75 Robotics in Dermatology

Meghana Phiske

Key Message reliability has increased due to infallible robotic

accuracy; medical robots remain in their infancy.
• Functions of robots resemble those of Robotic assist devices, such as the da Vinci robot,
­people, but they have little or no ­intellectual guided by human hands are used perform urologic
capacity. and gynecologic surgery through small incisions
• Robotically assisted surgeries have greatly unable to accommodate human hands. Robotically
reduced skin and organ trauma, shortening assisted surgeries have greatly reduced skin and
recovery time. organ trauma, shortening recovery time, but the
operating time is increased, prolonging ­anesthesia
• May be used to perform skin biopsy, for
exposure, and there is increased expense due to
administering cosmetic injections, follicular
the single-use robotic surgical devices. In spite
unit extraction (FUE).
of the shortcomings associated with robotic sur-
• The ARTAS system is the first and only Food gery it is anticipated that robotic surgeries will
and Drug Administration (FDA) cleared increase.1
technology for hair restoration.

WHAT IS ROBOT AND ROBOTICS?

INTRODUCTION
According to the Robotic Institute of America,
Science fiction movies have glorified and vilified a robot is “a reprogrammable, multifunctional
robots and their role in human society.1 The world manipulator designed to move materials, parts,
of science fiction abounds with intelligent robots tools, or other specialized devices through v ­ arious
possessing fantastic abilities. They have skillful programmed motions for the performance of a
hands and powerful arms allowing them to move variety of tasks.” This definition fits most m
­ edical
about and even fly. They can communicate with robotics systems fairly well, in that they are
each other and can also converse with human ­typically mechanical manipulators with rigid links
beings and can think like humans.2 connected by joints that allow relative motion
from one link to another. Medical robots have
In reality, the mechanical functions of robots been applied in many fields such as neurosurgery,
resemble those of people, but they usually have orthopaedics, and urology.3
little or no intellectual capacity. They repeat pre-
programmed tasks. Generally, they have only Robotics is a branch of technology that deals
one arm, equipped with two fingers or grips, and with the design, construction, operation, and
they cannot usually move around in their working application of robots, along with computer
­
places. Most of them are firmly fixed on rigid bases systems for their control, sensory feedback,
­
and can only access a limited area.2 Some mobile and information ­ processing. This technology
robotic systems have been developed that are deals with ­ automated machines that can take
either used for educational or novelty purposes, place of humans in dangerous environments or
such as robotic tourist guides in amusement cen- manufacturing processes, or resemble humans
­
ters, or for more serious tasks like carrying heavy in appearance, behaviour, and/or cognition. The
or dangerous materials in factories. potential use of robots did not grow substantially
until the twentieth century but today it is a r­ apidly
Many fields have been revolutionized by robots, growing field with development of new robots that
like automobile industry where manufacturing serve various practical purposes.4

