Coalition member Dr. Robert Bernstein is a pioneer in the field of hair restoration and has an outstanding reputation for producing only the best hair transplant results.  Recently, he attended and participated in the annual 2012 ISHRS (International Society of Hair Restoration Surgery) scientific meeting in the Bahamas.  Below, Dr. Bernstein provides this community with his expert insight on Scalp Micropigmentation (SMP), the process of tattooing the scalp to promote an appearance of naturally growing hair.   Visit the “Highlights from the 2012 ISHRS (International Society of Hair Restoration Surgery) Scientific Meeting in the Bahamas” for more highlights from the meeting. View Dr. Bernstein’s expert feedback below.

For readers that are not familiar with it, Scalp Micropigmentation (SMP) is a permanent cosmetic tattoo that mimics the very short hairs of a closely shaved scalp.  I think that Scalp Micropigmentation (SMP) is a useful new adjunct to hair transplantation with interesting potential and I am pleased to see that doctors in our field, particularly Dr William Rassman and Dr. Jae Pak, are spearheading the development of expertise in the technique and promoting the technology to make it more widely available to patients.   

 One of the things that was apparent from their presentation at the ISHRS is that SMP is an “art” and that proper technique is extremely important in getting an aesthetically satisfactory result.  This includes: the angle that the instrument is inserted, depth control, the amount of pigmented deposited, and color match – not to mention proper patient selection. 

 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. I think that it is wise for all those considering extensive SMP to do this.

 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. 

 I was particularly impressed with some of the darker skinned patients of Dr. Rassman that had extensive SMP to create a shaved look and with how satisfied they were with the procedure. 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 seems to me that it should be particularly useful in women who have thinning, but not bald areas, where SMP can give the appearance of more volume and their existing hair can give the scalp texture.

 When SMP is used to enhance a hair transplant, rather than stand alone, the range of people who might benefit from the procedure increases dramatically, 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 good sense of how the technique will withstand the test of time. 

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Blake – aka Future_HT_Doc

Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum

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