Hair Transplant Price Per Graft vs Per Session
Written by Hair Transplant Surgeon Ali Emre Karadeniz
Publish Date: 27.08.2019
The traditional way in the Western world to price hair transplants is "price per graft". There are both technical and ethical problems about it. Paying per session is healthier.
The traditional way in the Western world to price hair transplants is to "price per graft". I'm going to talk about the problems I see in this pricing method. Initially, it looks like the more grafts you do there's more work, so it looks like it's normal to charge for the number of grafts you do. It's like buying let's say an ounce of apples or oranges, but I'm not sure if that's entirely true and here are the reasons why. There are both technical and ethical sides of this problem.
The Technical Problem
The technical problem is that when we do FUE hair transplant, how do we take more grafts? You can take more grafts in FUE in three ways:
1. Do it faster: If we do faster we will do more grafts. If we do it faster we actually damage more; we cause more tissue damage, more graft damage and wastage. If you're paying per graft and we're going to do it faster in order to give you more grafts we're actually increasing the damage and wastage. So you're paying more to get more damage. As you can see that's not to the patients' benefit.
2. Do closer "punch" hole: If you do closer punch holes you'll get more grafts. If you do too close punch holes you cause more scarring and you decrease the donor density significantly that it may be depleted and look moth-eaten. You're destroying the appearance and the aesthetics of the donor area. The second way of getting more grafts by making closer punch holes doesn't benefit the patient either. You're paying again for something that doesn't benefit you.
3. Use a smaller FUE punch: This may sound good at first but if you use a smaller FUE punch than needed (a punch that is smaller than the width of your follicular unit) you will not be able to take that follicular unit in, you're going to cause more damage, more follicle transections if the punch is too small. The third way of doing more grafts by using a smaller punch also increases the damage and wasted hairs.
As you can see there are three ways in FUE that surgically brings us more grafts, but none of them are in the patients' benefit. By paying per graft you are encouraging the clinic to do something that is not in your benefit.
There are ways to take more grafts in strip surgery (FUT hair transplant) too.
1. Take a wider strip: By taking a wider strip you're going to close the wound under tension and this is going to be much more painful, difficult to heal and you're going to get a worse scar. I've seen on public forums where the patient had a huge number of 4000 grafts strip taken and the surgeon was unable to close the wound and he had to leave it open and the patient received a two to three fingers thick scar and a very bad healing period. That was because the agreement was on grafts. By taking 4000 grafts the clinic kept their promise, there was nothing in the agreement telling if the wound is not closed or the scar is poor, nor there's going to be a penalty for the clinic; agreement is for grafts and the agreement is kept.
2. Over cut: Let's talk about another thing in FUT surgery. Let's say we take a strip which is a normal strip, proper closure, no problem there. But, in order to get more grafts we can over cut or we call that "subdividing follicular units" to make more single and double haired follicular units to get more grafts. Let's say we have a strip containing 6000 hairs, theoretically we could create 6000 grafts with one hair each. Or we could do 2000 grafts with 3 hairs each, so for the same strip with the same amount of hairs you would pay three times more when the clinic over cuts or subdivides the follicular units and so you pay three times more for the same coverage and same number of hairs. As you can see again it's not your benefit to pay for the number of grafts. The other thing related to this, it's proven in scientific studies that skinny grafts which are predominantly single haired survived less than chubby grafts, so not only you pay more for the same amount of hairs but you get poorer growth. As you can see none of that is to the patients' benefit. These were all surgical reasons why paying for the number of grafts is not to the patients' benefit. There are also ethical reasons too.
The Ethical Problem
If you pay for the number of grafts, chances are the clinic will be encouraged to offer you a higher number of grafts, so they make more money. Chances are you'll be advised to use up more of your donor hairs, perhaps you didn't need that much. There are clinics that will recommend 4000 grafts or 5000 grafts whereas 2000 would do, so as you can see there's an ethical problem.
The other ethical problem I have in mind is that for instance let's say you have a certain budget, you have $5000, and let's say in our clinic we charge 5$ per graft, so we find out that your budget is $5000 and in this case you can afford only 1000 grafts. The clever salesperson in the clinic is going to realize that there's no point in recommending your 3000 grafts even if you do need it, because he knows you're not going to be able to pay and you're going to run to another clinic that's cheaper. And finally he recommends you 1000 grafts, and you'll make an agreement thinking that that's within your budget but you're getting an amount of grafts that's too small for your situation and you're going to get a result that's not satisfactory. From an ethical point of view this clinic should have refused you because you have insufficient funds. But because you're paying per graft they are free to give you the number that you can afford.
Paying Per Session Is Healthier
For all of these reasons, I believe paying per graft is harmful and unethical. Paying per session on the other hand is healthier because you're just paying for the performance of the clinic that you believe they're going to do their best. A quick question you may ask: "what if the clinic does deliberately less number of grafts because they're too lazy when the agreement is on per session". Yes, they can do that. But this clinic will be judged with the results they provide. If the clinic keeps doing less number of grafts than needed they will get poorer results and less coverage and other patients will look at that and say "we don't want to go to this clinic". If the clinic does that, they will not be able to get away with it.
Paying per session is much healthier than paying per graft. But there's one extra thing I have to say is that, 99% of surgeries are charged per session in Turkey but not for an ethical reason. It's because, in most of these surgeries there is no doctor and technicians are used for the surgery. And then it becomes unnecessary for the clinic to charge for grafts because it doesn't matter for the clinic to tell these technicians to take 2000 or 4000 grafts, it doesn't matter for them. So they just have a fixed fee. So the only exception that you have to look at is if a clinic is charging per session, try and make sure this is not a technician-only clinic with no doctor in the procedure because they are charging for the session, not because they're too ethical that's because there's no doctor in the procedure. This is not the case for our clinic, i.e. AEK Hair Clinic. We have insisted on being a high quality clinic where the doctor offers to be significantly involved in the surgical procedures and thorough supervision of his team.
Written By Dr. Ali Emre Karadeniz, MD, PhD
Ali Emre Karadeniz, MD (Dr. K) is the only American Board of Hair Restoration Surgery Certified Turkish plastic surgeon. He has performed over 2000 hair operations. He is an active member of the International Society of Hair Restoration Surgery (ISHRS).