2629

Chapter_75.indd 2629 06/02/15 11:48 PM

 2630 IADVL TEXTBOOK OF DERMATOLOGY

HISTORIC ASPECTS Touch

According to the Oxford English Dictionary, the Current robotic and prosthetic hands receive far
word robotics was first used in print by Isaac less tactile information than the human hand.
Asimov, in his science fiction short story Liar!, Recent research has developed a tactile sensor
published in May 1941. Czech writer Karel Čapek array that mimics the mechanical properties and
in 1920 introduced the word robotics derived from touch receptors of human fingertips. Scientists
the word robot, which comes from the Slavic word from European countries and Israel have devel-
“robota” meaning labor. oped a prosthetic hand in 2009, called Smart
Hand, which functions like a real one.
In 1927, the Maschinenmensch (“machine-
human”) gynoid humanoid robot was the first and Vision
perhaps the most memorable depiction of a robot Computer vision is the science and technology of
ever to appear on film. Norbert Wiener in 1948 machines that see and is concerned with the theory
formulated principles of cybernetics, the basis behind artificial systems that extract information
of practical robotics. Fully autonomous robots from images. There is a subfield within computer
appeared in the second half of twentieth century. vision where artificial systems are designed to
The first digitally operated and programmable mimic the processing and behavior of biological
robot, the Unimate, was installed in 1961 to lift system at different levels of complexity.
hot pieces of metal from casting machine.4
Manipulation
COMPONENTS OF ROBOTS
Robots need to manipulate objects; pick up, mod-
Power Source ify, destroy and so on. Thus the “hands” of a robot
At present mostly (lead-acid) batteries are used are referred to as end effectors, while the “arm”
as a power source. Many different types of bat- is referred to as a manipulator. Most robot arms
teries can be used as a power source for robots have replaceable effectors, each allowing them to
for example, silver cadmium batteries. Potential perform some small range of tasks. Some have a
power sources could be pneumatic (compressed fixed manipulator that cannot be replaced, while
gases), hydraulics (liquids), flywheel energy a few have one very general purpose manipulator,
storage, organic garbage (through anaerobic for example a humanoid hand.
­digestion), and faeces (human, animal).
One of the most common effectors is the g ­ ripper.
Actuators In its simplest manifestation it consists of just
two fingers that can open and close to pick up
Actuators are like the “muscles” of a robot, the and let go of a range of small objects. Hands that
parts that convert stored energy into movement. resemble and work like a human hand include
The most popular actuators are electric motors Shadow Hand, Robonaut hand, while Delft hands
used especially in industrial robots. But there are are of a mid-level complexity. Shadow Hand is
some recent advances in alternative types of actu- highly ­
dexterous maipulator, with 20 degrees of
ators, powered by electricity, chemicals, or com- ­freedom and hundreds of tactile sensors.
pressed air. In walking humanoid robots elastic
actuators are used. Electroactive polymers are a
Locomotion
new plastic material that can contract substantially
from electricity, and have been used in facial mus- For simplicity, most mobile robots have four
cles and arms of humanoid robots. Elastic nano- wheels. Researchers are trying to build one or
tubes are a promising artificial muscle technology two wheeled robots having advantages such as
in early stage experimental development. Human greater efficiency and reduced parts, as well as
biceps could be replaced with an 8 mm diameter allowing a robot to navigate in confined places.
wire of this material that might allow future robots
to outrun and outjump human. Environmental Interaction and Navigation
Though a significant percentage of robots in com-
Sensing
mission today are either human controlled, or oper-
Sensors allow robots to receive information about ate in a static environment, there is an increasing
a certain measurement of the environment, or interest in robots that can operate autonomously
internal components. This is essential for robots in a dynamic environment that require some
to perform their tasks, and act upon any changes combination of navigation hardware and soft-
in the environment to calculate the appropriate ware to traverse their environment. Some highly
response. advanced robots such as ASIMO, and Meinü robot

Chapter_75.indd 2630 06/02/15 11:48 PM

 CHAPTER 75: Robotics in Dermatology 2631

have particularly good robot navigation hardware Autonomy Levels

and software.4
Control systems may also have varying levels of
autonomy.
Human-Robot Interaction 1. Direct interaction is used for teleoperated
It is thought that robots will eventually be capable devices, and the human has complete control
of communicating with humans through speech, over the robot’s motion.
gestures, and facial expressions, rather than a 2. Operator-assist modes have the operator com-
command-line interface. manding tasks, with the robot automatically
figuring out how to achieve them.
Speech Recognition 3. An autonomous robot may go for extended
periods of time without human interaction.
Davis, Biddulph, and Balashek designed the first
“voice input system” which recognized “ten digits
spoken by a single user with 100% accuracy” in ADVANTAGES OF ROBOTS5 (Box 75.1)
1952. Currently, the best systems can recognize Robots often enhance and extend human capabili-
continuous, natural speech up to 160 words per ties. They have many advantages (Box 75.1).
minute, with an accuracy of 95%.
Box 75.1. Advantages of Robots5
Robotic Voice
For social reasons, synthetic voice proves sub- 1. Robots accuracy and repeatability may reach
optimal as a communication medium making it submillimeter level.
necessary to develop the emotional component of
2. Robots can be optimized to perform tasks
robotic voice through various techniques.
demanding a high amount of precision at
fast speeds, automatically and tirelessly,
Gestures thus increasing productivity and efficiency.
Many systems have been developed to recognize 3. Robots performance output is consistent and
human hand gestures. predictable.

