P
Purist
Valued member
Hi
Does anyone know what are the benefits of the FUE "ARTAS" system?
Thanks
Does anyone know what are the benefits of the FUE "ARTAS" system?
Thanks
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Westcoaster
member
I believe the Artas is inferior to hand held punches. If you have an abundance of donor hair it could work for you, otherwise the donor harvesting by this machine is limited. Reasons :- after studying patient cases it appears the Artas will harvest from prime donor areas mainly the mid section of the back and sides of the scalp, it does not appear to harvest from the trickier hard to get to areas. It also uses a larger punch than the hand held options.
topccat29
29 year HT veteran
The benefits of the ARTAS is that it is a turnkey system. Very easy for anyone with a medical license to hang a shingle and get into business. Also a good system for those in the past who deterred patients from having FUE even if it was the better option as they did not possess the skills or the trade off on their bottom line was not high enough. This system makes it easier for those same clinics to now promote the procedure. Good system for those with poor eye/hand coordination and weak hands.
In the long run it could cut down on staff overhead which would make it more profitable. Last year there was a big conference by one of the clinics promoting this device and one of the bullet points included
Turn your clinic into a million dollar operation
I would probably say that is going to be a big positive for many. Maybe not so much for the patient but obviously for some of the clinics.
One can also perform more extractions in one sitting then by hand. For example this procedure extracted 5000 grafts. Most doctors performing by hand would not extract that many grafts and even when the numbers go higher it's done over a 2 day period. Their hand actually acts like a governor...............a safety mechanism that regulates the speed. With robotics it almost like opening up the carberator on a 69 GTO I guess it can be kind of a thrill ride.
In the long run it could cut down on staff overhead which would make it more profitable. Last year there was a big conference by one of the clinics promoting this device and one of the bullet points included
Turn your clinic into a million dollar operation
I would probably say that is going to be a big positive for many. Maybe not so much for the patient but obviously for some of the clinics.
One can also perform more extractions in one sitting then by hand. For example this procedure extracted 5000 grafts. Most doctors performing by hand would not extract that many grafts and even when the numbers go higher it's done over a 2 day period. Their hand actually acts like a governor...............a safety mechanism that regulates the speed. With robotics it almost like opening up the carberator on a 69 GTO I guess it can be kind of a thrill ride.
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Westcoaster
member
Depending on quality of person doing the extractions I don't believe the Artas is faster at all. There is a protocol that has to be followed whilst using this equipment. You have an operator monitoring the screen, a doctor mapping out the extraction zones, usually one or two technicians extracting the grafts plus the technicians who will examine and cut the grafts.
During the operation the patient will have their head strapped down to prevent any movement, a small mapped out segment will be punched then then extracted. Then the patient will be unstrapped, re positioned and strapped down again for the next grid. This takes quite some time, admittedly the robot will not suffer from fatigue but the whole procedure will take longer than someone extracting via a hand held device.
It looks extremely uncomfortable for the patient having the head strapped down for long periods of time. Clinics who have perfected fue can achieve 4000 graft procedures by hand in a single day.
Some will say this may cause additional trauma and should be split over two days, I don't think there has been any conclusive studies carried out to prove this.
During the operation the patient will have their head strapped down to prevent any movement, a small mapped out segment will be punched then then extracted. Then the patient will be unstrapped, re positioned and strapped down again for the next grid. This takes quite some time, admittedly the robot will not suffer from fatigue but the whole procedure will take longer than someone extracting via a hand held device.
It looks extremely uncomfortable for the patient having the head strapped down for long periods of time. Clinics who have perfected fue can achieve 4000 graft procedures by hand in a single day.
Some will say this may cause additional trauma and should be split over two days, I don't think there has been any conclusive studies carried out to prove this.
A
Admin
Member
Here is an article by Dr Ball.
Robotic FUE hair transplants
Mr Edward Ball was the first hair surgeon in Europe to introduce a hair transplant robot to his practice. He discusses the technology, its development, its benefits and limitations and a look to the future
Patients desire full and natural looking hair. For years we have been able to achieve these goals with the strip technique, which involves removing a piece of skin from the back of the head. However, patients also want minimal scarring it s no good having a great hair transplant with a troublesome scar.
