I recently met a prospective patient (Asian male) with a very low hair density who kept his hair very short. He wanted a follicular unit extraction (FUE) procedure and I strongly advised against it as in his particular case, the tiny white punctuate scars he would get from FUE might become detectable. His skin was a dark olive color. He did consult with another doctor by phone who told him after seeing his photos that he could easily get 4000 FUE grafts in the first session followed by 3000 in a second session and that he would have a reasonably full head of hair.

We then discussed a strip procedure and I told him that in a single session he might get approximately 1500 grafts, yet still another doctor told him that he easily could get 3500 grafts from a strip session. The prospective patient asked me why these other doctors were so enthusiastic about the surgery they recommended and why I was so low with my estimates on the strip procedure. I told him that I was an ordinary, mortal doctor with human limitations and he needs to understand that this is more than a number difference because the doctors may be talking about different things. I always talk about follicular units which is the graft count that I obtain at surgery. In other words, I’m not going to recommend something to this patient that will ultimately not be in his best interest and I am not one who victimizes patients for what they have in their wallet by charging for something that is not a follicular unit.

There is math and economics in these various estimates. For example, this patient’s graft count could be pushed higher if the grafts were divided so that each graft would have less hair. What one doctor calls a graft (1-3 hairs each) another doctor can cut down into grafts that contain less hair each (shifting to mainly 1 hair grafts) and get the illusion that there is more ‘value’ because the number of grafts is higher. If the amount of hair is say 5000 hairs, one can produce grafts ranging from 1500 to 5000 grafts from this hair count. So first, one has to define what the doctor means by a graft, does he cut them down into small units to get higher number of grafts? Economically for the doctor, it is better to cut these follicular units down (in the number of hairs each) because the fee is based upon the number of grafts. So more grafts means more money for the doctor (and higher fees for the patient). What matters is not just the graft count, but the total amount of hair that is removed in the procedure. Then add to that the way it is divided into small hair units (ideally it should be true anatomical follicular units). In the case of a strip procedure, the value would reflect the ‘area’ of excised scalp. Grafts should reflect the normal anatomy of the follicular unit that G-d created, not one that the surgeon invented (a subset of the follicular unit devised to push up his income).

We are not all equal with regard to the amount of hair that can be moved in a single session because the hair density between people can vary significantly (some people have more than twice the hair density of others). Also the looseness of the scalp may mean than in one patient twice as much scalp can be moved than in another patient. Merging these two measurements, when comparing two people, the maximum safe capacity for moving hair can reflect differences of 4-5 fold. I believe what is ethical from a fee point of view, should reflect the amount of work that the surgeon and his team invest in performing in the surgery. That is why, if true follicular units are what is counted, then the ‘apple for apple’ comparison is appropriate in the calculations for value. A patient should demand knowing that he is receiving follicular units, and not a number reflecting a subset of the follicular units for the purpose of pushing up fees.

We spent some time talking about what he could and could not expect. Expectations really reflect the amount and distribution of hair used in the transplant. The issue of value discussed above, should reflect the number of actual ‘true’ follicular units removed. It is wrong for not educating the patient. A doctor who did not take the time to review what he was going to do, how he was basing his graft count, what constitutes a graft and how he determined the charges for each graft is not doing his job. If you know this information, then you have done the proper research and you have a better chance of getting what you are paying for.

For further reading, plenty of similar links to past blog posts can be found here.