have with them, uh, that I, maybe I could talk more freely about the new guys can.

Dr. Shah:

Uh, but, uh, that's, that's one of those things that it's an under estimated part about the artist is how well designed that punches the sharpen Adele and how safe that is and how it really lowers your, um, that, that transection rate. I'm going to define transection rate for our listeners because not everyone knows what a transection is. So essentially when we're harvesting hair, uh, hair is kind of like, it has a root to it in a ball. And if you damage the ball or damage, the root, the hair is basically useless. You're taking out nothing. And basically what we're talking about is you have to be precise enough to take off, we'll have a illustration showing this, you have to be precise enough to take the hair out without damaging that ball, because if you do, you basically doing nothing, you're damaging the patient's hair, you're losing hair.

Dr. Shah:

Um, so this is, this is the problem is because when you're trying to harvest hair by hand, which is called, uh, fue or follicular unit extraction, most of the time I say most of the time, I'm not exaggerating most of the time. I think people are transecting the hair, uh, and they're not taking the hair out properly. Um, so that's that aspect with suction based versus with that aspect. So that's the cutting part. Um, uh, the other aspect is, uh, the suction itself. Um, uh, I think it dries out the hair. I know lots of people off the record who don't use the suction part with it. It can desiccate the hair and have issues with it. Um, was artists ever conceptualizing suction or was that sort of ruled out right away or during that process?

Speaker 5:

Yeah. Yeah. So, um, we do use, um, suction. So, um, let's, let's talk a little bit, just, I want to mention about, uh, artist IIX and INX punch. So we did go through dozens probably even maybe up to a hundred revisions of a punch and finding the best possible punch that works on all kinds of skin types. It's, um, it's quite a bit of a science and, uh, actually art to, to find good punch, you know, it takes, you know, material matters, you know, the machining process matters a lot of the angles of, uh, of the very taper matters. It matters how it's been stored. There's a lot of, uh, variables that go into making a good punch. So, um, we pay, uh, that's, that's a very important part of our system. And then, uh, we do use suction. Yes. So, uh, we, the suction to elevate the graph a bit before, um, a technician, uh, picks it up. Uh, I want to, um, mention that our system has vision. So you can see on the camera, those graphs that are being elevated by the needle and the punch, and then you have direct feedback how good that follicle looks like without, without using loops or anything like that, because we have high magnification system. So we, um, elevate the graph so you can see what the quality is, and you can also easily pick it up

Dr. Shah:

With the suction, but I think it's a different level of suction if I'm not mistaken, because when you're using the suction on the artist, it's merely to elevate it because if you're

Speaker 5:

Gentle, gentle suction. Yes,

Dr. Shah:

Exactly. Versus when you suck it up in a tube, I mean, you, you can do that in artists if, uh, if you're, uh, you're cutting aspect of it, but if you suck all of your graphs, your, um, I think your desiccating them cause the suction too hard and the way those come out, there's a difference, I think, between leaving your hair in there and lifting it up again. This is me talking about that. Maybe we can talk a little bit about that, um, versus when you strip the hair out, um, I've seen the graphs on the suction based devices and they see when they come out, they're, they're kind of really, they call them skinny graphs. They're super skinny. I mean, they're like, oh my God, how are we going to put this graft in? Because it's so skinny versus you can design a graft on artist depending on the age and a 19 versus an 18, and you can create a chubby graph, you can trim it down. We tend to trim it down and look into the scope. Um, so I think it's nice to have that flexibility versus that, that stripped down graph that attempt to get suctioned out with a pure cutting section that pepperonis

Speaker 4:

That's correct. And, and really you'd like to see graphs that have a lot of soft tissue around them all the way down to the bottom, that fatty tissue and some of the, the, uh, um, you know, stem cells and all the good missing Kamal cells that are in there. So we try to preserve as much tissue around the graft as we can. And, um, you know, our system, we could use, we could suck it all the way into the system, but, uh, what we found is that just elevating it in the field, letting it stay in the surgical field and then having a, um, a technician, very gently remove that with a nice technique, preserves the graph structure. Um, it's very quick and easy to do as well.

Speaker 5:

And also to mention four, there are some graphs that still may be pulled out because we do have, you know, on some patients it's easy to, um, separate follicle from the scalp. We have a full sailing plush system, which provides, um, fluids for the graft to survive. So it's not as if we are just letting, letting it die. Um, it goes into follicle trap. It has a plenty, plenty of sailing there or storage solution as well.

Dr. Shah:

Um, I think one of the other parts about artists, which is interesting, um, there's, there's lots of hair blogs and hair podcasts, and they always talk about how do you know how many hairs you're getting? How do you know what your transection rate is? And if you have an artist it's actually like a lot of this, like counting and dealing with the, the mathematical and quantitative aspects of it are actually taken care of for you. Uh, so for, in my aspect, in my practice, I've always been into quantification because you don't know what your outcomes are because everyone always says, I think I'm doing better. Uh, and then you look and you look at numbers and that can really drive your decision-making. So for me, in my practice, um, I look at something called the T rate, the transection rate. I also look at empty sites, which can happen with anything when, um, and then I look at, um, those are kind of two factors I'm looking at.

