“Permanent” Scalp Micropigmentation

13A “Permanent” Scalp Micropigmentation

William Rassman, Jae Hyun Park, Jino Kim, Ronald Shapiro, and Nicole Large

Summary

Scalp micropigmentation (SMP) is a medical tattoo process that recreates an appearance of naturally growing hair for people who are balding or have thinning hair. It can be used either alone or as an adjunct to hair transplant surgery to treat a variety of conditions that cause hair loss. These conditions include nonscarring alopecia-like primary male and female pattern hair loss, alopecia aerate, post–cancer radiation, or chemotherapy-induced alopecia, as well as a host of other systemic or medical conditions. It is also useful for camouflaging scalp scarring from a variety of causes, including donor scars from strip-follicular unit transplantation or follicular unit excision surgery, plastic surgery, neurosurgery, trauma, infection, etc. In some cases, it has offered treatment options where none existed before. In this chapter, we discuss the history of SMP as well as different indication, factors that affect results, and potential complications. The differences between permanent and temporary SMP (also called “temporary scalp trichopigmentation”) will also be discussed.

Keywords: scalp micropigmentation alopecia scarring alopecia balding thinning scalp scars cosmetic tattoo hair transplantation temporary SMP scalp trichopigmentation

Key Points

•Scalp micropigmentation is a medical tattoo process that recreates the look of shaved hair.

•It can be used by itself or in combination as an adjunct to hair transplantation to help patients with alopecia from different causes.

•It has expanded the ability of hair transplant surgeons to treat and better help patients with little options in the past (i.e., alopecia totalis, cicatricial alopecia, scar camouflage, advanced hair loss, etc.).

•It appears simple but takes correct technique and experience to prevent complications such as a color change, blotchy spreading, and unnatural patterns.

13A.1 Introduction

Scalp micropigmentation (SMP) is a medical tattoo process that recreates an appearance of naturally growing hair for people who are balding or have thinning hair. While remotely similar, in principle, to traditional tattooing and/or permanent cosmetics procedures, there are a number of critical differences that make SMP unique and specifically suited for the scalp. The pigments, machines, and technical aspects are far more sophisticated and specifically designed to produce a result that is natural while helping control variables that cause unwanted side effects like color change and migration. The goal is to create exact replications of hair follicles that are extremely discrete and are comparable in diameter to a single hair or follicular unit and to exactly replicate the appearance of shaved hair follicles or stubble of hair. One of the appeals of SMP is that the results are relatively immediate and it is less invasive than surgery. SMP can be used as a standalone treatment or as an adjunct to improve the results of hair transplant surgery. There are some conditions where SMP offers treatment options that none existed before, like alopecia universalis and severe cicatricial alopecias.1^,²^,³ When performed properly by skilled practitioners, SMP yields excellent results. However, it is not as simple as it looks, and in unskilled or inexperienced hands, poor results and complications can occur. In this chapter, we discuss the history of SMP as well as different indication, factors that affect results, and potential complications. The differences between permanent and temporary SMP (also called “temporary scalp trichopigmentation”) will also be discussed.

13A.2 History and Terminology

13A.2.1 Tattoo and Permanent Makeup

Traditional tattooing as a form of body art has been around for thousands of years and with historical records dating as far back as 1300 BC. The use of tattooing as for permanent makeup of the face was first documented in 1902 by the famous UK tattoo artist Sutherland McDonald who would give “pink cheeks’ to his clients. The tattooist George Burchett in the 1930s described in his memoirs how beauty salons performed permanent makeup on many women without their knowledge, offering it as a “complexion treatment by injecting vegetable dyes under the top layer of the skin.”

In the 1980s, a more advanced and refined form of permanent makeup, called “micropigmentation,” became popular for recreating eyebrows, permanent eyeliner, and lips. With time, paramedical applications such as recreating the areola in breast cancer patients or camouflaging vitiligo and cleft lips developed. In 2001, the first use of micropigmentation for treating scars in the scalp was published by Avar Traquna, MD.

13A.2.2 “Scalp” Micropigmentation for the Treatment of Hair Loss and Balding

It was soon after this that the technique of micropigmentation started to be used to treat the scalps of balding men and the term “scalp” micropigmentation was created. One of the first clinics to offer this service was HIS Hair Clinic in the United Kingdom started by Ian Watson in 2002. Supposedly, Ian Watson suffered alopecia after the sudden death of his brother and worked to develop a method of replicating hair follicles with pigment that was realistic. Working with the widow of his brother, a former permanent makeup artist, they claimed to be the first to perfect their technique of creating a look of shaved hair.