The development of follicular unit extraction (FUE) has been a huge step forward because the removal of individual follicular units leaves tiny dot scars, rather than the linear scar from a strip procedure. This gives far more flexibility in hair style or length. However, there are limitations to FUE. It is a skill that takes time to learn and it is labour intensive. Each follicular unit is extracted individually in a process that can take several hours. This can lead to patient and surgeon fatigue and a potential loss of graft quality.
Hair surgery involves fine precise movements of a repetitive nature and this is an area in which robots excel. A robotic system can provide a solution that is precise, consistent and efficient and, of course, robots do not fatigue. A robotic harvest can produce robust, high quality grafts thousands of times in a single session. This accuracy and consistency can enhance the patient and surgeon experience whilst optimising graft survival and growth.
A robot for hair surgery
I use the ARTAS system, which utilises an image-guided robotic arm, which assists the surgeon by dissecting the individual follicular units, allowing them to be extracted by a manual forceps technique. The remainder of the hair transplant process is currently no different to manual FUE surgery.
A magnified image of the patient s scalp is displayed on a 55 inch screen, providing detailed visual access to the donor area. Viewing the skin in three dimensions, the ARTAS Robotic System uses programmed algorithms to select the follicular units, adjusting for variations in hair angle and direction, as well as skin texture and depth, to achieve a consistent harvest. Taking readings 50 times per second, the robot is able to safely compensate for any patient movement.
It has a unique two punch system an inner sharp needle and an outer rotating dull punch. The sharp needle scores the skin, anchors the punch and opens the way for the outer, blunt punch to dissect down around the follicle. Minimising the sharp dissection reduces the risk of transection damage to the follicle. The surgeon is able to adjust the settings without interrupting the procedure, producing extraction rates of approximately 400-800 grafts per hour, depending on the patient s hair and skin characteristics.
Patients are prepared for the robot in much the same way as for a manual FUE procedure. Their hair must be cropped short (grade 0) at the back and sides. We dye the donor hair if it s fair, grey or white because the robot has to be able to see the hairs. Without the need for stitches, patients can experience a comfortable recovery and may return to work within a few days of the procedure.
A team of four individuals is required to operate the robot. This comprises the surgeon with a handset controller (responsible for tensioner placement and managing dissection parameters, follicle selection and graft quality), a technician manning a desktop computer (assisting the surgeon), a technician performing forceps extraction of the dissected grafts alongside the robotic punch mechanism and a technician at a microscope who inspects and counts the grafts and performs any limited graft trimming as required.
Origins
The ARTAS System, developed by Restoration Robotics, showed during the preliminary studies a transection rate of 8% was compared to a figure of 26% for manual FUE.
There have been numerous updates to the software that has seen increases in efficiency and automation. The transection rate is now close to 5% and with the latest update we are able to achieve harvests 500 to 1000 grafts per hour.
Robot-assisted surgery certainly reduces fatigue and patients enjoy the aesthetic and comfort benefits associated with a lack of stitches or linear scarring. Patients can potentially undergo larger sessions than might be achieved manually, therefore creating greater recipient density and coverage.
Limitations
Some patients find the chair uncomfortable during longer sessions. In order to enable the robot to access various areas of the head, the chair requires positional adjustments during the case. The tensioner device, which stretches the skin and orientates the robot, can be tricky to position well in certain parts of the scalp and in patients with very lax or mobile skin. The requirement to shift the tensioner each time a new area of donor hair is to be harvested can slow down the extraction process. Some parts of the head can present a challenge to harvest with the robot, highlighting the importance of a surgeon s competence in the manual FUE techniques.
The 1.0mm diameter of the sharp inner needle is larger than some manual FUE devices and may, therefore, leave slightly larger dot scars. However, the patient s skin characteristics tend to hold more influence over scar appearance than small variations in punch diameter. The robot s larger needle may, in fact, help to produce more robust grafts with greater tissue support.
Future developments
So what s next? A smaller punch has just become available. It measures 0.9 mm and will provide greater flexibility, enabling the surgeon to tailor the punch size to the patient s hair calibre and donor density.
I d like to see some more surgeon control, including the ability to choose precisely which units are to be harvested and to specify a certain number of one, two or three hair follicular unit grafts. I expect this will soon be possible.
In the US, the robot can already make recipient site incisions and I have little doubt that it will ultimately be able to actually extract the grafts and place them into the recipient area.
