Aesth Plast Surg (2014) 38:205–206 DOI 10.1007/s00266-013-0265-3
EDITOR’S INVITED COMMENTARY
NON-SURGICAL AESTHETIC
Micropigmentation: Camouflaging Scalp Alopecia and Scars in Korean Patients W. Lampeter
Received: 13 December 2013 / Accepted: 13 December 2013 / Published online: 11 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. The use of tattooing as an adjunct to reconstructive procedures and scar treatments is well documented in the plastic surgery literature [1, 2]. As Dr. Park and his coauthors have persuasively illustrated, it also is applicable for improving the cosmesis of male-pattern baldness (MPB) and female-pattern hair loss (FPHL). Oftentimes used as a complementary measure for hair transplantation, tattooing may have certain applications as a primary nonsurgical treatment for individuals disinclined to a surgical approach, as described in the published report [3]. Having been graciously invited by Dr. Spinelli to comment on this publication, I submit for your consideration several concepts gathered from my personal experience tattooing scars and scalp alopecia over the years. In contrast to the published report, which compiles data on exclusively Korean patients, my demographics to date have been predominately in the treatment of Caucasians, as well as in various other combinations of racial heritage. I believe, however, that the techniques of tattooing have many commonalities applicable across the lines of race and ethnicity. I therefore offer this commentary to share my clinical preferences as they pertain to the published report. First, the authors report using only black ink for these procedures because all 43 patients had ‘‘black-colored’’ hair [3]. I find that black ink must almost always be tonally W. Lampeter (&) Lenox Hill/Manhattan Eye, Ear, and Throat Hospital, 210 East 64th Street, New York, NY 10021, USA e-mail: [email protected]
‘‘warmed’’ with an orange-based pigment, even for individuals with black hair, to minimize the bluish tint, as evidenced in Figs. 1–3 [3]. The addition of this tint has been shown to minimize bluing over time without substantially altering the ink color at the time of implantation [4]. Additionally, I emphasize that tattooing for hair loss, in my judgment, is most effectual when used on scalps with some hair coverage or as a complementary therapy in conjunction with hair transplantation. Performed on completely glabrous skin or wide areas of scarring as in Fig. 4, I believe that the total lack of hair somewhat compromises the potential outcome and may overshoot the indications for this medium. It certainly is understandable that some individuals may decline the surgical option, but I think the result could perhaps have been further optimized with a course of gentle self-massage to loosen the involved area and subsequent scar excision before tattooing [5]. In contrast to the author’s recommendations, I find it difficult to express the target tissues for pigmentation in a millimeter range because they are ideally the papillary dermal layers, and this depth may vary greatly among individuals, as well as among body areas. This is one aspect that requires operator judgment and expertise to attain the optimal placement of coloring, which generally is signified by the drawing of blood as an end point. Additionally, I prefer to position the needle at a 45° angle in an antegrade fashion to perform what decorative tattooists often call ‘‘pushing ink.’’ When tattooing scalp alopecia, I personally favor tiny strokes with the tattoo needle as opposed to the pointillism techniques described by Dr. Park and his coauthors. Orienting these patterns in the direction of hair growth, in my opinion, typically offers a more natural appearance of the treated areas. This simply is an alternative method for the
123
206
reader to consider because I am certain that both processes may yield satisfactory results. I agree with Dr. Park and his coauthors regarding the favorable use of iron oxide–based pigments, iron oxide being a common constituent of formulations ranging from pale auburns to black and generally well tolerated. Although individual circumstances may vary, I find that most patients typically require two to three treatments when this type of ink is used, which I schedule at 4- to 6-week intervals. In some situations, additional treatments may be required to achieve the desired outcome. During subsequent sessions, the color may be adjusted and needle patterns reconfigured to provide greater visual complexity of the final result. Over time, the color will fade, and I have found that the majority of patients may desire a ‘‘touch-up’’ procedure every year or two. In many ways, the temporal nature of this pigment type is beneficial because it may be modified over time to accommodate changes in hair color and graying. I also concur with the authors that cicatricial tissue is inherently unpredictable when these procedures are performed. Scars often are quite resistant to pigment or conversely retain coloring more aggressively than the surrounding tissue. Sometimes both characteristics may be
123
Aesth Plast Surg (2014) 38:205–206
present in different areas of the same scar. Therefore, I believe it is best to begin conservatively, as the author suggests, adding intensity as desired over subsequent sessions. Again, I commend Dr. Park and his coauthors on their innovation and excellent presentation of this method. It is my earnest hope that this article will generate continued research and engagement of these techniques within the realm of plastic and reconstructive surgery.