13A.2.3 Era of Rapid Growth and Problems

A huge new market of balding men had been tapped, and the popularity of SMP grew rapidly. Many new players entered the fray over the next 10 years. However, this period was marked by problems. A large number of aesthetically poor results were occurring including solid blue heads, blotchy results, and poor design. As it turned out scalp skin does not behave the same as body skin; therefore, modifications and improvements in the technique were sorely needed (Fig. 13A.1a–d).

Fig. 13A.1 Patient with early scalp micropigmentation (SMP) done in 2010 with poor technique. (a) Unnatural bluish, blotchy look, and poor hairline design. (b) Repair after six tattoo hairline laser removals plus reapplication of SMP with modern methods. (c) SMP pigments placed too deep producing pigment bleeding. (d) Pigments removed with Q-switch laser and process repeated.

Unfortunately, most new clinics were focused more on “cornering the market” than improving the field. There was a cut-throat atmosphere with little sharing of information. There was so much paranoia that business owners would not even let their own technicians know the type of pigment they used or who their suppliers were. Many new clinics were started by ex-patients, ex-technicians, or other permanent makeup artists who wanted a piece of this market but had no real training or experience in the technique. Since there was no sharing of information, there was a lot of experimentation and mistakes being done.

Editor’s Note

In the editor’s opinion, another reason for early problems was a lack of appreciation that hair loss is a complex affliction, with many causes, degrees of severity, and psychological impact. “One shoe does not fit all” and often a multifaceted approach is needed, combining medical, surgical, and cosmetic components to properly treat a patient. Most of the early clinics doing SMP were run by tattoo artists or permanent makeup specialists. While they were probably experts in their respective fields, they most likely did not have a grasp of the complexity of treating hair loss sufferers.

13A.2.4 Current Status

Slowly, over the past 5 years, the situation has improved. There have been many improvements in pigments, equipment, technical protocols, experience, and training options. One major reason is hair transplant physicians recognized that this procedure could be a great adjunct to their practice and began the process of collaborating with experienced technicians. As a result, more comprehensive approaches are being used.

13A.3 “Permanent” Scalp Micropigmentation versus “Temporary” Scalp Micropigmentation

Currently, if a patient researches the term “SMP,’’they will find references to both “permanent” and “temporary” techniques. The difference between these two terms can be confusing, as they were created years ago, and do not accurately reflect the changes that have occurred to “permanent” SMP techniques in recent years. Modern “permanent” SMP look very different than early “permanent” SMP techniques. Some of the differences between “permanent” SMP and “temporary” SMP have begun to blur especially in the last 5 years. To illustrate this better, we will first describe the differences between early and modern “permanent” SMP techniques and then describe how they compare to “temporary” SMP (also called “temporary scalp trichopigmentation [STP]”).

13A.3.1 Early “Permanent” Scalp Micropigmentation

When early SMP first began in the early 2000s, clinics used tattoo or permanent makeup pigments that were meant to be permanent and not fade. Depending on the specific ink and depth of deposit, results could last for 10 to 20+ years. There was no “temporary” technique that existed at that time, so the terms “SMP” and “permanent” SMP were used interchangeably. Clinics promoted SMP as a permanent process, as it was felt this would be desirable to patients. Unfortunately, as alluded to above, early attempts at permanent SMP were associated with a significant percentage of poor aesthetic results. The most common problem being bluish color changes or blotchy results that patients would be stuck with due to the “permanent” nature of the ink. Multiple tattoo laser removal treatments were required to fix these problems if they occurred. There was obvious need for improvement.

13A.3.2 Modern “Permanent” Scalp Micropigmentation

SMP technique has evolved tremendously since its rough beginnings, especially in the last 5 years. Probably the most significant change is the use of newer pigments, specifically carbon-based pigments that are supposed to be “pure black” and fade to grey rather than blue. In addition, the importance of limiting pigment depth, the use of smaller needles, better design, and so on have improved results. Modern SMP is still not designed to fade completely, but it does fade to a lighter grey tone and become less distinct over 2 to 3 years. If one desires complete removal of the pigment, laser treatment is still required. Touch-ups are usually required every 2 to 4 years to refresh the faded dots; otherwise it begins to look more solid. Although these touch-up or maintenance requirements are very minor, the term “permanent” is possibly no longer an accurate representation of the technique if it is being used for marketing purposes to imply “one and done” with no more visits.