Facial Expression
These technical strengths may make them suit-
Robotic faces have been constructed by Hanson able for a number of hair transplantation tasks,
Robotics using their elastic polymer called Frubber, such as FUE.
allowing a large number of facial expressions due
to the elasticity of the rubber facial coating and DISADVANTAGES OF ROBOTS5,2 (Box 75.2)
embedded subsurface motors. Robots like “Kismet”
and the more recent addition, “Nexi” can produce Box 75.2. Disadvantages of Robots
a range of facial expressions, allowing it to have
meaningful social exchanges with humans. 1. Robots are costly.

2. They are nonversatile.

Personality
3. They are unable to process qualitative
Researchers are trying to create robots that appear information.
to have a personality. One commercial example is
“Pleo,” a toy robot dinosaur, which can exhibit sev- 4. They lack judgment.
eral apparent emotions.
5. The application of robots is limited by
degree of flexibility of their hands.
Control
6. Variety of replaceable hands may be needed
The mechanical structure of a robot must be for each different task.
controlled to perform tasks. The control involves
three distinct phases—perception, processing, and
action (robotic paradigms). Sensors give infor-
ROBOTICS AND DERMATOLOGY
mation about the environment or the robot itself
(e.g., the position of its joints or its end effectors). Robotic Dermatology applications provide intrigu-
This information is then processed to calculate ing opportunities for improved patient care.
the appropriate signals to the actuators (motors), Dermatologists excel in diagnosing rare condi-
which move the mechanicals. tions, but may suffer from ailments like a
­rthritis

Chapter_75.indd 2631 06/02/15 11:48 PM

 2632 IADVL TEXTBOOK OF DERMATOLOGY

and fatigue. In these situations robots excel at Flowchart 75.1: Robort-Assisted Injections
­precision and reproducibility, fluidly executing cho-
reographed movements, but lack the intelligence for The dermatologist would determine where the injections
should occur
more than following instructions. Hence the combi-
nation of dermatologists and robots is complemen-
tary and synergist; the physician being the training
Robot would be positioned over the patient in the
operator directing the robot, and the robot being
appropriate area
the reliable and steady extension of the dermatolo-
gist’s hand (Box 75.3).1
The robot creates a three-dimensional model of the
Box 75.3. Utility Robotics in Dermatology patient’s face using stereo cameras and⁄or laser scanners

1. Biopsy
Using an intuitive interface, the dermatologist would input
2. Cosmetic injections the injection locations
3. Follicular unit extraction

4. Augmented reality systems Robot would plan a path to visit each site and return to idle
position

Biopsy
Robotics is currently being used for research Physician approval for the path and each dosage
purposes in obtaining and analysis of ­
­ biopsies.
Traditionally for microscopic analysis, a 3 mm punch
biopsy is submitted for e­ mbedding and ­preparation The robot would move its manipulator along the
of Hematoxylin and Eosin slide. However, smaller precomputed path, continually verifying the patient’s
position using its cameras
specimen may be lost in p ­ rocessing or present han-
dling problems for the histology technician. At pres-
ent, it is possible to robotically slice and examine
30+ specimen from the surface of a 3 mm punch. Upon arrival at each injection site, the robot would wait
for the physician to confirm the injection location and then
Robotically excised specimens can be as small as administer the injection
0.25 mm. It obviates the need for suture closure
and is scarless. The agility of a robotic blade and
robotic microtome cannot be matched with human
hands. Hence in future robotic scarless biopsies will Hyaluronic Acid Injection
gain increasing importance. In future robots might be developed with the ability
to inject 0.1 mL of hyaluronic acid over the entire
cheek at the identical preprogrammed depth to allow
Robot-Assisted Cosmetic Dermatology
increased dermal hydration for 6 months allowing
Injection System—Future Implications a long-lasting moisturizer. Also, there might be a
The use of robotic injections is just the start. There robotic needle so small that it could fit between the
could be emergence of robotically ­ administered nerve endings to deliver the least painful injections.
injections with synthetic vision (Flowchart 75.1).
Advantages of Robot-Assisted Cosmetic
By this method the following injections could be
Dermatology Injection System
administered.
1. The robot could produce a procedure log for
patient’s electronic medical record, which would
Botulinum Toxin Injections
include a picture of the injection sites tagged
Only a robotic hand will be able to deliver precisely with the depth and dose.
4.37 units of botulinum toxin into one site on the 2. Robotic camera-guided injections would pro-
forehead. In a challenging patient, this exact toxin duce the same results time after time elimi-
dosing might allow optimal facial relaxation of the nating injection variations and inconsistent
forehead without brow drooping. It might also cosmetic results. The robotic precision would
allow rapid one unit dosing of the entire forehead help guarantee exact reproducibility.
to achieve a more uniform, natural appearing 3. Exact dosing would eliminate waste of expen-
muscle relaxation. sive cosmetic dermatology materials.

