If ultra thin graft and dense packing are the best techniques; I already use it for more than 10 years.

For the past 10 years, I have performed hundreds of eyebrow transplantation. The ultra fine graft is exactly the size been used.
3 ultra thin graft photos took back in 2001 and 2002

(The grafts come with longer hair because they are used for eyebrow transplantation. With longer hair, patients can see immediate result and it also enables us to check the hair direction easily.)

I would like to present a typical eyebrow transplant that I did yesterday (December 7, 2006.) The patient is an Asian male. Each brow is about 5 cm in length, average width is 0.6 cm, and the area is 3 cm2. The total area for both eyebrows is approximately 6 cm2. We transplanted 555 grafts. This is about 92 grafts per cm2. I will post a series of zoom-in photos next week.

Our surgical team has the ability to perform ultra thin graft and extremely dense packing, but I only limit it to certain area.

Steven C. Chang, M.D.

Dr. Chang.

No offense intended, but your last post didn't address any of the concerns that Pat, myself, or B-spot have posted. I don't want to disrespect you because I value your input on this forum as I know others do as well...I think it's a great learning experience for everyone...but allow me to point out a few things that are troubling me:

quote:

If ultra thin graft and dense packing are the best techniques; I already use it for more than 10 years.

Your above quote "appears" contradictory to the below quote:

[quote]...The patient had a hair transplant surgery on December 1, 2005; the total graft number was 1581G, which included 300 single follicular units and 1281 modified follicular units. [quote]

What do you refer to as an "ultra thin graft"? Being that the majority of your grafts are modified into larger groups of hairs, what exactly is thin about it? Regarding dense packing, can you show us some photos of before/right after surgery/and after pictures of dense packing? For someone to day they've been dense packing for 10 years, when dense packing has changed dramatically even over the last 5 years doesn't give me much comfort. If you are willing to share with us, how have you changed your techniques from 10 years ago to today? That might address more of the concerns. What do you consider dense packing? What is the closest that you can put your grafts together in a single session...how many grafts per cm/2 can you yield in a single session assuming a patient warrants this type of dense packing?

Additionally, when you say "The ultra fine graft is exactly the SIZE been used" what size are you referring to? Are you talking about the incision size? Are you talking about dense packing?

I don't mean disrespect by my questions, but I still feel my flags are raised and I don't feel that you have attempted to explain or answer any of these questions.

Sincerely,

Falc

Thought I'd bump this post. Any other thoughts are welcome...feel free to tell me if I'm wrong, but there are still some "red flags" that are up for me that I feel should be addressed.

Falc

Hey Falc, yes you are right to have some red flags, buddy!!!!

I really think Dr. Chang is surprised at how we view his current techniques. I also think he really wants to join our community.

Once I saw the tiny eyebrow incisions, I thought, "Wow, this guy can do Ultra R. F. U. G., but is simply not choosing to do so!"

I sent Dr. Chang a PM about some perspectives that I have and how a difference exists between non-educated vs. educated patients. In addition, I suggested a couple of changes that might help him out.

I normally would not be so presumptious, (yeah right!), but I felt Dr. Chang is really feeling his way out here, so why not?

Again, it is a good idea to keep a close watch and steer people to the right Doc's, but I hope Dr. Chang ends up being one of them.

Time will tell....

Cheers Buddy!!!

Falc,
You are not wrong at all. You are just looking for clarification of his techniques. Yes, a doc may be able to dense pack an eyebrow but why is he using such large numbers of modified Fu on the scalp? Many of the patient photos on his site are not spectacular in my opinion.

Hey guys,

I was pretty sure I was spot on....but thanks for letting me know I'm not alone . I agree B Spot...hopefully Dr. Chang ends up being one of them...I wish all Drs would move forward to use the latest technologies and techniques...not doing so is primitive and not looking out for the patient's best interest. I'll be looking forward for his answers and hope that he doesn't resist moving forward.

Falc

The ultra thin graft is for eyebrow transplant only, mixed size grafts (FU, modified FU) is for hair transplant only. Please don't get confused.