13A.3.3 “Temporary” Scalp Micropigmentation or Temporary Scalp Trichopigmentation

Temporary scalp trichopigmentation refers to a specific technique, developed by Milena Lardi in Milan, Italy, approximately 10 years ago (2009). It was a direct attempt to address the problems that occurred with the “ early” permanent SMP procedure (described earlier). The main difference in her technique was the development and use of sophisticated pigments specifically designed to break down and fade completely within 6 to 24 months. Milena named this technique “scalp trichopigmentation” to differentiate it from the “permanent” SMP technique of the time. However, it became popularly known as “temporary” SMP.

STP does fade and requires touch-ups every 1 to 2 years to maintain results. However, laser removal is not required. If the patient desires complete removal of the pigment, they simply have to wait for it to fade completely. STP is discussed in detail in Chapter 13B, “Temporary” Scalp Micropigmentation (Tricopigmentation).

As one can see there were huge differences between “early” permanent SMP and temporary trichopigmentation. These differences have lessened over time with the improvements in modern SMP. STP and modern SMP now share a number of similarities which include the following:

•Both fade and require touch-ups, just to varying degrees.

•Both have modified the ink to limit color change.

•Both have modified the technique to limit migration.

The biggest differences in procedures today are as follows:

•While both will fade, STP fades completely over time and modern SMP does not. Therefore, laser treatment is still required if, for some reason, complete reversal is desired with modern SMP. However, laser removal today is not that difficult, requiring only one to two visits. This is vastly better than the multiple painful visits needed to remove older techniques.4

•While both fade and require touch-ups, the frequency of touch-ups is less with SMP at 2 to 4 years versus with STP at 1 to 2 years.

•Both currently use pigments that have less risk of turning blue; however, the pigments are different. While STP uses only various colored iron oxide pigmented powders, SMP has begun to use carbon-based pigments that are on the black scale.

There has been much controversy over the advantage and disadvantage of permanent versus temporary approaches. Proponents of permanent emphasize less maintenance, while proponents of temporary emphasize safety and reversibility. A number of clinics now offer both approaches. They start with STP to be safer, and then switch to the more permanent technique once they are certain the patient will be satisfied.

13A.4 Problems and Poor Results that Can Occur during Scalp Micropigmentation

There are a number of potential problems and poor results that can occur with any SMP technique. Probably the two most important are color change to blue and migration causing discreet dots to spread, blur, and coalesce. This can lead to either a “blotchy” or “solid” look. Other problems include poor retention; uneven fading; toxic or allergic reactions; and, last but not least, poor, unnatural design. Table 13A.1 lists these problems as well as some of the reasons they occur.

Table 13A.1 Common problems and poor results that can occur during SMP

Color change (usually blue)

•Incorrect inks or pigments with constituent colors

•Deep penetration causing migration and separation of color

•Light refraction of dark pigment under pale skin

Migration (spreading and separation of ink)

•Needle and pigment place too deep

•Incorrect angle of needle during penetrating

•Incorrect duration of needle against skin (high number of cycles)

Helmet or solid appearance

•Repetitive migration causing discrete dots to spread and coalesce

• “SMP greed” (patient pushing for darker look). Mistakenly thinking “more is better”

Poor retention (although this is disappointing to patients, it is fairly easy to fix)

•Needle too shallow

•Skin issues such as scar tissue or inflammation

•Poor post-op care (sunburn, aggressive washing, etc.)

Medical complications

•Allergic reactions or exposure to toxins

•Infection

Design errors (inexperience and lack of knowledge)

•Hair line placed too low

•Hairline too straight

•Not considering future hair loss

Abbreviation: SMP, scalp micropigmentation.

13A.5 Technical Variables that Influence Scalp Micropigmentation Results

At first glance, the SMP process looks amazingly simple; however, in reality it is more complicated than it seems. It is an extremely tedious, detail-oriented procedure that takes hours to perform and requires multiple visits. There are many variables that influence results. The following are some of the most important variables.