Dr. Shah:

So everything is quantified because, and then from a patient's perspective, uh, their stories of patients going somewhere and saying, Hey, guess what? I signed up for a thousand graphs or whatever graphs. And then who knows how many you've had with the handheld punch. You have no idea. And how many were successful. There's no, there's no data behind that. On, in artists, everything is sort of photographed and captured, you know, how many were empty, how many were not empty? You know, how, how successful the machine is. It'll give you a smiley face. So I think patients from a quality standpoint, you can tell what's going on. And I think from me knowing that as, as a patient as well, I've had myself, I've had artists done. Um, uh, it's nice to know what are my stats? Like, what did I, what did we bring to the table?

Dr. Shah:

How successful we are? Well, great. Who cares? How many transactions did I have? Um, how many, uh, graphs were sucked up? So you know, that number, and I'm a quantified guy. I think most of my guys who do, um, hair are they're into numbers. They know stats on baseball players and all that aspects of it. So I think that's an underestimated part about that, about, uh, what we're talking about. So, um, another aspect of that, that, um, going through there, um, how accurate are, um, uh, for me as a user, when I'm looking at that, how accurate are those stats? If I'm looking at that and saying, Hey, guess what? I am empty. I had that, uh, I mean, they seem super accurate when I'm looking at it and counting that, but your, your data pool, I mean, you have a metric, tremendous Deadpool. So how accurate you think they are?

Speaker 4:

I think that the measurements are pretty accurate. So, um, you know, of course we, we count all the harvests and, you know, in order to, to quantify the amount of transactions and things that at this point still needs a human to look at it and to say how many we transect and things. Um, but we have things that will count empty sites and all that it's quite accurate. We have the vision system on this, um, device is, is quite, um, precise. And it has a resolution of like 44 microns, which is on the order of half the width of a hair. So, uh, the, the, um, the system can see, uh, things, um, that we sometimes can't, and that allows it to be quite accurate when you're talking about things like counting hairs, counting follicles, counting, empty sites, things like that.

Dr. Shah:

Um, and let's talk about that vision. So when you're looking at the vision of that, um, if we compared someone wearing loops to someone with artists, just the vision aspect, so we have the, the robot we're going to compare those two. So let's do that kind of as a thought experiment of saying, so that way people can kind of understand the differences. So first we're going to go vision. So we have, um, and I've done this experience, but by the way, I'll tell you my results at the end of this. Um, but so first of all, we're going to take the best fue hair harvester in the world. I had to Sue supposedly the best FTE person in the Midwest, um, doing this. Um, so we're first going to do vision, um, vision on a person wearing loops versus vision with an, uh, with artists, with its vision topics. So we'll, we'll kind of compare those to first.

Speaker 4:

Oh yeah. Um, so, you know, I think that, um, what would you have to have, like at least 10, 10 times loops to see at that level? Or can you even like, you know what,

Speaker 5:

Yeah. I mean, the beauty of RS is that you don't need loops anymore. First of all, it's very hard to write. I can see the big screen

Dr. Shah:

It's beyond 10 X. I believe, I believe it would be. Um, my, my understanding was that it would be like 12 or 14 experts. I don't even think they make that

Speaker 5:

There. So, you know, we like to talk at you. So in terms of resolution, so we S uh, the system can see, uh, it has a resolution of about 44 microns, which is just half of the hair. So you can see the hair on the screen. Here it is. And yet that's only like about a hundred microns. It's very highly zoomed in very, very, you can, you can see the shape of the follicle, the caliber, you know, what, what kind of angle it, uh, um, it is. So, um, it's, it's much, much more pleasant to work then with loops that's. Yeah.

Dr. Shah:

And I, I think it's, it's, it captures it better than you can see with, uh, with Luke's because there's something about it where you don't see that quite the same with loops. And I think the number I've equated is anywhere from, it's probably around a 12 X loop, which I don't think exists. Um, the highest loop, um, some people say they're wearing eight X loops, but if you actually measure them out, and I've done that with a couple of, of wood manufacturers, I don't think that some of those, the cheaper ones that flow down are actually eight X, um, we've measured a couple of them. And some of those are closer to 2.5 and three X there's, nowhere near eight X. Um, so if you're looking at the screen, looking at that, so I'm going to give the vision to artists, because it's just clear that aspect.

Dr. Shah:

Um, the other aspect we looked at, um, is kind of comparing the two things is steadiness. This is one of the hardest things to do. I'm a surgeon. I work on the face. So I'm used to working with my hands. I wear loops when I work. Um, and I'm used to working at the base in harvesting hair. What it takes in harvest to hair is extraordinarily difficult because you have a spinning device trying to go to a small thing. We're talking about microns thick, you know, about 60 to 70 microns thick. You have to see the hair on the outside. You have to also understand where the hair is on the inside. That angle changes as the spinning device hits your skin. It's going to move your hand if your patient's breathing, it's going to move. Um, which we talk about how the artists, uh, handles people with reading.

