Scalp micropigmentation (SMP) is a highly sophisticated medical tattoo process for balding or thinning hair. SMP looks amazingly simple, but this novel technique must be customized for each patient because the skin in each patient differs with regard to how the scalp reacts as it holds on to the tattoo dye. There are many variables involved with performing SMP that makes this process more of an art form than a science. SMP is a very labor-intensive process that could require multiple sessions and up to 20 hours of procedural time to satisfy the patient. This review discusses applications and technical considerations of the SMP process.
Key points
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SMP is a medical tattoo application for balding or thinning hair.
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SMP is a permanent concealer that reduces the color contrast between hair and scalp.
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SMP can be used for men or women with thinning hair.
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SMP can be used as an adjunct to hair transplantation.
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SMP can be used as a styling solution for a balding man who is willing to shave his scalp.
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SMP is an art form and requires a good understanding of the instability of the balding process.
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SMP can create extremely happy or unhappy patients so it is critical to fully implement informed consent.
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SMP is very effective for the treatment of scalp scars of almost any cause.
Introduction
A concealer is a product applied to the scalp to reduce the visual contrast between the color of the hair and the color of the skin. This procedure can be done by darkening the skin with powders, pastes, or paint-like substances, thickening the hair shafts with a keratin-like material or dying the hair to bring its color closer to the color of the scalp. Concealers are used by men and women with thinning hair or genetic patterned balding. The tattoo, when applied to the scalp, becomes a type of permanent concealer. The first recorded medical use for a tattoo as a concealer was published by Traquina in 2001 but its use was crude and quite detectable. The refinement of the process, called scalp micropigmentation (SMP), requires that the tattoo pigment be placed in microdots of less than 1 mm in size and 1 mm apart, similar to the distance between follicular units evident on a shaved scalp.
SMP is like a stippled painting and it is an art form. The placement distance and the size of the pigment dots vary with the targeted goals of the surgeon (artist) and the patient. Although it is initially thought that the mathematical density of the dots for SMP should approximate the follicular unit density, in the authors’ earlier experience, we have since come to realize that the actual distribution of dots is not a purely mathematical constant tied to the follicular unit density of a particular patient. When used to address deformities of the hair and scalp, it is found that the pigment must be blended with the blemishes and scars found in the patients. What needs to be done is based on the “soft” requirements of the art form that best defines the dot size, density, and color of the pigment. The intensity of the dots and how they are worked on the scalp give shade and texture to the area being addressed. The requirement for each area of the scalp may vary based on many factors, including the following:
- a.
Presence of scars and/or hair
- b.
Smoothness of the scalp
- c.
Color of the skin and hair
Introduction
A concealer is a product applied to the scalp to reduce the visual contrast between the color of the hair and the color of the skin. This procedure can be done by darkening the skin with powders, pastes, or paint-like substances, thickening the hair shafts with a keratin-like material or dying the hair to bring its color closer to the color of the scalp. Concealers are used by men and women with thinning hair or genetic patterned balding. The tattoo, when applied to the scalp, becomes a type of permanent concealer. The first recorded medical use for a tattoo as a concealer was published by Traquina in 2001 but its use was crude and quite detectable. The refinement of the process, called scalp micropigmentation (SMP), requires that the tattoo pigment be placed in microdots of less than 1 mm in size and 1 mm apart, similar to the distance between follicular units evident on a shaved scalp.
SMP is like a stippled painting and it is an art form. The placement distance and the size of the pigment dots vary with the targeted goals of the surgeon (artist) and the patient. Although it is initially thought that the mathematical density of the dots for SMP should approximate the follicular unit density, in the authors’ earlier experience, we have since come to realize that the actual distribution of dots is not a purely mathematical constant tied to the follicular unit density of a particular patient. When used to address deformities of the hair and scalp, it is found that the pigment must be blended with the blemishes and scars found in the patients. What needs to be done is based on the “soft” requirements of the art form that best defines the dot size, density, and color of the pigment. The intensity of the dots and how they are worked on the scalp give shade and texture to the area being addressed. The requirement for each area of the scalp may vary based on many factors, including the following:
- a.
Presence of scars and/or hair
- b.
Smoothness of the scalp
- c.