Chapter_75.indd 2632 06/02/15 11:48 PM

 CHAPTER 75: Robotics in Dermatology 2633

Augmented Reality Systems—Future In the last decade hair transplant surgeons

Implications have advanced modern-day single-follicular-
unit donor harvesting with FUE using motorized
Augmented reality systems provide users with
and robotic devices. Their work demonstrates
enhanced perception of their surroundings,
that large ­ number of harvested hair follicles
through view screens or head-mounted displays.
(>2000 ­ follicular units) can be obtained in a
These systems can assist physicians by bringing
single day with excellent patient tolerance, hair
relevant medical images and literature into view
regrowth, and a low follicular transection rate
during procedures by projecting them on the
comparable to f­ollicular unit transplantation.8
patient, such as projecting anatomical landmarks.
Automated harvesting of follicular units using
The augmented reality system would use a motion
a robot-assisted system is set to revolutionize
capture system or linkage to a robotic arm that
hair restoration surgery in terms of speed and
would track the position of the viewfinder.
efficiency and also gain wider acceptance by
patients and physicians.6
Advantages of Augmented Reality Systems
1. In invasive and cosmetic surgical procedures, the The restoration prototype system is a state of art,
avoidance of nerves and blood vessels is crucial. interactive, image guided robotic system designed
The augmented reality system would use stereo to conduct automated harvesting of follicular units
cameras or laser scanning to image the patient’s in hair grafting surgery.9
skin surface, query a database of anatomical
information and patient history, and highlight the Six well-established motorized or robotic FUE
location of nerves, major blood vessels, and prior devices are available.
surgery, which could reduce physician error and 1. The Safe System, using a dull punch designed
minimize bleeding or other complications. by Harris.
2. This system would also be useful in laser 2. Feller and True’s motorized sharp punch sys-
procedures. The robot could precisely adjust
­ tems; a computerized sharp punch system
movement of the hand piece, monitor the designed by Cole.
depth of tissue heating, and avoid critical facial 3. An updated version of the French-manufactured
landmarks. This would minimize poor outcomes Omni system, marketed as NeoGraft in the
and scarring as a result of overaggressive United States and North America.
photothermolysis and increase the unifor-
­ 4. The newest FUE-automated robotic device,
mity with which the facial skin is treated. The called ARTAS.8
mundane job of moving the laser hand piece
centimeter by centimeter over the patient’s
­
face would be eliminated and improved with
The ARTAS System (Fig. 75.1)
robotic m
­ onitoring and accuracy.
The ARTAS System (Restoration Robotics, Inc.)
was pioneered by a team of hair restoration phy-
Robotic-Assisted Follicular Unit Extraction for
sicians, robotic engineers, and clinical experts. It
Hair Restoration
is the first and only FDA-cleared technology
Hair restoration is a prevalent cosmetic proce- that allows physician-controlled, image-guided,
dure among men, and its popularity continues to robotic-assisted FUE. It enables the physicians
grow. According to the International Society of to offer their patients a minimally invasive proce-
Hair Restoration Surgery, the total market size dure to deliver permanent, n ­ atural-looking, con-
for hair restoration surgery has increased almost sistent and reproducible results while resolving
50% since 2008, with a worldwide market close the challenges inherent to the FUE technique.6,7
to $1.9 billion. Hair transplantation has evolved
from grafting relatively large segments of skin This system allows a physician with very little
to implanting individual follicular units into small experience to produce grafts as good as those
recipient sites. Bernstein and Rassman used follic- achieved with several years of experience after
ular units as the only element in hair transplanta- a couple of hours of training. This method
tion and first described FUE as a surgical technique represents a new way to attract prospective
­
in medical literature.6, 7, 8 patients who would not normally consider hair
restoration ­
surgery, due to its recovery time
The high demand for hair restoration procedures and visible scarring. Hence this system is a
has created an impetus to offer better, less ­invasive major milestone for the entire hair restoration
treatments. industry.7

Chapter_75.indd 2633 06/02/15 11:48 PM

 2634 IADVL TEXTBOOK OF DERMATOLOGY

Fig. 75.1: First FDA cleared “ARTAS System” pioneered by Restoration Robotics,
Inc. for robotic-assisted FUE.