Dr. Shah:

Um, so all these factors, when you're dealing with micron type surgery, all of these factors affect it. Once you hit the skin, the hair is at a different angle than what you see on the outside. What you're I see oftentimes, and most people are looking with loops, actually, don't see stereoscopically, which is what the artist sees. They actually see, um, kind of what the two-dimensional aspect to it. So they're missing the three-dimensional relationship and it hits it. So I think comparing the world's best fue person manually versus artists, uh, I'll go back to you on your thoughts. You have to assume that this is the best fue harvester ever in the planet we can use instead of the Midwest. Um,

Speaker 4:

Um, yeah, I think there are to be sure there are some extremely talented doctors and surgeons who have amazing skills with their hands and, and do quite well. Um, you know, manually, I think it's, it's, it's a very difficult thing to do. I don't think everyone, um, has those skills. And we also have to remember, it's not just once or twice. This is, you're doing this 2000 times. And so, uh, can you say that the 1550th time you do it is the same as the second or third time you do it? I think it's really difficult. There's a sort of a re a repeatability aspect with the robot that is just built into robotic precision it's repeatable, and it's efficiency is what you get from, from our robotic and just the ability to, um, maintain focus, concentration, and that sort of, um, physical dexterity over that amount of time is very, very difficult. Um, you know, there are some, you know, outstanding surgeons who get very, very good results, but I think for most doctors, um, it's hard to compete with a device that sees so well. It has such a precise movements and is, is extremely repeatable, um, over thousands and thousands of these very small, repetitive moments movements.

Dr. Shah:

I would, I would say it's impossible for a human to compete with that. It's not going to happen. And I just don't think it's possible because it's not possible for someone to do that. And if you did it on one case and you did it over and over again, most of the people are actually going to get some sort of wrist issue or elbow issue. Cause it's that aspect, that repeated motion. Um, so even if you could do it, I have not seen a person who could do it yet, whether it's a surgeon or technician, whoever I have not seen a person who can do that repeatedly, like as good as an artist, I've never seen a person who's good as an artist. Um, and that aspect is me looking at lots of docs and looking to under scopes and microscopes and looking at T's looking at data.

Dr. Shah:

That's the big thing. Um, I have not seen a human that can do it as well as an artist. Okay. So we're talking about harvesting the mechanics of harvesting. We're talking about the vision of harvesting, which I think are two really important parts about that. And I think the part that you mentioned is non fatigability re reproduce reproducibility. These are things that people don't take an account, so you know what you're going to get with an artist. Um, again, I'm I measure myself, this is a, it looks like a wedding ring. Um, although I wear it on my merit, um, it's actually an aura ring, so I know what my sleep, so my sleep number was good last night, but let's say I had a bad sleep number. I know that I'm prepared. I was prepared today. My sleep readiness score was like in a way in the eighties.

Dr. Shah:

Um, I try to make myself as zoned in as possible, as reproducible as possible. So I'm always on, but I'm a human being and we can't always be, um, you know, um, you know, we can't be always as perfect. At least we know what the artists we're going to get something that's super reproducible. It's never going to have a restless night of sleep. Um, and again, I try not to, I try to make myself as, um, as much like, like a robot. You see what I'm saying? That, uh, with those aspects of that, so I can be as reproducible and have everything, um, like that. Okay. So I think if you're comparing, we're talking about best case scenarios with that, that's harvesting, that's getting the hair out. Um, and I think my experience has been, um, it was mind blowing when I looked at data.

Dr. Shah:

Um, so I used to do things by hand. This is me, and this is me having other people assist me in that aspect. The numbers, I think that people report on transactions are probably way, way exaggerated, and it's their guesstimates because people aren't keeping track of it. And when you look at those data points, people sometimes talk about 5%, 10%. I believe they're at best case scenario, 30% transactions. That's my opinion. And some probably higher than that. And that's why you're seeing people, um, use 2000 graphs to try to get a thousand graph results. That's why you're trying to people doing that because they know there's some waste in there. We have a limited number of hairs here. We only have so many hairs we can harvest why waste those hairs. Um, you need to preserve every one of those hairs. So the extra value you would get from artists, it's, it's inserting your result.

Dr. Shah:

And one of my, one of my best, um, results is a patient. I did, I think I did 500 graphs on him. And if you look at his result with 500 graphs, people are like, how the heck did you get a 500 graph, uh, result with him? There's no possible to do that. His T rate was zero. So I had a zero rate T rate and, um, he had therapy, other stuff like that, but it's, that's not the point where he got his hair from every graph I put in. I'm sure survived because there's no way it's possible to do that with 500 graphs. So, um, he was quoted 2000 graphs, 2,500 graphs. I did 500 graphs on him and you can tweak the artists in so many different ways, uh, uh, including skipping ones and doing that. So you can maximize the number of hairs and minimize the number of graphs and having control as a physician and having control as a patient.

Dr. Shah:

I think it's such an underestimated part about this technology. Um, uh, so again, that's my, so my stats on myself, by the way, um, I could have had my hair done probably 15 years ago. Um, my first option was stripped and I never would put a scar on my head. Um, so it's one thing to, I just don't believe in that. So I just don't even offer that as an option in my practice. I would never do it to myself. The issue with that is, uh, some nerve numbness, um, issues with that aspect. Um, even at females, artists is not approved. It's not FDA approved for females. I do artists on them off label. Um, even for eyebrow patients, I use artists again, it's not FDA approved for that. I use it as an off-label indication of that, even in African-American patients. I use artists for that.

Dr. Shah:

It's at it's off label. This is stuff that you guys can't talk about, but I can talk about, um, I use it all the way I use it for every application of hair, because I'm a believer in the aspect of the technology and how it works for that. I don't believe in a scar in the back. So that's number one. Um, my second option was fue manually and again, knowing two pretty good surgeons across the country, that was not an option for me because if T rate and transection rate, I'm going to get the least amount of hairs out. So I had a thousand heres placed in my head. Um, and, um, everyone always wants to know like how many hairs are transected? It's the stat. I can see that you got people upstairs. I had one here that was transected, which was like, I mean, there's no one in the world who can do that. It's like, it's not even close to that aspect of it. And, um, it's one thing to see it on other patients, but when you experience it yourself, you're like, I mean, this is the, this is the game check game-changer technology in here. Um, 2011 was not the game changer technology. It was the beginning, it was the sapling, it was the trial, it was the trial that needed to be nurtured. And thankfully it was nurtured to where it is right now, which is this, uh, this prodigious giant, uh, so awesome.