References 1. Maxwell JP, Gabriel A (2009) Nipple–areolar reconstruction. In: Aston SJ et al (eds) Aesthetic plastic surgery, chap. 58. SaundersElsevier, Philadelphia, pp 721–722 2. Kim EK, Chang TJ, Hong JP, Koh KS (2011) Use of tattooing to camouflage various scars. Aesthet Plast Surg 35:392–395 3. Park JH, Moh JS, Lee SY, You SH (2013) Micropigmentation: camouflaging scalp alopecia and scars in Korean patients. Aesthet Plast Surg. doi:10.1007/s00266-013-0259-1 4. Lampeter W (2011) Commentary on use of tattooing for camouflaging various scars. Aesthet Plast Surg 35:396 5. Unger WP, Unger RH (2003) Hair transplanting: An important but often forgotten treatment for female pattern hair loss. J Am Acad Dermatol 49:857
EDITOR’S INVITED COMMENTARY
NON-SURGICAL AESTHETIC
Micropigmentation: Camouflaging Scalp Alopecia and Scars in Korean Patients W. Lampeter
Received: 13 December 2013 / Accepted: 13 December 2013 / Published online: 11 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. The use of tattooing as an adjunct to reconstructive procedures and scar treatments is well documented in the plastic surgery literature [1, 2]. As Dr. Park and his coauthors have persuasively illustrated, it also is applicable for improving the cosmesis of male-pattern baldness (MPB) and female-pattern hair loss (FPHL). Oftentimes used as a complementary measure for hair transplantation, tattooing may have certain applications as a primary nonsurgical treatment for individuals disinclined to a surgical approach, as described in the published report [3]. Having been graciously invited by Dr. Spinelli to comment on this publication, I submit for your consideration several concepts gathered from my personal experience tattooing scars and scalp alopecia over the years. In contrast to the published report, which compiles data on exclusively Korean patients, my demographics to date have been predominately in the treatment of Caucasians, as well as in various other combinations of racial heritage. I believe, however, that the techniques of tattooing have many commonalities applicable across the lines of race and ethnicity. I therefore offer this commentary to share my clinical preferences as they pertain to the published report. First, the authors report using only black ink for these procedures because all 43 patients had ‘‘black-colored’’ hair [3]. I find that black ink must almost always be tonally W. Lampeter (&) Lenox Hill/Manhattan Eye, Ear, and Throat Hospital, 210 East 64th Street, New York, NY 10021, USA e-mail: [email protected]
‘‘warmed’’ with an orange-based pigment, even for individuals with black hair, to minimize the bluish tint, as evidenced in Figs. 1–3 [3]. The addition of this tint has been shown to minimize bluing over time without substantially altering the ink color at the time of implantation [4]. Additionally, I emphasize that tattooing for hair loss, in my judgment, is most effectual when used on scalps with some hair coverage or as a complementary therapy in conjunction with hair transplantation. Performed on completely glabrous skin or wide areas of scarring as in Fig. 4, I believe that the total lack of hair somewhat compromises the potential outcome and may overshoot the indications for this medium. It certainly is understandable that some individuals may decline the surgical option, but I think the result could perhaps have been further optimized with a course of gentle self-massage to loosen the involved area and subsequent scar excision before tattooing [5]. In contrast to the author’s recommendations, I find it difficult to express the target tissues for pigmentation in a millimeter range because they are ideally the papillary dermal layers, and this depth may vary greatly among individuals, as well as among body areas. This is one aspect that requires operator judgment and expertise to attain the optimal placement of coloring, which generally is signified by the drawing of blood as an end point. Additionally, I prefer to position the needle at a 45° angle in an antegrade fashion to perform what decorative tattooists often call ‘‘pushing ink.’’ When tattooing scalp alopecia, I personally favor tiny strokes with the tattoo needle as opposed to the pointillism techniques described by Dr. Park and his coauthors. Orienting these patterns in the direction of hair growth, in my opinion, typically offers a more natural appearance of the treated areas. This simply is an alternative method for the
123
206
reader to consider because I am certain that both processes may yield satisfactory results. I agree with Dr. Park and his coauthors regarding the favorable use of iron oxide–based pigments, iron oxide being a common constituent of formulations ranging from pale auburns to black and generally well tolerated. Although individual circumstances may vary, I find that most patients typically require two to three treatments when this type of ink is used, which I schedule at 4- to 6-week intervals. In some situations, additional treatments may be required to achieve the desired outcome. During subsequent sessions, the color may be adjusted and needle patterns reconfigured to provide greater visual complexity of the final result. Over time, the color will fade, and I have found that the majority of patients may desire a ‘‘touch-up’’ procedure every year or two. In many ways, the temporal nature of this pigment type is beneficial because it may be modified over time to accommodate changes in hair color and graying. I also concur with the authors that cicatricial tissue is inherently unpredictable when these procedures are performed. Scars often are quite resistant to pigment or conversely retain coloring more aggressively than the surrounding tissue. Sometimes both characteristics may be
123
Aesth Plast Surg (2014) 38:205–206
present in different areas of the same scar. Therefore, I believe it is best to begin conservatively, as the author suggests, adding intensity as desired over subsequent sessions. Again, I commend Dr. Park and his coauthors on their innovation and excellent presentation of this method. It is my earnest hope that this article will generate continued research and engagement of these techniques within the realm of plastic and reconstructive surgery.
References 1. Maxwell JP, Gabriel A (2009) Nipple–areolar reconstruction. In: Aston SJ et al (eds) Aesthetic plastic surgery, chap. 58. SaundersElsevier, Philadelphia, pp 721–722 2. Kim EK, Chang TJ, Hong JP, Koh KS (2011) Use of tattooing to camouflage various scars. Aesthet Plast Surg 35:392–395 3. Park JH, Moh JS, Lee SY, You SH (2013) Micropigmentation: camouflaging scalp alopecia and scars in Korean patients. Aesthet Plast Surg. doi:10.1007/s00266-013-0259-1 4. Lampeter W (2011) Commentary on use of tattooing for camouflaging various scars. Aesthet Plast Surg 35:396 5. Unger WP, Unger RH (2003) Hair transplanting: An important but often forgotten treatment for female pattern hair loss. J Am Acad Dermatol 49:857