Components of the ARTAS system 1. The ARTAS System offers a substantial reduc-
The ARTAS System uses two sets of special- tion in surgical time, often by a factor of two to
ized cameras to enable assessment of every fol- three times.
licular unit in its field of vision. Also, the latest 2. It produces higher quality grafts regardless of
in digital mapping to automatically assess the the surgeon’s experience level. The process is
angle and direction of each follicular unit is pres- accomplished more precisely by the vision and
ent. Sophisticated algorithms determine the hair follicular unit assessment algorithms of the
density as well as the proper angle and depth of ARTAS System instead of relying on human
incision required to effectively harvest the units. judgment and estimation.
The software algorithms also allow choosing and 3. Physician fatigue, which can result in lapses
dissecting the individual follicular units safely and of judgment and lead to an increase in follicle
efficiently under the guidance of the physician. transection rates, is not an issue when using
The system uses a small sharp inner needle to this system.6
score the skin followed by the insertion of a blunt 4. It allows more physicians and patients to take
outer dissection punch to harvest individual follic- advantage of the benefits of minimally invasive
ular units while maintaining low follicle transection cosmetic procedures.
rates.6,7 The ARTAS System can harvest follicular 5. The technology also requires fewer staff and
units in a random pattern, according to distance physician hours.
limitations, or as a percentage of the total num- 6. Patients benefit from quicker healing times,
ber of follicular units in a designated area. Under excellent results, and wider availability of the
physician control and direction, targeted units are procedure.6
dissected at rates of over 500 grafts per hour.7 7. With this system 500 or more grafts can be
taken per hour.7
Advantages of the ARTAS System (Box 75.4) 8. Robotic-assisted FUE produces better grafts.
Box 75.4. Advantages of the ARTAS System 9. The ARTAS System consistently shows a follicle
transection rate of about 8% independent of
• Reduced operating time operator experience.
• Reduced manpower Thus the ARTAS System provides physicians a
very safe method for consistently extracting a
• Good quality grafts high volume of healthy, intact hair grafts in a short
• No surgeon fatigue time. Follicular units require little or no trimming
and are ready to implant immediately after har-
• Faster healing time
vesting. This increases graft success rates and

Chapter_75.indd 2634 06/02/15 11:48 PM

 CHAPTER 75: Robotics in Dermatology 2635

reduces technician time, allowing more efficient NANOROBOTS

­appointment scheduling.7 Robotic assisted fol-
Nanotechnology involves the engineering of
licular harvesting procedure is mentioned in flow
molecularly precise structures and molecular
­
chart 75.2.
machines, and nanomedicine is the application
of nanotechnology to medicine, including the
Flowchart 75.2: Robotic-Assisted Follicular
­development of medical nanorobotics.10
Harvesting Procedure

Position the patient Nanomedicine can address many important medi-

cal problems by using nanoscale-structured mate-
rials and simple nanodevices .This includes the
The robotic arm placed over target area identifies interaction of nanostructured materials with bio-
follicular units logical systems. Subsequently biotechnology will
make possible even more remarkable advances in
molecular medicine and biobotics—microbiological
The physician chooses the units to be extracted robots or engineered organisms. The ­ worldwide
market for nanoscale devices should grow 28%
per year, rising from $406 million in 2002 to
$1.37 ­billion in 2007, with a 35% per year growth
The robotic arm carries out dermal punches to extract
follicular units rate in revenues from biomedical nanoscale
devices.11

