Scalp micropigmentation (SMP), is a permanent cosmetic ‘tattoo’ that mimics the short hairs of a closely shaved scalp. SMP offers a new treatment option for patients who are not hair transplant candidates and are willing to keep their hair very short or shave their hair to scalp level. There are a few medical conditions that may have clear applicability to this procedure including patients with alopecia areata, alopecia totalis, and a variety of scarring types of alopecia. SMP also offers excellent camouflage with a short hair style for patients who have been disfigured by old plugs, scalp reductions, and scars from hair transplant surgeries that are disfiguring or not amendable to the individuals styling needs. There is a segment of regular hair transplant patients who would like to cut their hair short but are limited due to hair transplant scar from various harvesting techniques. SMP also offers an alternative to men who do not want a hair transplant surgery.

Since 2010, New Hair Institute (NHI) has been offering SMP to a select group of patients who are not hair transplant candidates or for those who have had disappointing hair transplant results from failed hair transplant procedures. The following are case presentations of such individuals and their personal stories.

Case 1: Patient Bill

Bill is a healthy male in his mid 30’s and has been diagnosed with scarring alopecia in his teens. He is not a hair transplant candidate. SMP addressed the scarring by blending in the hypo-pigmented areas with the adjacent shaved scalp.

Case 2: Patient Chuck

Chuck is a 30 yo male who has had alopecia totalis since his teens. He always wore hats (indoors and out) and the condition has significantly hampered his self-esteem and social life. SMP gave Chuck a frame to his face and the look of a shaved scalp. While it may be a subtle look to others, this was a life changing event for Chuck.

Case 3: Patient Doug

Doug is a 55 yo male, Norwood 5, who had the 1980’s plugs with a series of scalp reduction surgeries. His donor area was limited. He gave up on corrective surgeries as he had a hard time trusting hair transplant surgeons altogether. After 25 years of wearing a hair system he wanted the freedom of a shaved scalp. SMP filled in the hypo-pigmented plug scars and redefined a new normal hair line. He is considering a limited FUE by removing some of the remaining plugs on the front of his scalp and spreading those hairs in the bald area to create stubble that he can feel and others can see.

Case 4: Patient Earl

Earl is a 32 yo male, Norwood 5, with thin quality brown hair who wanted to wear his hair short and wanted more fullness to the front, top and crown areas of his scalp. His donor laxity was not good and his donor density was low. His goals was to cut his hair short and keep his budget under control. An FUE solution would have been outside his budget and it may not have adequately addressed his highly visible scar from two FUT procedures done in the past. SMP addressed the scar, the thinning of the crown and smoothed out a hairline that he only dreamed about before.

Case 5: Patient Frank

Frank is a 22 yo male, Norwood 3V, with medium quality brown hair. He had an FUE procedure believing it to be a scar-less surgery. His logic was that if the surgery did not give him the results he was promised by the doctor or if he continued to lose his hair, that he could just shave his scalp and accept his balding fate. He did not expect the FUE to produce hypo-pigmented scars nor the ridging on the front corners of the recipient sites. SMP addressed the hypo-pigmented scars as well as the visibility of the ridging in the front corners. This photo was taken immediately after the first SMP session so you can note the slight redness of the scalp which usually last 2-3 days after the procedure is done.

Case 6: Patient Glen

Glen is a 45 yo, Norwood VI, who always shaved his head. He hated the shadow that gave the classic Norwood class VI/VII look. He was very clear that he did not want a hair transplant surgery. SMP provided Glen with a non-balding hair line and an overall look of a clean shaved head.

The above patients all have their unique story and reason for choosing SMP. They all accepted that SMP is not a substitute for real hair or a complete solution for their hair loss issues; however to these individuals, the benefits of SMP outweigh its limitations.

The limitations for SMP are as follows:

The primary concern for SMP to potential patients is the potential change in the color of the pigment over time.The pigment used for SMP is chosen to match the color and tone of shaved hair underneath ones skin. Despite variation in hair color most patients have a grayish (and greenish) tint after the hair is shaved from the dark roots of the hair showing through the layers of dermis and epidermis. Much like how blood vessels appear green under the skin, the increased absorption of the red spectrum of light give rise to this phenomenon explained by the trichromatic theory of color vision (i.e. if you absorb red you will perceive green). The light propagation through human tissue has also been modeled to show the greater decrease of red spectrum remission (1). In short, there is no true perception of black when it is deposited beneath the skin. The greater depth of pigment deposit, the greater the potential change in color perception. Thus one must choose the appropriate SMP pigment color and control the depth of pigment deposit.
The next concern is the permanence of SMP. Like all tattoos and micropigments the color of SMP will likely fade to a lighter shade over time. Exposure to sun will accelerate changes in color, as well. At this point we do not have a ample patient population large enough to judge the time it takes for a significant color change requiring a touch up; however from experiences of other clients who have undergone similar process as well as the collective tattoo clients over the world, we assume the longevity of SMP should be in the order of many years. Touch-ups may be a requirement for patients in managing their pigment changes over time. The alternative of complete SMP removal through laser ablation may also be an option but there has been no case report of this that we can find. The laser ablation of SMO only remains a theoretical solution for those individuals who want to reverse the process.
Bleeding of pigment from one spot to another is a real problem and may be technique dependent. Too many procedures tends to lead to the bleeding of pigment into the depth of the skin.
Finally many SMP patients ask about the graying of their hair over time. This is an important issue that must be addressed before a patient undergoes SMP. SMP should be considered a permanent life style changing process. One must accept keeping their hair kept short to almost a shaved appearance. If this primary concept is accepted, the graying of hair with age should not be of an important issue as SMP is applied over the entire scalp thus blending in with any grey stubble that may arise. The dying option for patients always remains.

The tattooing of the scalp is not new. This technique has been attempted by tattoo artists for years and has been used by hair transplant surgeons in the past (2). Scalp tattooing is a well discussed topic on numerous hair transplant forums and it is offered in a niche segment of the permanent makeup industry in Asia, Europe and in the U.S. In general, scalp tattooing is shunned by most physicians and potential patients because the results are highly variable. Techniques and instruments vary with tattoo machines used, needle configuration, needle designs, inks used, and the artistic styles of those providing the service. Internet chatter has been building over the past year. We have been slowly perfecting the SMP technique and we hope to standardize the techniques through more experience, continuously analyzing the results we obtain. As the process is permanent, patient deformities resulting from imperfect techniques by inexperienced operators who do not understand the subtle nuances of SMP may produce significant mal-practice risks for the novice entering the field with no training.

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