Bernstein Medical - Center for Hair Restoration - Scalp Micro-Pigmentation
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Q: In what cases do you think Scalp Micro-Pigmentation (SMP) is most useful?
— M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is used in patients who want to make their thinning hair look fuller and want to avoid the nuisance of daily application of cosmetic concealers, powders or fibers. It is for patients who want a permanent solution, but who do not want, or who are not candidates for hair transplant surgery. It can achieve a variety of looks such as a buzz cut by tattooing hundreds of microdots that appear like follicles or it can reduce the contrast between generalized dark hair that is thinning over a pale scalp. It can even give the appearance of hair over a scar that has now become noticeable.

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Q: How is Scalp Micro-Pigmentation (SMP) Performed?

How is SMP done? — B.P., Long Island, NY

A: Scalp Micro-Pigmentation (SMP) is applied with tiny microneedles that mimics the appearance of hair in an area of the scalp that looks thin. It requires the use of local anesthesia and is performed in a doctor’s office. SMP is typically performed over a series of three or more sessions spaced at least 2-4 weeks apart. The length of each session varies depending on the area to be tattooed and can last from a few hours to a full day.

To perform successful SMP, the hair length and color must be analyzed in consultation along with a discussion of cosmetic goals and the potential techniques that could be implemented for the patient’s hair type. The procedure is performed under local anesthesia and is generally well tolerated with very few post-op limitations.

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Q: What is Scalp Micro-Pigmentation (SMP)?

What is SMP? — M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is a medical-grade scalp tattoo. It is a form of permanent cosmetic camouflage that can mimic the appearance of hair in locations such as scars or balding areas. SMP gives the appearance of fullness of hair without actual hairs being present. Although permanent dyes are generally used, semi-permanent materials can be substituted that will purposely fade over time.

Dr. Shaver is our dedicated in-house physician for Scalp Micro-Pigmentation procedures.

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Q: I have read a lot on the forums about hair transplant reversal and hair transplant repairs. Are they the same thing, if not, what is the difference? Can you reverse a hair transplant? — K.J. ~ Park Slope, N.Y.

A: A “hair transplant repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods. A “hair transplant reversal” refers to techniques that enable the individual to appear as if no hair restoration surgery had been performed. Although the techniques in attempting to perform a repair or a reversal may be similar, the ultimate goals of each are quite different. It is important to understand that although significant improvement can often be achieved, perfect repairs and/or full reversals are generally not possible.

The main reasons for seeking a repair include; large grafts transplanted to the frontal hairline giving an unnatural, “pluggy” appearance, a frontal hairline placed too far forward, hair placed in the wrong direction, and donor and recipient site scarring. Outdated procedures such as scalp reductions and flaps also need to be repaired.

If the transplanted grafts are large (“hair plugs”), it is possible to surgically excise these grafts, microscopically dissect them into smaller follicular unit grafts, and re-transplant them into the scalp in a more natural-looking, aesthetic way. After these large grafts are removed, the sites are sutured closed and heal with very fine, often imperceptible, white scars. Hair plug removal is often followed by one or more sessions of FUT or FUE in order to harvest additional hair for use in camouflaging any remaining plugs or improving the appearance of the region where the plugs had previously been. These combined repairs can lead to excellent outcomes.

If the grafts at the hairline are not large but are placed too low or too broadly, it is possible to use laser hair removal and/or tweezing to remove these hairs. Repeated treatments may be necessary until the hair ceases to grow back at these locations. Additionally, hair which was placed in a direction different from the way hair naturally grows will usually need to be removed.

Another challenge in hair transplant repair is fixing widened donor scars that had resulted from poorly performed FUT/strip procedures. These scars are permanent and may be visible if the hair is not worn long enough. Scars from FUT procedures can be repaired by harvesting hair from the surrounding donor area (using FUE) and transplanting these follicular unit grafts into the scarred tissue.