Dr. Shah:

Okay. So, um, a couple of things on artists, we've talked about some of the technical aspects for, um, let, let's talk about some stats on this, cause you guys know some stats that I don't know, what's the most hairs that have been harvested in an hour on an artist. Do you guys know off the top of your head? I don't know that number,

Speaker 4:

But I think it's probably 1,414, Uh, 1400. Yeah, we have some, we have some, um, there are some artists users that pretty regularly can harvest, uh, over 1200, um, per hour and, uh, as high as 1400, I think we've seen in an hour

Speaker 5:

That depends, you know, on the, on, uh, on the donor area of the patient, on the training level and experience level.

Speaker 4:

Yeah. And a lot of is also a, you know, some doctors are very, um, you know, uh, have a very tight surgical workflow and other doctors, not maybe as tight, you know, some doctors are very, every single it's, everything is sort of scripted and choreographed within the, uh, within the procedure. So everyone kind of needs to know what they have to do it we're at time and they save they're much more efficient that way. So these are some doctors that have really mastered the surgical workflow and they can come up with these rates, you know, other doctors aren't, as you know, aren't as picky about that. And so maybe they don't go quite as fast.

Dr. Shah:

Yeah. I think the fastest I've been was like 1100. And, uh, again, a lot of it varies. I think my experience on that is going to be patient selection. Um, it's some patients have, um, you know, it just like with anything with surgery and for me, it's not a race you want to get the best outcome from that. Uh, but I also want to minimize the time that someone's in the chair, because I think out of graph time, that's something, um, I emphasize to patients and I'm just going to kind of clarify that as to our listeners. So autograph time is the amount of time your graft is out of your head. And so we always try to minimize how long that hair is out of your head so we can put the hair right. Kind of back in. And, um, I think I view here when you take out a hair and a quickly unit out as an Oregon.

Dr. Shah:

And so kind of like when you take what people do heart transplants and they do kidney transplants, um, you really have to nourish that hair and everyone has their own proprietary thing that they nurse the hair with to prevent it from going into shock. Um, and I think that, you know, you know, for me, it's really important to get the hair back in because just like we wouldn't want to put a heart in two weeks later. Uh, we probably don't want to do that to hair. Um, kind of going with that, how many artists procedures do you know that have been performed to date? Um, kind of worldwide? Do you know that number off the top of your head? I,

Speaker 4:

Yeah, it's, it's prob, uh, w we re estimated over 30,000 to date 13,000.

Dr. Shah:

It's a lot of hair follicles and now is this true? I've noticed I've had it. I love it from the get go, but I've noticed even in the last year, it seems like it's just even smarter than it was like a year ago. Not like a lot, but just a little bit more consistent, a little. It just, I mean, it was, I mean, I did my hair like almost a year ago. Uh, but, um, again, I I'd love to do that to get go, but I've noticed that it's been less variability from patient to patient. Um, and it's just, um, smarter than it was even a year ago. Is that possible?

Speaker 4:

Yeah. Yeah, yeah, yeah, definitely. I, you know, I, you know, Augie can speak to this, but I, you know, I'll just, maybe it doesn't, they, they work incredibly hard all the time and trying to improve the system. So, you know what he's talking about, how we started with doing, you know, 40 hairs in the case, and now 4,000 at the same thing is true in human was talking about, well, they develop the automation to make it faster, and that's a continuous improvement cycle that we do. We're always looking at ways to make it, uh, get better outcomes for the patients to make it faster, easier for the, for the doctors more accurate. And so it's an ongoing, you know, this is an ongoing, um, uh, you know, activity for us.

Dr. Shah:

Um, and I think one of the things with artists too, is that it's not just in anyone's hands. Like I can't just go to someone and say, I'm going to buy an artist. You have to, you have to buy it from restoration robotics and enjoy that aspect of it because, um, you have to get trained it because this is a piece of technology. That's not like me buying a laser and say, Hey, we're going to have a one day seminar on it. I think one of the coolest things about it, and this is me from being, um, you know, an artists' user and a lover of a product is that, um, there's a lot of dedication at a side of restoration for products where your company, uh, trains people, you physically send people over and say, Hey, we want you to be comfortable with this robot.

Dr. Shah:

And you have to reach a certain level of competence just to use this device, because if you can't, you know, we don't want you using this device, you have to be. So it, it provides a sort of consistency throughout the brand and the product. Um, and I think that speaks volumes to it because, um, if there's a problem and this is what I tell my staff, it's not probably the robot it's probably us. And that, it sounds strange. Uh, but it's kind of one of those things, like I always say, like, if something didn't get sent, I don't think the computer made the mistake. We probably made the mistake. What did we need to do better? And I think they think the same thing with artists. I think we have to think like a computer, like did, um, what did we doing to make this?

Dr. Shah:

So it's consistent from patient to patient. So the experience, so from someone with blonde hair, um, you know, so from, uh, Eric and August hair, if you look at their hair, you say, how can we make your hair? Both of you guys have fantastic hair, by the way, I'm not telling you, you should be on the, uh, uh, under the artist a thing yet. Uh, but you both have option here, but making sure that your hair results your case, if you have two patients similar hair, you're going to get the exact same experience. And so we've tried really hard to make sure that that's the SU, because I don't think it's the artist, it's the, it's us doing that aspect, which I found to be true too.