I find it is an amazing piece of technology which is capable of producing remarkable hair restoration results. With the right patient it produces excellent grafts with efficiency and consistency. However, I don t think there will ever be one solution to all patients needs. I believe that a hair surgeon should also be skilled in the manual FUE technique, allowing them to select the best approach for each particular patient. It is hard to beat the artistic skills of an experienced doctor but a robot is certainly an excellent tool that has a great deal to offer both surgeons and patients. I have no doubt that robotic hair restoration is here to stay and it s going to be very exciting to see where it takes us in the future.
Mr Edward Ball is a hair transplant surgeon in London and clinical director for Ziering UK
Robotic FUE hair transplants
Mr Edward Ball was the first hair surgeon in Europe to introduce a hair transplant robot to his practice. He discusses the technology, its development, its benefits and limitations and a look to the future
Patients desire full and natural looking hair. For years we have been able to achieve these goals with the strip technique, which involves removing a piece of skin from the back of the head. However, patients also want minimal scarring it s no good having a great hair transplant with a troublesome scar.
The development of follicular unit extraction (FUE) has been a huge step forward because the removal of individual follicular units leaves tiny dot scars, rather than the linear scar from a strip procedure. This gives far more flexibility in hair style or length. However, there are limitations to FUE. It is a skill that takes time to learn and it is labour intensive. Each follicular unit is extracted individually in a process that can take several hours. This can lead to patient and surgeon fatigue and a potential loss of graft quality.
Hair surgery involves fine precise movements of a repetitive nature and this is an area in which robots excel. A robotic system can provide a solution that is precise, consistent and efficient and, of course, robots do not fatigue. A robotic harvest can produce robust, high quality grafts thousands of times in a single session. This accuracy and consistency can enhance the patient and surgeon experience whilst optimising graft survival and growth.
A robot for hair surgery
I use the ARTAS system, which utilises an image-guided robotic arm, which assists the surgeon by dissecting the individual follicular units, allowing them to be extracted by a manual forceps technique. The remainder of the hair transplant process is currently no different to manual FUE surgery.
A magnified image of the patient s scalp is displayed on a 55 inch screen, providing detailed visual access to the donor area. Viewing the skin in three dimensions, the ARTAS Robotic System uses programmed algorithms to select the follicular units, adjusting for variations in hair angle and direction, as well as skin texture and depth, to achieve a consistent harvest. Taking readings 50 times per second, the robot is able to safely compensate for any patient movement.
It has a unique two punch system an inner sharp needle and an outer rotating dull punch. The sharp needle scores the skin, anchors the punch and opens the way for the outer, blunt punch to dissect down around the follicle. Minimising the sharp dissection reduces the risk of transection damage to the follicle. The surgeon is able to adjust the settings without interrupting the procedure, producing extraction rates of approximately 400-800 grafts per hour, depending on the patient s hair and skin characteristics.
Patients are prepared for the robot in much the same way as for a manual FUE procedure. Their hair must be cropped short (grade 0) at the back and sides. We dye the donor hair if it s fair, grey or white because the robot has to be able to see the hairs. Without the need for stitches, patients can experience a comfortable recovery and may return to work within a few days of the procedure.
A team of four individuals is required to operate the robot. This comprises the surgeon with a handset controller (responsible for tensioner placement and managing dissection parameters, follicle selection and graft quality), a technician manning a desktop computer (assisting the surgeon), a technician performing forceps extraction of the dissected grafts alongside the robotic punch mechanism and a technician at a microscope who inspects and counts the grafts and performs any limited graft trimming as required.
Origins
The ARTAS System, developed by Restoration Robotics, showed during the preliminary studies a transection rate of 8% was compared to a figure of 26% for manual FUE.
There have been numerous updates to the software that has seen increases in efficiency and automation. The transection rate is now close to 5% and with the latest update we are able to achieve harvests 500 to 1000 grafts per hour.
Robot-assisted surgery certainly reduces fatigue and patients enjoy the aesthetic and comfort benefits associated with a lack of stitches or linear scarring. Patients can potentially undergo larger sessions than might be achieved manually, therefore creating greater recipient density and coverage.
Limitations
Some patients find the chair uncomfortable during longer sessions. In order to enable the robot to access various areas of the head, the chair requires positional adjustments during the case. The tensioner device, which stretches the skin and orientates the robot, can be tricky to position well in certain parts of the scalp and in patients with very lax or mobile skin. The requirement to shift the tensioner each time a new area of donor hair is to be harvested can slow down the extraction process. Some parts of the head can present a challenge to harvest with the robot, highlighting the importance of a surgeon s competence in the manual FUE techniques.