13A.5.1 Type of Pigment Used

Using a pigment that is safe (contains no toxins and is hypoallergenic), will not turn blue, and will not spread over time has been one of the most sought-after goals in SMP. We call this the “holy grail” of SMP. Unfortunately, most dark pigments are made by mixing multiple colors. The high proportion of blue in these pigments is one of the reasons they have the undesirable effect of turning blue over time as they fade or spread.

Unfortunately, it has been difficult to know the ingredients used in many of the pigments available for purchase because suppliers are not required to list them and usually want to protect their “proprietary.” Older tattoo and permanent make-up pigments could include any number of ingredients such as inorganic metal oxides, heavy metals, various plants, fruits, and nuts. Some of the ingredients were toxic metals such as allergens.

Europe has made the most strides with respect to regulating pigments. The EU law has banned 1,328 chemicals from cosmetics that are known or suspected to cause cancer, genetic mutation, reproductive harm, or birth defects. In comparison, the U.S. Food and Drug Administration has banned or restricted only 11 chemicals from cosmetics.

13A.5.2 Depth of Penetration

There is some controversy about the perfect depth for ink to be deposited, but most agree that it is somewhere in the upper dermis. If the depth is too deep, there is risk of migration (spreading) which, as we stated earlier, can lead to color change and blotchiness. This is one of the most common mistakes made by beginners. However, if the depth is too shallow, retention may be poor. Since the thickness of the skin varies in different patients and parts of scalp, the depth needs to be varied from patient to patient and area to area. Different methods of controlling depth are used in different techniques. Some do this by experience and touch, while others use a depth guard.

13A.5.3 Needle Size

There are differences in opinion over the perfect size of needle to use. In SMP, most use either a single-point or triple-point needle. Many will use a three-point needle for the central area and a single for the hairline. Others feel if a shaved look is being produced, a single needle should be used in all areas and that a three-point needle should only be used for a thickening look.

13A.5.4 Duration of Penetration and Puncture Cycle

Technicians can adjust the length of time their needle touches the skin as well as the number of penetrations per second that will be delivered. The longer one holds the needle on the skin and the greater the number of cycles per second, the more ink that will be deposited and the more trauma that will occur, allowing room for spreading at the base. The best duration and cycle will change based on the type and area of skin being treated.

13A.5.5 Timing Protocols

Often two to four passes are needed initially to create a desired effect. Currently, the market standard is that of three sessions. There are different opinions regarding how much time should be allowed between passes. The proper time frame may vary depending on the ink and tools used by a specific clinic. Some will do three passes over 3 weeks (or less), while others over use three passes over 3 months.

13A.6 Indications for Scalp Micropigmentation

The indication for SMP can be divided into three general categories which include:

1.Creating a shaved look.

2.Creating a thickening effect.

3.Camouflaging scars from past hair transplants, other surgeries, trauma, etc.

There are various specific reasons or causes that would lead a patient desire to use SMP for one of these purposes (Video 13A.1).

13A.6.1 Creating a Shaved Look

The “shaved look” has become an increasing popular look for people who would like to maintain the appearance of closely cropped full head of hair. This procedure simulates the uniform appearance of growing stubble similar to when the hair reaches a length of between 0.1 mm (0 guard) and 0.5 mm (1/2 guard) growth on a shaved scalp.

Specific patients for whom a shaved look may be appropriate include:

•Patients who are not candidates for a hair transplant due to very poor donor supply.

•Patients who are candidates for a hair transplant but simply prefer having a shaved looked for one reason or another. Some may simply prefer a shaved look to a hair transplant. This is especially true if a limited donor supply means they would only be able to create a more conservative look with hair transplants. Others may be afraid of surgery or not want to go through the time and expense that is required.

•Patients who have had a past transplant and are disappointed with the results. One option for these patients is to shave down the transplanted hair and convert over to a shaved look (Fig. 13A.2a, b).

•Patients with inflammatory or immunological disorders like alopecia aerate universalis or extensive cicatricial alopecias can also be treated with a shaved look. These are entities that did not have a good treatment option in the past (Fig. 13A.3a, b).

Fig. 13A.2 Scalp micropigmentation (SMP) can be used to imitate the look of a shaved head. This patient had a previous hair transplant which he was unhappy with, and rather than try to do more surgery he preferred to convert to the look of a shaved head. (a) Before SMP with hair transplant that did not reach his goals; (b) after SMP shaved look.

Only gold members can continue reading. Log In or Register to continue