Scalp Micropigmentation (SMP) is a permanent cosmetic tattoo that mimics the very short hairs of a closely shaved scalp. It is a relatively new technique that offers an alternative for patients who are not candidates for hair transplant surgery. It can be used as a concealer in both men and women for camouflaging the appearance of thinning hair and scalp scarring due to a variety of causes.

The application of SMP is an “art.” Proper technique is extremely important in getting aesthetically satisfactory results. The angle that the instrument is inserted, depth control, the amount of pigmented deposited, and color match – not to mention proper patient selection – are all important to make this procedure successful. The SMP procedure was introduced to the medical community by Dr. William Rassman of New Hair Institute in California. He and his group have significant expertise in this technique.

Possible applications range from simply adding pigment to a small scar, to mimicking a full head of hair. The most obvious use is that of helping to camouflage a widened donor scar from a Follicular Unit Transplant (FUT) procedure. When one is considering adding pigment to an entire bald head, i.e., using it as a stand-alone procedure, the usefulness depends upon the taste of the individual person. Fortunately, there are enough patients that have now been treated, that those considering the procedure can see actual results.

Since SMP looks different from natural hair, the best way for patients to decide if the procedure is right for them is to see results first-hand. The situation is somewhat analogous to a hair system in that it is a good solution for some, but not right for everyone. The important distinction, however, is that SMP is permanent, so patient education is much more important in advance. Even though it is possible to do a test area, it is definitely not one of those things that someone should “just try and see if you like it.” SMP pigment can be removed with lasers (usually a Q-switched YAG is most effective) but, like the removal of conventional tattoos, it can take several treatments and may leave permanent hypopigmentation and scarring.

Particularly in darker skinned balding patients, extensive SMP can create the appearance of a shaved look and is useful in those who are not candidates for a hair transplant or that have chosen not to have one. The procedure is particularly useful not only with donor scars but in many types of scarring alopecia i.e., burns, scars from the treatment of skin cancer, and scars from old, plug-techniques and scalp reductions. It can be particularly useful in women who have thinning, but not bald areas, where SMP can give the appearance of more volume with ones existing hair providing texture.

When SMP is used to enhance a hair transplant, rather than as a stand-alone procedure, the range of people who might benefit from the procedure increases, but so do the issues of long-term planning. All of us who perform hair restoration surgery understand the difficulties in planning the transplant of permanent hair in a patient whose balding pattern will continue to evolve. With SMP it is even more complicated, as the implanted pigment will also change over time.

With time, permanent pigment disperses deeper in the skin, changing its hue and giving it a smudgy, less distinct appearance. When adding color to a donor scar, these changes are relatively inconsequential and one generally must only consider the greying of a patient’s hair over time – a problem easily corrected with hair dyes. On the other hand, subtle changes in the look of a totally tattooed scalp can be significant. Although many of us have observed the evolution in appearance of traditional tattoos as they age, SMP is a relatively new procedure and it will take years to get a good sense of how the technique will withstand the test of time.


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