Ultra Thin Graft is almost bare hair only. It is thinner than regular FU.

If you would like to see before and after result please see Eyebrow Photo Gallery

Eyebrows are located at the center of face; patients require much natural and dense result than hair transplant (This is the reason a lot of physicians perform hair transplant but not eyebrow transplant). 90% of our eyebrow patients finished in one session, 10% requires a touch-up. We did three eyebrow surgeries this week.

How close and how many grafts can we implant in one cm2?

Slits are made by hand, they are impossible to be exactly even. The best way I will do is to show you the coverage area with ruler on it for you to figure out the size. And close up photo of slits for you to count. Please see Eyebrow Restoration Process

According to our calculation the distance between each graft is 0.8mm (11 cm /125=0.8mm), we implanted 92 grafts per one centimeter squares (555 G/6cm2=92 G per cm2).

Steven C. Chang, M.D.

Dr. Chang,
Thanks again for responding to our forum. I think we all appreciate the fact that you are explaining your techniques and providing some definitions of basic transplant jargon.
I believe though, unless I missed something, that we are talking about 2 different things. Most of this post is pertaining to HT of the scalp. There is no question that doing eyebrows requires different incisions and is very refined. I might be wrong, but I think many of us want clarification as to why you are using so many larger MIXED FU on the scalp if you have the ability to do strictly ultra refined like you say do?

Dr. Chang,

Thank you for clarification of the "Ultra Thin Graft" that it pertains to eyebrows only. But for the rest of the discussion, we are primarily interested in HT on the scalp, not the eyebrow...so I'd ask that you please see the above posts and address them per Scalp HTs and not eyebrows.

Falc

Question: What is your transplanted hair growth rate?

Question: Why don’t you use all single follicular units (SFU) for hair transplant?

Question: Are you concern about the possible pluggy look due to larger grafts size of modified follicular unit (up to 4 hairs in one graft)?

Question: Given the same donor size, less number of grafts will be produced with larger graft size. If only SFU are used, it will result in almost double amount of grafts compare to modified FU for hair transplant. In another words, it will increase NHT double income. Why don’t you follow the trend?

Question: Do you have enough staffs to perform 5,000 grafts per session?

Question: Is there any person is contradicting to use whole SFU?

Please see Replies to these questions and concerns.

Best Regards,

Steven C. Chang, M.D.

Dr. Chang,

Thank you for responding in detail to these questions on your website. And now some thoughts regarding what you wrote. Bear with me as I play devil's advocate here

Regarding your question number 2: "Why don't you use SFU for hair transplants"

Just so everyone here is informed...what you are referring to as "SFU", I assume you are talking about FUs right? SFU makes it sound like we are talking about single hair follicular units, where nobody here is advocating that only single hair follicular units be used (unless we are talking about the hairline), but FUs, which are naturally growing 1,2,3, and 4 hair grafts. So please clarify. For this discussion, I'm going to assume you mean FUs and not Single Hair FUs.

You bring up 3 concerns - quoted directly from your site:

1. Higher Telogen (resting) stage hair loss due the process of thin graft preparation.
2. Poorer growth rate when use thin graft than chubby one.
3. Cost to patient is almost double when use SFU.

Regarding concern 1:

You state: "Man typically sheds 60 to 100 hairs per day and natural hair re-grow after three months. It amounts to 10% to 15% of our total hair lost in this natural process and it is invisible. If SFU is prepared, it must trim off the tissue next to the grafts and possibly the invisible hair inside the tissue. 10% to 15% of hair is lost in the trimming process. Dr.Seager, Dr.Beener, Dr. Beeher, Dr.Reed and Dr.Raposio all had comparison studies to compare chubby and thin grafts. The results all indicate that chubby grafts' growth rates are 20% to 51% more than the thin grafts. So far, we haven’t heard any report indicating that the thin graft’s growth rates are better. "

I'm not sure what "invisible hair" you are referring to. Even in the telogen phase the follicle is still in tact and would be seen under the microscope. So there will be no trimming of "invisible hairs" and no hairs will be lost. Am I missing something? What are you referring to when you talk about a "thin graft" and a "chubby graft"? Are you talking about FU vs MFU again? Since all a MFU is, however, is putting FUs together, how exactly would the growth rates increase by doing this? I'm not a doctor, but it doesn't seem sensical. This does raise, however, a question for me, about creating insicions in the recipient area...if some of the hairs are in telogen phase, it's very possible that incisions will be made over these follicles causing possible transection of the telogen follicles. But that's something to address in another thread I think, because it would apply to both FUs and MFUs.