The 1.0mm diameter of the sharp inner needle is larger than some manual FUE devices and may, therefore, leave slightly larger dot scars. However, the patient s skin characteristics tend to hold more influence over scar appearance than small variations in punch diameter. The robot s larger needle may, in fact, help to produce more robust grafts with greater tissue support.
Future developments
So what s next? A smaller punch has just become available. It measures 0.9 mm and will provide greater flexibility, enabling the surgeon to tailor the punch size to the patient s hair calibre and donor density.
I d like to see some more surgeon control, including the ability to choose precisely which units are to be harvested and to specify a certain number of one, two or three hair follicular unit grafts. I expect this will soon be possible.
In the US, the robot can already make recipient site incisions and I have little doubt that it will ultimately be able to actually extract the grafts and place them into the recipient area.
I find it is an amazing piece of technology which is capable of producing remarkable hair restoration results. With the right patient it produces excellent grafts with efficiency and consistency. However, I don t think there will ever be one solution to all patients needs. I believe that a hair surgeon should also be skilled in the manual FUE technique, allowing them to select the best approach for each particular patient. It is hard to beat the artistic skills of an experienced doctor but a robot is certainly an excellent tool that has a great deal to offer both surgeons and patients. I have no doubt that robotic hair restoration is here to stay and it s going to be very exciting to see where it takes us in the future.
Mr Edward Ball is a hair transplant surgeon in London and clinical director for Ziering UK
topccat29
29 year HT veteran
I like that the article notes the larger dots with the 1.0 mm punch. In the past the clinics that were offering this device would just keep repeating that this was not the case and that larger dots did not matter. Why would anyone keep repeating this ¦ ¦ ¦ ¦ so that they can get customers into the chair. So in a way they were just telling a lie and that is the problem. Once you starting telling lies then most of what one says cannot be believed. Does this matter...............I guess only if you are the patient.
The article states that the transection rate for manual fue is 26%. Does anyone here actually believe that number. Is that a true number or is that a number chosen from some source in order for someone reading this piece to actually believe the device works better then a small hand punch in skilled hands. Kind of treating the reader as not being smart enough to know any better.
The funny thing with numbers is you can manipulate them to say whatever you want them to say. I have watched one doctor over the last 10 years do mega session fue and I would say he transaction rate is 50% judging by the results so why not just use that number. My own experience with manual fue tells me my extraction rate was about 0%-1% so I would use that number. We can now say that this device is fine except that the transaction rate is 4 times higher than that of a skilled doctor using a much smaller hand punch. Hmmmm..............4 times higher...............wow that now sounds kind of messed up to me, not sure I want to waste 4 times as much hair and have to toss it into the garbage can. After all it is a finite source so that is going to matter.
We could also say that the wound size of a .75 punch compared to a .9 punch is just under 40% smaller or in other words the .9 punch is 40% larger which would of course leave a much larger dot.
Most people would just read this piece without giving anything in it a second thought which I understand. What those that work in the ht industry should understand is that when you go for a medical procedure outside of ht the same thing is being done only 10 times worse. If you don't have the information you will definitely pay the price long term. Doesn't sound too appealing does it?
The article states that the transection rate for manual fue is 26%. Does anyone here actually believe that number. Is that a true number or is that a number chosen from some source in order for someone reading this piece to actually believe the device works better then a small hand punch in skilled hands. Kind of treating the reader as not being smart enough to know any better.
The funny thing with numbers is you can manipulate them to say whatever you want them to say. I have watched one doctor over the last 10 years do mega session fue and I would say he transaction rate is 50% judging by the results so why not just use that number. My own experience with manual fue tells me my extraction rate was about 0%-1% so I would use that number. We can now say that this device is fine except that the transaction rate is 4 times higher than that of a skilled doctor using a much smaller hand punch. Hmmmm..............4 times higher...............wow that now sounds kind of messed up to me, not sure I want to waste 4 times as much hair and have to toss it into the garbage can. After all it is a finite source so that is going to matter.
We could also say that the wound size of a .75 punch compared to a .9 punch is just under 40% smaller or in other words the .9 punch is 40% larger which would of course leave a much larger dot.