Speaker 4:

Yeah, no, I think that that consistency is, is a really important thing. And, you know, I sometimes think of artists as like a, uh, as like a surgical fellow that, uh, is always there. It's it, um, always shows up it's the best fellow you could ever have because it's, it's always happy to be working. It's never gets tired. It does exactly what the attending physician says. And it's always accurate, always precise. Um, every single time

Dr. Shah:

Kind of a trend I'm seeing inherit now too, is I'm seeing people getting fue elsewhere. Sometimes they're going overseas, they're going to people handheld fue, and then what's happening to the back of their head is you see an obvious, I'm not my hair. I have an artist that you can't see anything, so I can show that in the back. But what you see is this, it's like a shotgun went off in their head and you can see these obvious areas where they're missing hair, obvious things, there's obvious patterns of hair loss. And, um, again, I can't speak to that cause I don't do handheld like that. But, um, can, can you explain why are artists, uh, prevents over, uh over-harvesting and prevents that visibility? So what's built into it, what's baked into it to prevent that, that look, cause I've never seen it, one of my artists patients, but I see it all the time in these outside patients and it's really, it does a disservice to fue, right?

Speaker 4:

Yeah. I mean, the artists can be programmed to harvest whatever, you know, number of hairs and there, it has intelligence to sort of choose hairs in a way that that sort of leaves it natural. So if you just set it up and you set certain parameters on that, like how much, um, you know, how much density you want to leave, or, you know, what's kind of spacing you that you want to get, uh, uh, as a doctor between your harvested hairs, the robot will do that and it'll do it in a way that leaves a natural result. Um, if you're doing it just by hand, you're sort of, uh, kinda picking and choosing. And, uh, it's sometimes hard to see the forest through the trees and that type of situation. So there may be cases where someone just doing it by hand and over harvests harvest area, artists will never do that. Um, unless the doctor programs it in and says, yes, I want you to harvest every single hair in this area, which you know, they wouldn't do. But, um, there are a lot of, uh, that's part of the, a great automation and the intelligence of the system is that the doctor can sort of set the basic parameters and the artists we'll go and we'll select the right hairs and leave a result. That is a very natural looking result.

Dr. Shah:

Okay. W we're going to talk about sight making for a little bit. And so, um, we, we talked a lot about the harvesting aspect of artists. Um, we've talked and so, uh, for site making for the audiences, once the hair is harvested, you talk about making sites where the hair's going to go. And, um, uh, so w we'll talk about that aspect. So with the artists system right now, we'll talk about site making before we talk about graft implantation. Um, and then we'll talk about where you think that's going to go in the future and some challenges. Uh, so with site making, essentially what happens is we make little sites throughout the head. Um, and then those are the sites where the hairs that have been taken out are going to go back into, um, into the, into the hell, into the scalp. So, um, with site making, um, that's been probably the second phase.

Dr. Shah:

Um, obviously the, uh, the harvesting is still always being updated, but that was the second phase of, of the artist system was assigned making. Um, uh, so what were some of the challenges of site making and what are some of the areas that, um, I, I currently do site making by hand, um, uh, I'm a data driven guy. Um, so, um, maybe you'll convince me, I have that feature. Maybe you convince me to, I should use that more. Maybe not more, uh, we'll go back and forth and talk about that too a little bit. So let's talk about site making. What were some of the challenges and where it's at right now?

Speaker 5:

Uh, yeah, I mean, side making is a great option for physicians. Um, so one of the main, um, feature of decide making, uh, is that the doctor is still in fully in control. So we provide software to create a treatment plan. So the doctor can choose, uh, where all the hairs are going to be placed in which directions they're going to grow. What are the densities, um, and the, that plan is they're being transferred to the system, which executes that plan when the system creates sites. Uh, we can see here just like when we do harvesting, we also see here existing terminal here, and we avoid them. So that can be, um, that's easier for us than a person just doing it by hand, of course, for all, all non reasons that we talked about. Um, and, um, you know, our speed is also well over 2000 sites per hour, so it's quite comparable probably faster than a human hand.

Dr. Shah:

Um, yeah, and I think my, uh, my use of sight making is if I shave the head, I'm doing sign making, and if I'm, um, if I leave the hair long on doing it, doing it by hand, and that typically is how I roll with it. Um, and I think the advantage of that, I think the cool thing in the sight making software, as you can see the number of hairs that were saved, which is a nice thing for patients to see that and visualize that aspect of it. Um, that's one of the challenges in site making. Um, I think, uh, is temple still a hairline and crown, right? That's still, um, would you say to couple areas that kind of designing the front of the hairline, which I get, that it comes into the surgeon aspect of it, that's the artistic aspect of it. Um, and then, um, and temples, uh, and do you think that will change anytime soon or you think that's still always going to be kind of one of those hand touches?

