Pro: Although it is easy to compare the graft price between clinics, it should not be assumed that one-hair grafts and four-hair grafts have the same value.

Cons:
1. There is a conflict of interest: when the price is tied to the number of grafts, the clinic may have a tendency to cut more grafts even with the same donor size.
2. It encourages doctors to use all Single Follicular Units (SFU)—the smallest size graft. But for some patients, this is not in their best interest.

Nowadays, SFU is being cut skinnier and skinner. Ten years ago, medical reports showed that fatty grafts produce 15-33% more hair than skinnier grafts. The denser the packing, the skinnier the grafts. But there is no conclusive evidence on this idea. Some surgeons have decided to cut even skinnier and have come up with the very skinny graft named “Extra Thin FU”. Several years ago a female hair transplant surgeon from Arizona was asked to deliver a minimum of 3,000 grafts to qualify to join the Extra Thin FU Dense Packing Club. After years of experience and analyzing the results, she changed to the bi-follicular unit. Steven C. Chang, MD respects her courage—as using the bi-follicular unit is the way he has been performing surgeries for more than 27 years. His practice has been criticized for an obsolete technique, but insists that it is in the best interest of the patients.

3. There is no incentive for the surgeon to consider other graft sizes to see if they will increase the growth rate. In the study “Do paired grafts survive as well as intact FU grafts?” published in Hair Transplant Forum International (2012), Michael Beehner, MD concluded that the bi-follicular unit has better regrowth rate and hair quality than SFU—in other words, the graft with more tissue around the hair has a better growth rate.
4. There is competition for more graft numbers (or more dense packing), instead of paying attention to the hair number.
5. There is no way to cut the exact pre-determined graft number; there are either too many or not enough hairs (hair density is different all over the donor site some clinics cut by follicular unit—not by size. The size of a follicular unit varies).
6. There are not enough grafts. To achieve the promised number of grafts, the surgeon needs to cut smaller grafts, even if it is not in the patient’s best interest.
7. There are extra grafts. When the graft number is more than the amount agreed upon, some clinics charge for extra grafts. This is unfair because it’s not the patient’s fault.

Charging by Donor Size

Pros:
1. It is possible to cut the pre-determined donor size precisely.
2. There is no conflict of interest: it is easier for surgeons to make decisions based on the patient’s best interest, not the clinic’s financial interest.
3. There is no pressure to achieve a certain graft number. The clinic can cut the graft size in the patient’s best interest.
4. The patient and surgeon agree on the exact fee before surgery.
5. It is easy to compare results—using the relative density, not the graft number
6. It is possible to use a mixed size of graft to have the best results without worrying about not having enough graft numbers.

Con:
It is more difficult for patients to compare prices between clinics because almost 95% of hair transplant clinics use the graft number system.