Color of the skin and hair
Applications and indications
Men and women have the option to control their hair length or to shave or buzz cut their hair. Creative hairstyling techniques have been adapted by many balding men and women to hide their thinning or balding problems. Shaving the scalp has been an acceptable styling option for balding men; however, when scars are present, the shaving options often disappear. In the 2011 International Society of Hair Restoration Surgery publication and presentation, SMP was presented for the treatment of many medical and surgically induced scalp problems, such as:
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Autoimmune diseases
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Genetic hair loss
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Surgical scarring from a variety of surgical procedures, including strip scarring from traditional hair transplant procedure
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Old punch graft donor sites
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Follicular unit extraction (FUE) scarring
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Craniotomy scarring
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Scars from scalp reduction surgery
The use of SMP has great value to augment a hair transplant in the many patients who do not have enough hair to undergo a hair transplant, whereby the hair supply does not meet the need for hair. SMP can also be an alternative to hair restoration surgery in some male patients who do not want to have a surgical procedure to treat their balding or the female patient who is thinning and may decide to use SMP as a permanent concealer. The best option for SMP in male patients who do not have enough hair for good coverage is to shave their head completely; however, the doctor may be able to design a strategy whereby SMP augments a hair transplant. When using SMP for this purpose, there must be some amount of hair present. If it is done when there is not enough density to obscure the dots, then the dots will easily be seen through the thin hair. The design criteria for using SMP as a background to thinning hair requires a unique strategy for each patient and varies with each problem being addressed.
The SMP process
SMP is a highly sophisticated medical tattoo process whereby a dye is inserted into the skin using one or more needles. The needles require depth control to limit where the tattoo dye is placed. The dye can passively extend beyond the confines of the needle point where it is placed. SMP looks amazingly simple and in concept it is simple, but the techniques that were developed must be customized for each patient as the skin in each patient differs with regard to how the scalp reacts and holds on to the dye. There are many variables in performing SMP that makes this process more of an art form than a science. Bleeding of the pigment colors into the skin is the most common problem confronting the artist performing the SMP procedure because the dot sizes must be comparable to the diameter of a single hair or follicular unit at the completion of the process. The variables in the artist’s control include the following:
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Size of the needles used
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Depth of needle penetration
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Duration of the penetration
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Puncture cycling of the needles if more than one is used
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Type of pigment used
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Incident angle of the needle entering the scalp
The SMP process is a labor-intensive process and could take multiple sessions and up to 20 hours of the surgeon’s time to meet the patient’s needs.
Once the SMP process is complete after the first session, the pigment is not stable and there is a tendency of the dots to fade or bleed (blend) into the surrounding skin, changing both the size and the color of the dot. The human body seems to attack the pigment such that the process often takes more than one procedure to produce a relatively stable result. A typical patient will come back for an additional treatment 2 to 3 times in a period of a month or so to refine the appearance of the pigment in the hope that the pigments that are placed are stable. Exposure to the sun can have an impact on the color and the size of the dots. It is important to explain to the patient that there may be a blue or green tint to the pigment. The greenish color of the black pigment is similar to how the red blood vessels appear green under the skin where the increased absorption of the red spectrum of light gives rise to a phenomenon explained by the trichomatic theory of color vision (ie, if you absorb the red color, you will perceive a green hue).
Graying Hair Considerations in Micropigmentation
The provider performing this procedure must explain this to each and every patient in the disclosure of the informed consent that every patient must sign before undergoing the SMP process. The informed patient often asks about the graying of their hair as they get older because SMP is a permanent process, like any tattoo, and the concern is that if they develop gray hair, the pigment colors of the SMP process will be detectable. If they shave their scalp, this is not a problem, but if they allow their hair to grow out, then dying the hair may have to be considered if the color/contrast becomes a problem as the patient ages. Because of the high variability associated with the elements in performing the SMP process, many doctors and tattoo artists tend not to offer this service. Patient deformities created by inexperienced operators will, for the most part, be permanent. We tell our patients that, this is a permanent process, so they must be careful to select an experienced person to perform the procedure. The only option for a poor result may be the use of the laser to remove the pigments, but it may take many sessions to reverse the process adequately and the reversal is not guaranteed.
Micropigmentation Procedure
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The procedure is performed under local anesthesia—the procedure is painful without it. The authors use 0.5 Xylocaine and 0.25% Marcaine and the anesthesia often lasts through the entire 6-8 hour process.
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The hand piece the authors use has 3 needles in it that are cycled at a rate of 140 cycles per second ( Fig. 1 ).