Speaker 5:

Uh, so hairline a is not a problem solver time. We talked about, you know, system being improved. So recently we have improved the workflow. So when we do site making actually patient sits in a, in a nice, comfortable position, which also allows the system to have a really good angle for creating a hairline. And we also provide, uh, very nice software tools for the doctors to replicate exactly what they would do by hand, we have special, uh, algorithms that we developed with, uh, together with, uh, um, very important doctors, how to procreate, um, hairline properly. So we, the system can do hairline. Nope, not a problem. And in addition, the new robotic arm is, uh, has, is able to maneuver better and we can get to the harder areas that, that were harder in the past, so we can get to the temporal areas easier, easier,

Speaker 4:

Right. And then the crown, the crown is, is, uh, for future development. And we fully expect to be able to do that. Uh, you know, it's, um, it's a big challenge, a bigger challenge to, to train a robot to go around in that. Um, there's a lot of logical things that you have to put in place and will decision-making that you have to, you know, uh, allow the, the system to do teach the system to do so that's definitely on our roadmap, but I think, you know, supporting what Augie said is we have, we do have some features, some new features now that allow for, uh, um, the establishment of the hairline helps the doctor do design. And then of course, um, it, it executes exactly the design that the doctor wants. So, um, um, we're, you know, we, we encourage the doctors to try that, but we also know that some doctors really like to do that by hand and that's totally fine and appropriate. It's just however they feel, uh, best.

Dr. Shah:

Um, and then, uh, if we're talking about, uh, implantation, so, um, you know, kind of implanting hairs, um, how, how has that changed over the last, uh, you know, um, I probably wouldn't say a few months, I'm sure that's still kind of a rapidly evolving, uh, technology part of that.

Speaker 4:

Um, yeah, so, so implantation is the newest, um, uh, functionality that was launched with our most recent platform, which is the IMX system. And, um, implantation is, you know, in some ways, I mean, it started at a really good level, but we're already seeing improvements. And most of those improvements are in the, sort of the, again, the surgical workflow and the sort of the speeds and rates that we can work at. Um, you know, this is, this is brand new stuff, right? We're, we're, we're sort of creating this. Um, and no one's done this before. And so there's always going to be a lot of learnings, but, and what we're seeing just in the, maybe the, you know, seven or eight months that the system's out there is that we're able to, um, doctors are able to more consistently, uh, achieve, you know, implantation rates that, um, rival, let's say one or two, two, um, texts like implanting. So we're talking about the six to 700 grasp per hour implantation. Uh, we're making it just more consistent, so doctors can achieve that in a more regular basis.

Dr. Shah:

Um, what's the smallest, uh, um, what's the smallest that you can make with sight making. Can you make it with, can you go down to a 20 with that, um, on, uh, or is it 19 or 18? Did you ever implant, uh, 19, uh, 19 gauge for a side making an implant? Yes. At 19 for that. Okay. That's what the company,

Speaker 4:

A millimeter.

Dr. Shah:

Yep. Okay, cool. Um, and then, um, uh, so again, awesome, amazing product that, um, I think that anyone thinking about hair and this is myself included, um, I'm, I'm an artist person, uh, that, uh, I'm, uh, again, I love my hair and, uh, it's always, uh, uh,

Speaker 4:

By the way, I was really happy to hear that you had an artist procedure cause your hair looks fantastic.

Dr. Shah:

Uh, it's not Photoshop, it's not a filter you're looking at when it goes off. You're not going to see like a giant dome, uh, going through here. Um, so where do you see artists in the future? So it's so many different areas. I use it off label. I talked about some things that I use it for, which I probably not. Um, I don't know if those are areas that you guys are studying. I use it for eyebrows. Um, I love it for eyebrows. It's amazing because you can pick ones, you can do different things with it, or I love it for it. I think in the past it was studied for African-American hair and actually we use an African-American w with great success. Um, and we have a lot of patients with traction, particularly African-American females. Um, and, um, we were a little nervous, usually this at the beginning and it's, um, it actually, we don't actually have to alter the angles too much. I was talking to a lot of people before we, um, we were starting to do this. It's actually super adept at doing that aspect of it. Um, and so, um, white hair, which is off-label blonde hair, we've used that obviously there's, there's alterations to this. Um, where do you see this product, um, in the future, uh, and, and future directions of where this is going.

Speaker 4:

Yeah. Give my opinion and I'll give you his, I mean, I know that, um, you know, we're going to continue to press the boundaries of the, the, uh, functionality and the technical aspects. I mean, for me, I see the cases becoming faster and more efficient. Uh, you know, we'd like to get the sizes down. So a doctor can, uh, can consider doing two cases in one day on a system. I mean, typically a hair restoration cases, a full day. Uh, we think that we can get it to a point where, uh, we can get it fast enough and efficient enough. So a doctrine can do two a day and that just really helps, um, you know, get with their, with their throughput. And, um, you know, if they're having technicians there, it sort of makes it, um, uh, more worth the while of having that technician there.

Speaker 4:

Um, I think we talked about some of the expansion to be able to do the crown. So I guess, providing it just a complete solution before be able to do hair everywhere. I think, you know, speaking to the, you know, the off label and things, of course, you know, our, our, um, we're, our indication is for straight dark hair on males. Um, that's a, that's a product of, of the study that we did. So we had to do a clinical study to get our clearance, uh, for hair transplantation. And, and, and, uh, on that study, we use males with dark hair, um, you know, for you, if to expand that indication, we would need to go back and redo that study for every other single type. And, you know, that's something we'll consider it, but, um, those that's a very difficult study to do because you're literally counting hairs and you have to wait a year after you do the patients and you have to follow them quite a long time. So, um, you know, there, there are some issues around that, but, um, um, we, um, you know, the, the same tools, you know, the, the, the system is the system and the doctor, um, is licensed to use that in the way that he or she thinks is best and what we have definite indications that, that we stick to when we talk about. Yeah.