Scalp micro-pigmentation (SMP), a permanent micro-tattoo, may be useful to further camouflage these linear scars. SMP can also be used to improve the look of the stippled scars of FUE in patients. This can occur with overharvesting, when patients wear their hair too short, or when the balding is more extensive than anticipated and extends into the harvested area.

A hair transplant reversal, in theory, has the goal of having the person look as though a hair transplant had never been performed. While reversing a hair transplant completely is not possible, the techniques previously discussed can be utilized to achieve a number of important things. The donor site scarring can be minimized and/or camouflaged and the smaller follicular unit grafts in the recipient zone can often be removed without leaving behind any visible scarring of the underlying skin. What is not possible is to restore the person’s density to a pre-procedure level as improperly performed transplants always result in wasted hair.

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According to an article published in the journal of Clinical Aesthetic, ((Rassman WR, Pak JP, Jino K, Estrin NF. Scalp Micro-Pigmentation, A Concealer for Hair and Scalp Deformities. Clinical Aesthetic, March 2015, 8(3): 35-42.)) scalp micropigmentation (SMP) is an effective cosmetic solution for millions of men and women who currently have significant scalp deformities for which there are few, if any, good medical treatment options.

Scalp Micro-Pigmentation is a Permanent Hair Loss and Scar Concealer

SMP is a permanent cosmetic tattoo of carefully selected pigments applied to the scalp in a stippling pattern to mimic closely cropped hair. This technique allows a physician skilled in SMP to effectively conceal a variety of alopecias and scars.

SMP can address the following situations:

  • Female hair loss not responsive to minoxidil or cannot be treated with a hair transplant
  • Hair loss due to chemotherapy
  • Deformities from autoimmune diseases, such as refractory alopecia areata or alopecia totalis
  • Scalp scars from scarring alopecias
  • Scars from neurosurgery or head trauma
  • A visible scar from a strip harvesting procedure or punctate scars from an FUE procedure
  • Visible open donor scars from older harvesting techniques – usually those from the 1950s through the early 1990s
  • A pluggy or corn-row look from older hair restoration procedures

Scalp micro-pigmentation can also create the appearance of fullness on an otherwise thinning or bald scalp with or without a shaved head.

The Scalp Micro-Pigmentation Process

The physician skilled in SMP has a variety of tools at hand, including pigments of different colors and viscosities. The pigments can be introduced into the skin using a number of different needle types and sizes.

The physician begins by taking a needle and inserting a tiny droplet of pigment through the top layer of the skin and into the upper dermis. Because the thickness of the top layer of the skin varies across the scalp, the doctor must judge the appropriate depth at each location by both “feel” and visual cues. For example, a portion of the outer skin layer that has more fat and hair follicles will have a different look and will produce a different feel when inserting a needle compared to a scarred or bald scalp.

To place the correct amount of pigment at the correct depth at a particular location on the scalp, the operator of the tattooing instrument must take into account the following variables:

  • The angle and depth of the needle
  • The time the needle is left in the scalp (in order to place the pigment into the upper dermis)
  • The resistance of the scalp, which varies locally across the scalp
  • The particular color and viscosity of the pigment
  • The size and shape of the particular needle

In order to produce the desired shading and create the desired illusion of texture and fullness, the doctor must vary the density of the stippling across the area of application. Because every patient is unique and every area of the scalp is different, the doctor must proceed carefully in order to achieve the desired aesthetic effect and to minimize the chances of the pigment bleeding into the area surrounding the point of application.

The complete SMP process usually takes two to four sessions.

