Written by William R. Rassman, MD,corresponding authora Jae P. Pak, MD,a Jino Kim, MD,b and Norman F. Estrin, PhDc
Scalp Micropigmentation – A Concealer for Hair and Scalp Deformaties
There are millions of men and women who have cosmetic problems with their scalps and hair resulting from dermatologic and/or genetic conditions, such as intractable alopecia areata or female genetic balding. There are also iatrogenic deformities in millions of men from hair restoration procedures done between the 1950s and 1990s, reflecting crude techniques of that period and scars from strip harvesting. Since hair loss is frequently a progressive process, genetic and iatrogenic conditions often become more pronounced over time. Scalp micropigmentation (SMP) uses a tattoo in a stippling pattern that mimics hair follicles that are cut close to the scalp.1,2 This relatively new technique can significantly address the cosmetic problems derived from the conditions noted above.
The tattoo industry is in the midst of a cultural expansion, growing from 14 percent in 2008 to 21 percent in 2012,3 making SMP a more socially acceptable cosmetic solution for covering appropriate scalp and hair problems.
This article discusses how the SMP process is used, demonstrates a variety of clinical applications, identifies challenges created by the technique, discusses the anatomy and histology of the tattoo pigment interactions with human physiology, and identifies some of the safety issues known today. The authors will show how SMP will have a great impact on people who, heretofore, have had no acceptable long-term solutions for hiding deformities created by a broad variety of diseases and traumas.
SCALP MICROPIGMENTATION, A PERMANENT HAIR CONCEALER
Scalp concealers are products used by men and women and constitute a multimillion dollar industry. A concealer includes pastes or fibers that are frequently applied to the scalp that approximates hair color and lessens the contrast between hair and scalp color. Scalp tattoos have been used in the past to darken the scalp in Caucasians with alopecia4; however, the art has not been aesthetically pleasing and, therefore, has not been routinely accepted by doctors or cosmetologists. Our recent refinement of the tattoo process for scalp applications blends the technical components of a tattoo instrument and carefully selected pigments. When this is combined with the artistic and technical skills of a provider, it can address coverage of many scalp and hair cosmetic conditions.
SMP can be utilized in a variety of ways, greatly expanding cosmetic treatment options for various forms of alopecia. It has great value as part of any effort to make a person’s hair appear more plentiful. It is very effective in camouflaging scars.
Alopecia (e.g., alopecia areata or female genetic unpatterned alopecia) generally reflects reduced hair densities, but varies by degree and distribution. For early thinning or balding, styling manipulations are the first step taken by people (e.g., comb-over, or bouffant). These styling options evolve over long periods of time as hair loss progresses. Many Caucasians with chronic alopecia may change their hair color from dark to light (blonde or light brown), effectively reducing the contrast between a dark hair color and a lighter skin color. Such changes can camouflage diffuse or regional areas of localized alopecia. The use of concealers can match scalp color and, when combined with styling modifications, can be effective in areas of the scalp where balding or thinning is occurring. Many temporary concealers, however, interact with the person’s environment, including shedding on clothing or bedspreads and becoming runny in the rain or with perspiration. These topical concealers often require modifications of a user’s activities and lifestyle.
THE SCALP MICROPIGMENTATION PROCESS
The skin of the scalp has an intricate anatomy. The normal thickness of the scalp has a significant supporting infrastructure for hair (i.e., glands, blood vessels, nerves, muscles, and fat) in much greater abundance than other areas of body skin because of the higher hair densities of terminal hairs. In androgenetic alopecia (AGA), the large terminal hairs become miniaturized over time, as the hair cycles between catagen and anagen phases. When hair bulk is lost through miniaturization or apoptosis, the supporting infrastructure is reduced in proportion to the loss of the hair.
Diseases and scalp surgeries also alter scalp anatomy, resulting in regional microscopic variations in the manner that each individual reacts to SMP. The atrophic scalp of a bald man, with its reduction of blood flow and dermal fat, will respond differently to the introduction and retention of scalp pigments than would a normal hair-bearing scalp. Many incurable scalp diseases produce skin deformities that persist despite treatment. The SMP process offers a good, creative, cosmetic solution to these deformities.
The use of small follicular units was introduced in the early 1990s5-9 and, when these smaller follicular units were artistically blended to camouflage large grafts, many of the surgical deformities from prior procedures were corrected. These “surgically corrected patients” frequently became donor hair depleted as the number of surgical corrective procedures increased, creating problems of coverage and scarring in the back and side of the head. The authors estimate that patients living with a see- through donor area, donor area hair depletion, and/or severe donor area scarring number in the hundreds of thousands.