Speaker 5:

Yeah. And I totally agree with Eric. I think a company as a company, we are quite focused right now on delivering a harvesting and implantation completely done in a much more reasonable time than right now. I mean, it's pretty difficult, both for the patient and for the doctor to do a hair transplant whole day to help the lungs. So we, we are committed to, to lessen that pain and, um, that's beneficial for the patient. It's, it's good for the, for the doctors as well. And, uh, we are on a good, uh, um, um, path to deliver that.

Dr. Shah:

Actually, I don't like the word hair transplant. And that sounds strange because I actually think it's an antiquated term and it's used from people using strips. And I actually think when the way people think of hair transplants, I think is kind of different because people used to think of this, Hey, guess what? I'm going to do a strip, and you need a minimum number of hairs. You need a thousand hairs or 2000 hairs. And I think a lot of people, especially the older surgeons think in those terms. Um, and I don't, I don't like that word hair transplant. I've had it done. I don't like saying I've had a hair transplant. So I actually say hair or redesign. Um, and I, I have a lot of patients who come in and say, Hey, guess what? This bothers me. I have a little issue with my temples.

Dr. Shah:

I have a little issue with this aspect. And if you want to throw 500 hairs, it's not a big deal to harvest 500 Harrison, put 500 hairs in someone to do bruh. So it you're redesigning your hair and that's the aspect of it. So I think of this almost as this fluid plastic, uh, again, this is me being a facial plastic and hair surgeon, um, that aspect. So I'm not a big fan of the word hair, um, a hair transplant. I like hairy design, cause I just don't think it's helpful. And it got along those thoughts, um, when people do a hair transplant, they're limited because they have a scar in the back of their head. And a lot of my patients, they want to wear their hair really short. And it's kind of underestimated that you can't do that anymore. It's never emphasized to them.

Dr. Shah:

And they sh they cut their hair down to a two guard and like, oh my God, what's this white line there. How do I get rid of it? Um, and so you want to have more hair flexibility, not less flexibility. You want to be able to do more things with your hair. Part of the reason I did it was because I wanted to do some crazy haircuts, but my hair actually, I didn't do anything crazy. My hair's not purple and a Mohawk, but, um, do you want to be able to do whatever you want to do with your hair? You can do that. And I think that's the whole point of, of this. Um, so, uh, yeah, so fascinating stuff with that aspect. Yeah. Um, I think another interesting thing is how artists is dedicated to their users. And, um, you guys had a user meeting, uh, typically every other year, every year where all the people with artists come together.

Dr. Shah:

So it's not just, you know, the AI part where people are, you know, the computers, you're getting the data, it's actually people talking about things. And you can see that, um, uh, I think Eric, you were at the, we were at the meeting in Las Vegas. I was at the, uh, uh, I was not, I missed that one, but, uh, my, my, my colleagues were for sure. Yeah. Okay. Um, but I saw a decent number of colleagues there. And it's interesting because, um, uh, you see this collaboration of what people are talking about. What's working, what's not working and you see a lot of people kind of taking notes of, you know, within the company itself and say, w what can we do to make this better? Because this isn't not like a static product that's fixed, it's a product that's always evolving, always getting better.

Dr. Shah:

And that's been my experience with, um, with, even within the last year, um, actually at the meeting, I was actually telling, uh, Augie about this a little bit earlier. Um, they had a magician, it was in Las Vegas, the last meeting. Um, and they randomly picked me up to go on stage. Um, and so one of the magicians act, uh, he had a night and he said, I want you to hold this board and don't move. And so we threw a knife, I have it on video and the hit, I think it's a real mic. I'm not sure if it was a real knife. And I was like, oh my God. Um, if you hit the hair, at least I, we can repair that and put some more hair up there, but, uh, don't hit my hands or hit my, it hit my face.

Speaker 4:

Yeah, no, I mean, I think your, your points there are, you know, appreciate them and, you know, we are always looking at making it better. And I think the other thing you touched on before was sort of the training, the educational aspects like this. Yeah. This is a different procedure than just say a laser procedure where you buy the box and then you send a technician in, you know, you are, uh, you know, basically you're taking tissue from them, placing a body movement to another, it's a surgical procedure. So, um, it's very important for us that we provide all the support that we can to our customers that's in training and then users meeting are a great way to share best practices and, uh, for us to be able to communicate those and then have the users talk amongst themselves and, and compare it, say, how do you get these, you know, how, how do you do your procedure? How do you become more efficient and things like that. So, um, we're super dedicated to the support aspect. Um, and you know, we want, you know, our, our success is tied to our customer success. Um, and we're just always striving to make it better, faster, easier, um, for a doctor to give a patient the outcome that he or she wants. Yeah.