After comfortably positioning the patient, the Nanorobots are nanodevices that will be used
hair area at the donor site is cut short, approxi- for maintaining and protecting the human body
mately 1 mm in length, and then robotic arm against pathogens. Nanorobotics has strong poten-
of the device is placed over target area of the tial to revolutionize healthcare, to treat disease in
patients scalp. The robotic arm is equipped with future. It opens up new ways for vast, abundant
two cameras that serve as stereovision sensor research work. Nanotechnology will change health
that can identify and detect follicular units on the care and human life more profoundly than other
patients scalp. The physician chooses which fol- developments.12
licular units are to be harvested and then inputs
this information into system menu. The number Components of Nanorobots
and type of follicular units, precise pattern of har-
vesting, angle calculation, orientation and loca- Power Supply
tion of each follicular unit on scalp surface can The powering of the nanorobots can be done by
be specifically chosen. This allows for an auto- metabolizing local glucose and oxygen for energy.
mated and customized follicular units harvesting In a clinical environment, another externally sup-
for each individual patient “as the patient moves plied acoustic energy would be another source.
and the robot moves,” allowing the system to Within the body other sources of energy can also
keep track of each follicular unit from each frame be used to supply energy for the devices. They
of the video stream of the cameras. This ability of will have simple onboard computers capable of
analyzing the video streams, combined with agile performing around 1000 or fewer computations
robotics, can compensate for patient movement per second.
to achieve required accuracy for the hair trans-
plantation. The robotic arm is used to accurately Communication
position and carry out dermal punches for har-
Communication with the device can be achieved
vesting follicular units. Each follicular extraction
by broadcast-type acoustic signaling. A naviga-
involves a 1 mm incision, which does not require
tional network may be installed in the body, with
the sutures or bandages. An approximate har-
station keeping navigational elements providing
vest speed of 750–1000 follicular units per hour
high positional accuracy to all passing nanorobots
can be achieved and using the robotic arm, only
that interrogate them, wanting to know their loca-
two people are needed.
tion. This will enable the physician to keep track of
various devices in the body.12
The current strip harvesting technique can take up
to 8–10 hours from harvesting to implantation for
Composition of Nanorobots
a typical 1500–2200 follicular units, but robotic-
assisted procedure can reduce procedure time to They will have a diameter of about 0.5–3 µm and
only 4–5 hours.9 will be constructed out of parts with dimensions

Chapter_75.indd 2635 06/02/15 11:48 PM

 2636 IADVL TEXTBOOK OF DERMATOLOGY

in the range of 1–100 nm. Carbon will be the nanorobot-mediated rejuvenation that should
principal element comprising the bulk of a medi- extend the human health span at least tenfold
cal nanorobot. Other elements such as hydrogen, beyond its current maximum length. The nano-
sulfur, oxygen, nitrogen, fluorine, silicon, and so medical solution will be the final step in the
on will be used for special purposes in nanoscale ­roadmap to the control of human aging.10
gears.
Advantages of Nanorobots12 are given in
Use of Nanorobots in Dermatology Box 75.5
1. A cream containing nanorobots may be used, Box 75.5. Advantages of Nanorobots
which would remove the right amount of dead
skin, remove excess oils, add missing oils, 1. Nanorobots will treat and find disease, and
apply the right amounts of natural moisturizing restore lost tissue at the cellular level.
compounds. 2. They cure many elderly ill patients and
2. In gout, a nanorobot could break up the crys- renew their lives.
talline structures at the joints, providing relief
from the symptoms, though it would not be 3. Nanorobotic probes are mainly useful for
able to reverse the condition permanently. monitoring, diagnosing, and treating sickness.
3. Microbivore nanorobots would function simi-
larly to the white blood cells in our bodies, but
they would be designed to be much faster at Disadvantages of Nanorobots12 (Box 75.6)
destroying bacteria. Thus they would be able to Box 75.6. Disadvantages of Nanorobots12
eliminate bacterial infections in a patient within
minutes, as opposed to weeks required for anti- 1. Cluster of different nanorobots with one
biotics to take effect. another is harmful.
4. An interesting utilization of nanorobots may be
their attachment to transmigrating inflamma- 2. Installation cost is high.
tory cells or white blood cells, to reach inflamed 3. Maintenance is difficult.
tissues and assist in their healing process.
5. Nanorobots will be applied in chemotherapy to
combat cancer through precise chemical dos- Natural Nanorobots in Human Body
age administration, and a similar approach
The human body already teems with many
could be taken to enable nanorobots to deliver
nanodevices. For example more than 40 trillion
­
anti-HIV drugs. Considering the properties of
single-celled microbes swim through our colon,
nanorobots to navigate as blood-borne devices,
outnumbering our tissue cells almost ten to one.
they can help in important aspect of cancer
Many bacteria move by whipping around a tiny tail,
therapy. Nanorobots with embedded chemical
or flagellum that is driven by a 30-nanometer bio-
biosensors can be used to detect tumor cells in
logical ionic nanomotor powered by pH differences
early stages of development.
between the inside and the outside of the bacterial
6. Medical nanorobots can readily treat genetic
cell. Our bodies also have more than trillion motile
diseases by comparing the molecular struc-
biological nanodevices called fibroblasts and white
tures of both DNA and proteins found in the cell
cells such as neutrophils and lymphocytes, each
to known or desired reference structures. Any
measuring perhaps 10 µm in size. These beneficial
irregularities can then be corrected, or desired
natural nanorobots are constantly moving around
modifications can be edited in place.12
in our body repairing damaged tissues, attacking
invading microbes, and gathering up foreign par-
Nanorobots and Aging ticles and transporting them to various organs for
Medical nanorobots can provide targeted treat- disposal from the body.11
ments to individual organs, tissues, cells, and
even intracellular components, and can inter-
BIOROBOTS
vene in biological processes at the molecular
level under direct supervision of the physician. Engineered bacterial “biorobots” are also being
Programmable micron-scale robotic devices will pursued. Only 300 highly conserved genes may
make possible comprehensive cure for human be required for life, constituting the minimum pos-
disease, the reversal of physical trauma, and sible genome for a functional microbe. An organ-
individual cell repair. This will lead to the com- ism containing this minimal gene set would be
plete control of human aging via nanomedically able to perform the dozen or so functions required
engineered negligible senescence coupled with for life like manufacturing cellular biomolecules,