HOW SCALP MICROPIGMENTATION IS PERFORMED
SMP functions as a permanent concealer, and the targeted artistic effect is similar to the visual effect of a stippled painting as dots are created between the pores of a balding scalp. This can be done with the hair remaining long or on a shaved scalp. The density of the stippling does not necessarily match the number of pores that contain the hair in the average adult. The average Caucasian has 50,000 pores (i.e., 50,000 follicular units), Asians have an average of 40,000 pores (i.e., 40,000 follicular units), and Africans have an average of 30,000 pores (i.e., 30,000 follicular units). The density of the stippling created in the SMP process can be designed to produce shading and create the illusion of texture and fullness to address the desired results worked out between the provider and the patient.
The establishment of a realistic expectation is a critical goal in the first consultation. What the patient sees and what the provider does must be designed to meet the patient’s initial objectives; however, if the patient wants to change his or her goal after the procedure is complete by trying to push the provider to create a painted scalp for more fullness, the patients should be brought to the understanding that seeing through the hair with some visible scalp, is the norm.
The tools in the operator’s hand include pigments of different hues in a variety of formulas and viscosities and instruments employing needle groupings from one to six needles packaged together, in various sizes and shapes. The requirements for each targeted area varies based upon numerous aesthetic factors, including the presence of blemishes or scars on the scalp, skin color, hair color, the amount of hair that is present, and the color and viscosity of the pigments used.
The SMP process begins by inserting a micro droplet of pigment through the skin and into the upper dermis, using a standard tattoo instrument, which supports between one and six needles cycling between 100 to 150 cycles per second. The needle(s) must perforate the epidermis to get to the upper dermis. The depth of needle insertion varies by “feel” and visual judgments made by the operator that reflect the undulating thickness of the epidermis at the point of introduction. The thicker scalp, with more fat and supporting infrastructure, will produce a different skin turgor than an atrophic or scarred scalp, impacting what the operator feels and sees as the SMP process is performed. The operator creates a constant mental feedback loop as he/she constantly adjusts to the effects that are felt and seen. There are additional factors that become important to place the correct amount of pigment, at the correct level, into the scalp for the desired effect.
Because every patient is different, every area of the scalp is different, and every point of insertion is different from the prior and subsequent points, the operator is trained to make technical and artistic judgments as the process advances, millimeter by millimeter. Scars retain pigment very differently than the skin of an atrophic or normal scalp. It is not unusual to have both normal and abnormal scalp conditions proximate to each other in the same patient. The artistic judgments in managing this often extend into the normal scalp since a scar that is white will have to blend into the tan or dark skin that surrounds the scar.
The stippling will vary in dot size based upon artistic judgments needed once the process starts. If the pigment is placed only in the epidermis, the process will fail because the pigment will leak out within a few days after the procedure is done. If the pigment is placed too deep into the dermis, it will fail as it diffuses outside the confines of its original area of placement. The observable size of the stippling may change into a noticeable confluent visual amalgam (bleeding) of ink.
The authors usually recommend multiple sessions for SMP. The number of “dots” may be higher than 40,000 points in each session. The sessions are often long, extending up to eight hours per session. Pigment bleeding, in any one session, will have to be addressed, possibly with a Q-switched laser before the next phase of the treatment is undertaken.
Many of the authors’ patients will have two to four sessions before the process is complete since they want to have good assurance that only the upper layer of the dermis is penetrated. Pigment bleeding will be minimized with a cautious, slow, and judicious approach in each session. This process is very stressful for the operator, both mentally and physically, and it is critical for the operators to take frequent breaks during the process.
Since the authors first presented SMP, physicians seem enthusiastic to offer this service. There are no formalized training programs so doctors often hire tattooists or go on Youtube and watch the process and then try to replicate what they see. What they see, however, does not address all of the variables discussed above. Professional tattooists have no experience dealing with the many variables of the human disease or scarred scalp. The authors have seen an increasing number of problems caused by the novices that reflect poor judgments in the technical and artistic delivery of SMP. Pigment bleeding is common, as are color changes from poor choices in pigments and poor post-procedure follow-through.
SMP is a relatively new modality for cosmetic dermatologists and hair transplant surgeons who wish to expand their practices. For this reason, the authors addressed the opportunities presented by the SMP process, its strengths and challenges, as well as a variety of medical and surgical scalp and hair complications that can result during its use. Since this is a cosmetic tattoo, the elegance of the results reflects the technical and artistic skills of experienced providers. Gaining experience in this process can bring great happiness to millions of people who have, heretofore, had few options in treating their hair and scalp deformities. The SMP goal of concealing the condition cosmetically is in marked contrast in risk to medical alternatives that treat the conditions themselves.
The authors’ experience has been that many of the complications experienced by others can be avoided through the use of carefully selected pigments and a good understanding of the variables confronting the physician by each new patient. SMP, in the hands of physicians, will eliminate most risks posed at tattoo parlors. As experience grows, and further research provides better substantiation of safety and effectiveness of tattoo inks and the existing tattoo hand pieces, this process is likely to become a standardized offering for physicians specializing in cosmetic procedures.
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