Dr. Shah:

Uh, I try to write this a little bit, but I, quick question I always get asked is, um, why aren't more people, why aren't more hair surgeons using artists? Because I saw it, I saw the latest version. It was like, it wasn't even, it wasn't even close. I mean, we talked about some of the, um, kind of physical advantages. We talked about some of the stereoscopic advantages we talked about, you know, kind of so many things built into it. Um, it's almost like a chess match. You can see the artist is not only harvesting the heritage working on it already knows where it's going next and it already knows where it's going next. So it's always a step ahead. Um, so my question is, um, as a patient, uh, you know, and as a doctor, I know what's best. Um, why do some docs still not get it? Like, what are some of the obstacles? I'm not sure you guys are on that end and more than the development, but w w

Speaker 4:

Yeah, I mean, I think I could probably speak to that a little bit. Um, you know, I think that, um, like in general, doctors are, um, fairly conservative and resistant to change and for good reason, right? I mean, they're, science-based, and they, um, want to make sure that, uh, when, when they get a technique that they believe works in their hands, of course, that's, that's the technique that they're going to use. And it's, it's, uh, sometimes difficult to change those ways. And I can speak also from experience of, um, you know, coming from a company like intuitive surgical, where you're training surgeons who have been doing a surgery a certain way to now use a robot. Um, there is a learning curve and someone becomes very, very good at doing a procedure in a certain way. And then you say, Hey, look, I've got a different way to do it.

Speaker 4:

They kind of have to go back and learn. And, uh, many doctors maybe aren't as, uh, open to doing that. They feel like the, what they do is, is good for their patients. So I think there's, you know, from our standpoint, I mean, we're, um, we have a long way to go in terms of, of, um, educating the community. Um, you know, what we, we try to, you know, do this through the different societies and things like that. And I think that, um, really, you know, as we, um, now have a device that provides a more complete solution where it can do the implantation, as well as the harvesting and the site making that doctors will start to see the, uh, the, some of the benefits there. Um, I think, you know, one of the things that we've talked about is some of the physical issues that dressy do.

Speaker 4:

And, you know, I think we'll see that in terms of preserving their, their career and, and their body and just the pain that they might feel, um, that using a robotic assistance solution is really quite a good thing that it actually can prolong their, their career and their practice. Um, they don't go home aching and having pains, uh, over the bodies because they're crouched over in certain ways trying to manipulate something thousands and thousands of times. So I think that, you know, um, we have a very, um, dedicated base of users that many are, are, came up as hair surgeons. We also see now that, um, there are other types of say dermatological, uh, surgeons, or, um, other doctors who are adding, uh, the hair hair, uh, uh, how'd you say, hair remodeling as a, as an redesign as a, as a, um, something that they offer.

Speaker 4:

And so, um, as we sort of get the word out and we have sort of add these features, I think the sort of the tipping point is coming where they're gonna say, okay, I see what it takes me to do it this way. I can go over here and do it the other way, and they're gonna start to choose a robotic assisted. And I, you know, I think that's in general, the trend in, in, um, in the, you know, in, in our, in our world that we're seeing the benefits that robotics can bring to many, many little tasks. Uh, and this is just a perfect one for a robotic application

Dr. Shah:

And in the hair world, it's interesting that even microscopes believe it or not, it's something like when people are looking at hair follicles, which is clearly a, the standard people were resistant to that in the nineties and then people. So it's like you see this resistance and even with open gallbladders versus laparoscopic people resistance to that. And I think one of the things you see is when people know a certain way of doing something, they feel like that's the best way. And they have to be, like you mentioned, it's open-mindedness to two things that are different than they're used to. And I think that's one factor is, uh, maybe close-mindedness open-mindedness of that aspect. Um, and, uh, you know, I always try to embrace technology, and I think that, um, if you deliver better outcomes for your patient, um, and, um, and the more educated patients right now are seeking this, I think they're demanding, uh, this technology.

Dr. Shah:

Um, and, um, I don't have people, again, I'm a different practice because I only do artists, but I don't have people saying, would you please do a strip on me? I mean, it's just like, not something we would even offer them. Uh, but I don't have that, uh, that aspect. And, um, or would you please not use this high-tech piece of equipment and just use your hand to take it out? I don't have anyone telling me to do that. So I think that's, um, you see where the trend is, and if you see where the future of medicine is going, it's not going to be going back to handheld stuff. It's going to be going more towards, um, automated, uh, improvements, uh, that, you know, we can do that. And combining the best of, um, artistic design with robotic design altogether. No.

Speaker 4:

Right. And I think your point about the, your consumers these days, they're very educated and they're, they have a lot of information at their fingertips and they, they will go and do the research. I mean, back in the day, you could go to the doctor that I said, well, here are your two options. And now, you know, that the patient would come in and say, I know all of the options I've done the research. There's five. Tell me about these two, or here are the ones that I'm interested in. And I think, you know, as we start to get, uh, like you said, patients, um, are seeking this type of technology. You're going to get more doctors who say, okay, I better take a look at what's going on here because I'm getting more and more people coming in and saying, I've done the research I know about what the strip is.

Speaker 4:

I know about manual fue. I know about suction devices. And I also know about artists, and I want you to tell me what's the best for me. Um, so doctors really kind of need to get on the ball with some of this new technology. You're also gonna miss I think a big part of the patient population, particularly, you know, the younger generations now, the ones who are sort of coming of age and, you know, certainly needing, you know, maybe looking for a hair remodeling, um, every development, every design and their, their hair redesign. And, and they, um, they want technology, they embrace technology and they, they see the benefits of that. And so, uh, you know, some doctors that aren't really up on that they're gonna miss, um, this whole class or generation of, uh, patients looking for these types of solutions.

Dr. Shah:

Awesome. Well, thank you so much for educating me and educating our audience on, on artists and, uh, and thanks for doing all you do for all of our patients, uh, including myself. Um, so, uh, uh, thanks so much, guys. Yeah,

Speaker 4:

Well, it's a pleasure. Thank you so much, Dr. Shaw.