Regarding concern 2: Considering on your website while answering another question you stated:

"How could anyone count thousand of hair in the recipient area?
How do you distinguish the growth versus the original hair in this area? Honestly, no one could answer these two questions in a scientifically acceptable methodology."

In actuality here, are you referring to growth rate or growth percentages? When I think of a growth rate, I think of how fast they grow and how long they are resting. When I think about growth percentages, I think about how many grafts actually grew out of the grafts transplanted.

However, either way...

If there is no scientific way to measure a successful growth rate, how you can you state that FUs have a lesser growth rate the DFUs? Looking at thousands of pictures over the last several years by top doctors in the industry also does not show indication that the growth rate is poor...in fact, seems pretty absolute. Now if you told me there was a lesser success rate with BHT, I would agree with you.

Regarding concern 3: It may end up being more expensive, that is true...however, I'd rather pay twice as much for a natural and successful hair transplant than half the price for one that could look pluggy. Besides, it's not twice the cost, because the majority of clinics discount significantly (almost half the price) for grafts over 2000.

Now I'm confused about your third question: "Are you concern about the possible pluggy look due to larger graft size of MFU (up to 4 hairs in one graft)? Regular FUs are up to 4 hairs in one graft, so I'm confused why if you only create MFUs to be up to this size, why you don't just use FUs. Perhaps you are just taking the singles and doubles and creating 2 or 4 hair MFUs, hence them being modified because it is taking two FUs and making them a combined or multi FU.

In regards to your answer to "Do you have enough staff to perform 5000 grafts per session", if your answer is "yes", why don't you do it? Perhaps this also goes back to your answer to the FU vs MFU philosophy. Surely a 5000 FU transplant would only be about a 3000 MFU transplant (not an exact conversion of course...it all depends on how you group them). Unless I'm mistaken, however, I don't see any evidence on your website that you do 3000 MFUs (or even close to it) in one session. Since you have the staff for it...why don't you do this?

If you are only using grafts up to 4 FUs, I can see how it may not create a pluggy look, assuming that you still use Single Hair FUs for the hairline, and still some 2s and 3s in there, filling in the gaps between all the 4 MFUs. I just think that the overuse of 4 hair MFUs CAN create a pluggy look (especially up close) if no FUs are filled in between.

In closing, looking at the bigger picture...I've always said in recent times anyway that "the proof is in the pudding". Looking at work from the top coalition doctors and their use of FUs in a single session, they have yielded outstanding and amazing results. Their success says to me, that FUT (and dense packing when appropriate for the patient) is the way to go. Additionally, the coalition also seem to (when appropriate) do larger single sessions than you and yield successful growth percentages (and rates ) without problem.. The fact that this is a concern for you is a red flag to me when so many doctors who have embraced the current trends do this so successfully. So your concern tells me one of two things, and no offense intended, but 1) you are not proficient enough to provide these success rates (either yourself or your staff or both) in a single session or 2) you are afraid of change and feel more comfortable using older technologies.

It is fun, for me, to discuss philosophies, and question them, in hopes in making doctor's think to even maybe improve methods in the future, however, it all comes down to the end result. Does it really matter how you get there as long as your patient has a nice and natural looking head of hair in the end? I don't think so...however, I think the points I made above prove that I have some concern that MFUs can provide a natural look as much as FUs. Some higher quality resolution pictures on your website from all angles would also be helpful. Thanks for taking the time to read my concerns and questions.

Falc