Most people would just read this piece without giving anything in it a second thought which I understand. What those that work in the ht industry should understand is that when you go for a medical procedure outside of ht the same thing is being done only 10 times worse. If you don't have the information you will definitely pay the price long term. Doesn't sound too appealing does it?
Westcoaster
member
Here is an article Dr. Umar wrote on the subject.
POTENTIAL PROS OF ARTAS
The prospect of a machine delivering FUE grafts is an attractive one if the machines can replicate the touch of an expert human practitioner.Also, the ARTAS System intends to boost the speed of the extraction process.
It is the opinion of Dr. Umar that these machines may suffice for clinics who wish to provide Follicular Unit Extraction, but whose physicians are still in the process of fine tuning their surgical skills in FUE.
Ultimately, he believes that robotic technology is still in its early stages of development and limited in their ability to replicate the nuanced and finer touch of a highly experienced FUE surgeon. For instance, the robot is currently restricted to scoring follicles in the middle areas of the back and sides of the head and not for lower laying hairs of the nape or even beard and body. It obviously has restrictions with regards to the color of hair and curliness of the hair.
CONS OF ARTAS
Regardless of how sophisticated a 3-D imaging system or color identification sensor may be, an automated device will still have limitations in discerning the best follicle for extraction. For example, it is important to select donor hairs with a specific hairline or eyebrow design in mind. An algorithmic approach is very technical. Therefore, a robot cannot make decisions to fulfill an artistic vision.
Many experienced FUE practitioners may find no reason for using robotics at this stage. However, it is conceivable that novice FUE practitioners lacking a firm grasp of FUE might find robots as a more viable option; a short-cut to the necessary time and learning curve required of advanced FUE.
Nonetheless, the inherent limitations of a machine may result in outcomes that fall short of a patient s expectations.
Therefore, the need for training in the FUE procedure cannot be over-emphasized.
Other issues Dr. Umar considers to be possible areas for improvement in robotic FUE include the following:
1. While the use of a larger bore punch of 1.65mm in the robotic technique may improve on the transection rate, it also raises the prospect of certain complications or undesirable effects such as:
2. It has long been known that a technique involving the use of a sharp punch that is followed by a deeper-reaching blunt punch may increase the risk of buried grafts, which may lead to cyst formations, in addition to damaging the selected follicle.
3. If a robotic device set to automatic punches out hundreds of grafts in that 5-10cm section before the surgeon checks for transections, then it would mean the potential loss of several of those grafts before the physician realizes what is going on. A surgeon is thus best advised to constantly check on transection rates in order to help ensure the health and integrity of the follicles.
4. As mentioned before, the Artas robotic system s approval is thus far limited to those with black or brown and straight hair only.
5. After the extraction process comes the insertion phase of surgery. This is where slits are prepared for receiving the grafts. The highest level of skill is required for creating natural looking angles and orientations.
A novice FUE practitioner using ARTAS must understand that extraction is only the first step to any kind of hair transplant. The provider must be skilled in the art of recipient area designs and principles. This is something no machine can execute on behalf of a surgeon. Replicating nature requires the natural touch of a doctor and an artist.
We at DermHair Clinic believe that no robotic device can replicate the fine touch of a skilled FUE physician using a hand-held extraction device.
POTENTIAL PROS OF ARTAS
The prospect of a machine delivering FUE grafts is an attractive one if the machines can replicate the touch of an expert human practitioner.Also, the ARTAS System intends to boost the speed of the extraction process.
It is the opinion of Dr. Umar that these machines may suffice for clinics who wish to provide Follicular Unit Extraction, but whose physicians are still in the process of fine tuning their surgical skills in FUE.
Ultimately, he believes that robotic technology is still in its early stages of development and limited in their ability to replicate the nuanced and finer touch of a highly experienced FUE surgeon. For instance, the robot is currently restricted to scoring follicles in the middle areas of the back and sides of the head and not for lower laying hairs of the nape or even beard and body. It obviously has restrictions with regards to the color of hair and curliness of the hair.
CONS OF ARTAS
Regardless of how sophisticated a 3-D imaging system or color identification sensor may be, an automated device will still have limitations in discerning the best follicle for extraction. For example, it is important to select donor hairs with a specific hairline or eyebrow design in mind. An algorithmic approach is very technical. Therefore, a robot cannot make decisions to fulfill an artistic vision.