Chapter_75.indd 2636 06/02/15 11:48 PM

 CHAPTER 75: Robotics in Dermatology 2637

generating energy, repairing damage, ­transporting of such technology. Possible dangers include the
salts and other molecules, responding to envi- robots destroying things, compromising privacy or
ronmental chemical cues, and replicating. Used being perceived as threatening.
in medicine, these artificial biorobots could be
designed to produce useful vitamins, hormones, Another function of law that gains relevance in
enzymes, or cytokines in which a patient’s body connection with service robots concerns con-
­
was deficient, to selectively absorb and metabo- struction and planning security. Service robots
lize into harmful substances like poisons and toxins are highly complex investments. Their successful
into harmless end products.11 implementation requires that certain conditions
are present, such as a living environment suit-
Robotics in the Clinical Laboratory able for robots or level streets expedient to robot
locomotion. These conditions can be induced by
Robotics was first applied to clinical laboratories means of legal regulation.
in the 1980s. Seligson of Yale-New Haven Medical
Center in 1981 reported the introduction of a In this direction the first step involves applying the
robot carrier for transporting clinical specimens. existing norms to the novel technology of service
The second presentation on robots in Clinical robotics and then assessing the consequences
Chemistry was by Hawk in 1983. with regard to their appropriateness. If regulatory
deficits exist, it become necessary to take a sec-
Robots could be introduced to clinical laboratories ond step and adjust the law in light of the factual
in many ways. For example, for the preparation and predicted technological development.
of specimens and sorting to various destinations,
for placing samples or specimens in and remov- If one considers service robots systematically a
ing them from a centrifuge, for transportation, for whole number of legal issues arise, going beyond
aliquotting to analysers, sorting for storage and to those of autonomy and damage liability. One
handle wastes. Typical examples of implementa- way to connect law and technology could be to
tion of robotics in the clinical laboratory are trans- implement some of the binding rules by prescrib-
portation of specimen, front end automation of ing compulsory elements of construction and
sample preparation, separation and aliquotting as ­making them part of a service robot’s makeup at
well as selected processes in a large scale auto- the outset. In this way, compliance and enforce-
mation system. ment deficiencies would be prevented from ever
developing.
Robotics could be used in clinical laboratories to
optimize workflow and increase throughput, to A uniform body of law for service robotics
shorten turnaround time, and to manage with does not appear practical at the present time.
fewer full-time staff equivalents or to reduce Provisions specific to service robots should be
chances of exposure to possible biohazards.2 introduced into the respective areas of law wher-
ever they are deemed appropriate. The intro-
LAW AND ROBOTS duction of mandatory liability insurance so as to
absorb the damages sustained by third parties
Some functions of law gain particular relevance is also needed. To be able to establish standards
when it comes to assessing the technological for negligence, certain basic safety rules must
impact of employing service robots. The protec- be in place in private and freely accessible public
tive function of law plays a major role. The state space which the operators of service robots have
has obligation to safeguard at least a minimum of to comply with.13
protection and facilitate opportunities for human
actions while minimizing the risks for others that
CONCLUSION
are caused by these actions.
There is no doubt that in medicine the robots have
Both aspects of this obligation to protect are highly come of age. Medical robots may be in the stage
relevant when considering the use of service of infancy but their use is fast gaining impor-
robotics: the employment of robots in the field of tance in various branches like Surgery, Urology,
nursing may help the elderly to protect and main- Gynecology.
tain their individuality by enabling them to remain
in the surroundings that they are accustomed to. In the field of Dermatology it can proposed that
robots developed by human hands can sup-
It is important to implement legal regulation pro- plement the human hands of the dermatolo-
tecting the beneficiary of robot services, as well gist. From increased surgical accuracy to exact
as third parties, from being imperiled by the use dosed injections to blood vessel detection to