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Hair restoration physicians William R. Rassman, Jae P. Pak, and Jino Kim have outlined a practical, permanent cosmetic treatment for hair loss, called scalp micro-pigmentation (SMP) in a paper published in the journal Hair Transplant Forum International. ((Pak JP, Rassman WR, and Kim J. Scalp micro pigmentation (SMP): novel application in hair loss. Hair Transplant Forum International, Vol. 21, No. 6, Nov./Dec. 2011, p. 1, 186-87. ))

Scalp micro-pigmentation, first described in the medical literature in 2001, ((Traquina AC. Micro-Pigmentation as an adjuvant in cosmetic surgery of the scalp. Dermatologic Surgery, Vol. 27(2) 2001: 123-8)) is a cosmetic tattoo that creates the appearance of the short hairs of a closely shaved head on an otherwise bald or thinning scalp. SMP (also referred to as ‘cosmetic transdermal hair replication,’ ‘scalp pigmentation,’ ‘cosmetic hair follicle replication,’ or ‘micro hair technique’) is an option for patients who are not candidates for a hair transplant and who are willing to keep their hair cut short or shaved. It is can also serve as a “filler” for those with longer hair.

The paper discussed case studies of six hair loss patients of varying age and hair loss condition who used SMP to camouflage scalp scars or areas of hair loss:

  1. A man in his mid-30s, who was diagnosed with scarring alopecia in his teens, used SMP to camouflage his scarring.
  2. A 30-year-old male, who had worn a hat continually since being diagnosed with alopecia totalis in his teens, used SMP to frame his face and re-build his self-esteem.
  3. A 55-year-old man, who had large-graft (“hair plug”) hair transplants and several scalp reductions, used SMP to fill in plug scars and re-define his hairline.
  4. A 32-year-old man used SMP to cover donor area scars from previous FUT procedures, fill in his thinning crown, and create a smooth hairline.
  5. A 22-year-old man filled in scars from a previous FUE hair transplant using scalp micro-pigmentation.
  6. A 45-year-old man, who had always shaved his head and refused hair transplantation, used SMP to create a hairline with an overall look of a clean-shaven head.

SMP can be applied to patients with alopecia areata, alopecia totalis, or pattern baldness. SMP can also help hide the scar tissue from several types of scarring alopecia. Finally, it can help to camouflage the scar tissue caused by large-graft “plug” transplants, scalp reduction procedures, or poorly performed or failed hair transplant procedures.

The authors note that adoption of SMP by physicians and potential patients has been slow because of the highly variable outcomes due to a lack of standardized SMP techniques and materials. However, the authors say a standardized SMP technique is being formalized that should support consistent high quality outcomes.

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According to an article published in the journal of Facial Plastic Surgery Clinics, ((Rassman W, Pak J, Kim J. Scalp micro-pigmentation: a useful treatment for hair loss. Facial Plast Surg Clin North Am. 2013;21(3):497–503.)) scalp micro-pigmentation (SMP) has been found to be a useful cosmetic treatment for hair loss and scalp scars.

SMP is a scalp tattooing technique that uses fine dots – like a stippled painting – to mimic the appearance of extremely short hairs on an otherwise bald scalp.

SMP can create the appearance of a fuller head of hair on a scalp that is losing hair by softening the contrast between the hair that remains and the color of the scalp. It can also effectively camouflage a scalp scar, like the donor scar from a strip hair transplant procedure, the scar from a scalp reduction or scars from trauma to the scalp.

Finally, SMP can help augment the results from either a Follicular Unit Hair Transplant (FUT) or a Robotic FUE Transplant (R-FUE), especially for patients who do not have enough donor hair to give the appearance of full coverage.

More Art than Science

While one might think the placement of the dots need only follow, in a straightforward fashion, the natural distribution and density of hair that occurs on a normal scalp, the application of SMP is in fact more art than science.

The effective application of SMP requires a strategy and technique custom tailored to each patient that takes into account the particular aesthetic needs of the patient and the particular characteristics of their hair and scalp.

To correctly design and execute such a tailored approach, a physician needs to have considerable expertise regarding where to place the dots, the proper needle size, the best angle of application, the depth and duration of penetration, and the best type of dye to use for a particular person’s scalp.

In addition to SMP being an art form, the article stresses that in the case of concealing pattern hair loss, a physician also needs to have a thorough medical understanding of the progressive nature of the genetic balding process.

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