Many experienced FUE practitioners may find no reason for using robotics at this stage. However, it is conceivable that novice FUE practitioners lacking a firm grasp of FUE might find robots as a more viable option; a short-cut to the necessary time and learning curve required of advanced FUE.
Nonetheless, the inherent limitations of a machine may result in outcomes that fall short of a patient s expectations.
Therefore, the need for training in the FUE procedure cannot be over-emphasized.
Other issues Dr. Umar considers to be possible areas for improvement in robotic FUE include the following:
1. While the use of a larger bore punch of 1.65mm in the robotic technique may improve on the transection rate, it also raises the prospect of certain complications or undesirable effects such as:
- The use of larger bore punches in robots, for example 16g (1.65mm in diameter) would create larger wounds. Larger wounds equal larger scars and more healing complication potential. Regular hand directed FUE tools utilize a 0.8-1.2mm punch on average. At these punch sizes, wound size is smaller, thus wounds have less healing complications and less scarring.[/*]
- The use of larger bore punches of 1.65mm in any FUE procedure also increases the chance of damaging the adjacent hair follicles. This raises the prospect of the complication that can sometimes accompany FUE hair transplants, called the halo effect. Each halo consists of a large circular area of loss from the removed grafts and surrounding hair that is damaged by the reach of a large punch. Many of these in a donor area could create a moth-eaten look.
2. It has long been known that a technique involving the use of a sharp punch that is followed by a deeper-reaching blunt punch may increase the risk of buried grafts, which may lead to cyst formations, in addition to damaging the selected follicle.
3. If a robotic device set to automatic punches out hundreds of grafts in that 5-10cm section before the surgeon checks for transections, then it would mean the potential loss of several of those grafts before the physician realizes what is going on. A surgeon is thus best advised to constantly check on transection rates in order to help ensure the health and integrity of the follicles.
4. As mentioned before, the Artas robotic system s approval is thus far limited to those with black or brown and straight hair only.
5. After the extraction process comes the insertion phase of surgery. This is where slits are prepared for receiving the grafts. The highest level of skill is required for creating natural looking angles and orientations.
A novice FUE practitioner using ARTAS must understand that extraction is only the first step to any kind of hair transplant. The provider must be skilled in the art of recipient area designs and principles. This is something no machine can execute on behalf of a surgeon. Replicating nature requires the natural touch of a doctor and an artist.
We at DermHair Clinic believe that no robotic device can replicate the fine touch of a skilled FUE physician using a hand-held extraction device.
topccat29
29 year HT veteran
Westcoaster I agree this device appeals to only those that are novices with fue. Anyone with the highest level of skill is not going to trade down it would make absolutely no sense.
Anyone that purchases one of these gizmos is saying to themselves..........I'm not good enough.............I can't compete without it.
Yes a patient can go to a novice............maybe they don't care enough. Good for them but I think it is a decision that they will regret somewhere down the line.
Anyone that purchases one of these gizmos is saying to themselves..........I'm not good enough.............I can't compete without it.
Yes a patient can go to a novice............maybe they don't care enough. Good for them but I think it is a decision that they will regret somewhere down the line.
topccat29
29 year HT veteran
Yes the size has come down but it is still often times too large and highly skilled doctors do not use .9 punches for 1 hair grafts as it makes no sense. Keep in mind these guys that first adopted this device were the same guys that were posting about the advantage of a .75 punch over a 1.0 punch on the forums years ago along with pictures of the difference. Yet they would now use a 1.65 punch when it first came out on a patient. Do you think they told the patient? Tell me what that is about. Is it about you the patient that they pretend to care so much about?
We have to accept that some people will compromise themselves for money. Somehow they rationalize it in their brain that well ¦ ¦ ¦ ¦ ¦ ¦it s okay. The guy at the seminar told us we can turn this into a million dollar operation so let s just keep pushing forward. I have seen the guy from the seminar s fue results with a hand punch and they look like complete crap so yes they do need to use the robot as it is better than completely butchering a patient.
We have to accept that some people will compromise themselves for money. Somehow they rationalize it in their brain that well ¦ ¦ ¦ ¦ ¦ ¦it s okay. The guy at the seminar told us we can turn this into a million dollar operation so let s just keep pushing forward. I have seen the guy from the seminar s fue results with a hand punch and they look like complete crap so yes they do need to use the robot as it is better than completely butchering a patient.