Chapter_75.indd 2637 06/02/15 11:48 PM

 2638 IADVL TEXTBOOK OF DERMATOLOGY

measurement of tissue heating, robots have a The possibility of performing procedures that humans
place in cosmetic dermatology. Their current use cannot perform but are necessary remains an ulti-
in biopsy specimen processing is just the start. mate goal for medical robotics. However, to be
Robotic-assisted FUE is the major advance- accepted in clinical practice, a robot must be intui-
ment of robotic cosmetic dermatology with the tive, require minimal operator training, must also be
promise of an almost scarless, minimally inva- quick and easy to set up, should not increase the
sive, procedure that is enticing to both patient length of procedures and should be cost effective.
and the doctor. Thus in future more and more Engineers and physicians should work together to
­dermatologists will gain confidence in performing create and validate these ­systems for the benefit of
advanced robotic procedures. patients everywhere.

REFERENCES
1. Draelos MT, Draelos ZD. Robotic cosmetic dermatology. 8. Williams KL Jr. Current practices and ­ controversies
J Cosmet Dermatol. 2011;10(2):87–8. in cosmetic hair restoration. Dermatol Surg.
2. Ozawa K, Schnipeslky P, Pardue HL, Place J, Truchaud A. 2013;39(5):797–801.
The expanding role of robotics in the clinical laboratory. 9. Petrou I, Robot I. Prototype harvests follicular units for
J Automat Chem. 1992;14:9–15. transplant. Dermatology times. 2009;66.
3. Cleary K, Melzer A, Watson V, Stoianovici D. Interventional 10. Freitas RA. Comprehensive nanorobotic control of human
robotic systems: applications and ­ technology state- morbidity and aging. In: Gregory FM, Michael DW,
of-the-art. Minim Invasive Ther Allied Technol. Coles LS, Harris SB, editors. The future of aging. New York:
2006;15(2):101–13. Springer Dordrecht Heidelberg; 2010. p. 685–805.
4. Wikepdia. Robotics 2013 Aug (20). Available from: 11. Freitas RA. Current status of nanomedicine and medical
en.wikipedia.org/wiki/Robotics. nanorobotics. J Comput Theo Nanosci. 2005;2:1–25.
5. Dua A, Dua K. Follicular unit extraction hair transplant. 12. Prajapati PM, Solanki AS, Sen DJ. Importance of nanoro-
J Cutan Aesthet Surg. 2010;3(2):76–81. bots in health care. IRJP. 2012;3(3):122–4.
6. Harris J. Robotic-assisted follicular unit extraction 13. Dreier T, Döhmann ISG. Legal aspects of service robotics.
for hair restoration: case reports. Cosmet Dermatol. Poiesis Prax. 2012;9(3–4):201–17.
2012;25:284–7.
7. Winnington P. Robotic Surgery: with new technology come
new opportunities? Practical Dermatology. 2012:1–2.

Chapter_75.indd 2638 06/02/15 11:48 PM