Aesth Plast Surg (2014) 38:199–204 DOI 10.1007/s00266-013-0259-1
ORIGINAL ARTICLE
NON-SURGICAL AESTHETIC
Micropigmentation: Camouflaging Scalp Alopecia and Scars in Korean Patients Jae Hyun Park • Jae Seong Moh • Seung Yong Lee Seung Hyun You
•
Received: 18 March 2013 / Accepted: 17 November 2013 / Published online: 24 December 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Abstract Background The aim of this study was to identify the usefulness of micropigmentation as a technique for alopecia and scalp scar camouflage in Korean patients. Methods Micropigmentation was performed in 43 Korean patients from November 2011 to October 2012. There were 23 female patients with female pattern hair loss (FPHL), 14 male patients with male pattern baldness, and 6 patients with scalp scars. Results The results for one patient with FPHL Ludwig stage I were satisfactory according to the physician’s assessment, but the patient was dissatisfied because she did not notice any remarkable changes after the procedure. The results for the other 42 patients were highly satisfactory and there were no adverse effects or complications. Conclusions Micropigmentation appears to be a good method for camouflaging hair loss and scalp scars. Level of Evidence IV 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. Keywords Micropigmentation Male pattern baldness Female pattern hair loss Scalp scar
J. H. Park (&) J. S. Moh S. Y. Lee S. H. You Dana Plastic Surgery Clinic, Human Tower 11F, 20-9 Jamwondong, Seocho-gu, Seoul, Korea e-mail: [email protected]
Introduction Regardless of sex, hair loss is a factor that causes a person to appear older than their actual age and thus less attractive. Recently, hair transplantation surgery and medications have shown improved therapeutic effectiveness for hair loss in men and women and are beginning to be recognized as standardized treatment methods. Some patients develop surgery phobia after multiple hair transplantation procedures and decide not to pursue surgical options despite their hair loss. Camouflaging hair loss by methods other than surgery, e.g., wearing a wig or spraying black powder regularly, is another possible course that some patients pursue. However, wearing a wig can be challenging when performing outdoor exercises or using public bath facilities (popular and generalized in Korean society), and many patients complain about the high temperatures and the sweating on the scalp when wearing a wig in the summer. Use of black powder spray is also quite cumbersome as it has temporary effectiveness and should be applied for every outing, and it looks bad if it gets wet. Furthermore, hair transplantation onto scalp scars often produces disappointing outcomes based on the low hair survival rate. Scarring causes a whitish skin color and leads to greater contrast against black-colored hair, thereby making the ‘‘see-through appearance’’ of the scalp much more noticeable. Many patients choose micropigmentation as a primary treatment option because of their surgery phobia. In these cases, micropigmentation can be a good option for camouflage. Here we report our experiences with micropigmentation for treating scalp alopecia and scars in Koreans together with the results of a literature review.
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Materials and Methods A total of 43 Korean patients who visited our clinic for alopecia or scalp scar treatment from November 2011 to October 2012 underwent micropigmentation. Among these patients, 23 had female pattern hair loss (FPHL), 14 had male pattern baldness (MPB), and 6 had scalp scars. Of the FPHL patients, seven were Ludwig stage I, 14 were stage II, and two were stage III. Their age range was 21–58 years, with a mean age of 38 years. For the MPB patients, eight were Norwood class III vertex, three were class IV, two were class V, and one was class VI. Their age range was 21–43 years, with a mean age of 36 years. Of the six patients with scalp scars, five had hair transplantation surgery donor scars and one had a post-traumatic scar from an accidental fall 5 years earlier. We performed scalp micropigmentation and reviewed the medical records retrospectively. All 43 patients were Koreans with black hair. Patients with bright brown hair or underwent frequent hair coloring were removed from the list. Most Koreans have dark black hair and only black ink was used for micropigmentation. Because of the variety in hair color and density, subtle tonal adjustment of the ink was essential and achieved by mixing it with normal saline. Five of the 23 patients with FPHL and six of the 14 patients with MPB had a previous history of hair transplantation. The average area affected by the procedure was 104 cm2 for scalp alopecia and 9.2 cm2 for scalp scars. For FPHL, the smallest size was 4.5 9 9 cm (40.5 cm2), the largest size was 15 9 18 cm (270 cm2), and the mean procedure area was 112 cm2. For MPB, the smallest size was 6 9 7 cm (42 cm2), the largest size was 12 9 15 cm (180 cm2), and the mean area was 92 cm2. The actual scar area ranged from 1 9 3 cm (3 cm2) to 1 9 28 cm (28 cm2), with a mean area of 9 cm2. Initially, the area to undergo the procedure was indicated with a marker pen based on preoperative consultations, and the local anesthetic EMLA cream (5 % lidocaine topical cream; AstraZeneca, Sweden), was applied. After application of the EMLA cream, we waited for 20–30 min and then draped the area in a sterile manner. A local anesthetic injection was not used in most cases, except for two patients who were very sensitive to pain. We used a professional tattoo machine with ink cartridges. This machine had the advantage in that an ink cartridge could be used to select various needle liners depending on the shape and size of the surgical site. We chose the most appropriate needle, mainly from the 1, 3, 5, and 7 liners, based on the surgical site and size. A loupe of 5.59 magnification was used for the procedure. While using the thumb and index finger to stretch the site to be treated, we inserted the needle holder as one
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Aesth Plast Surg (2014) 38:199–204
holds a pen, ensuring that its angle was 90° to the skin surface. The procedure should be performed with caution with respect to the depth that the needle penetrates the skin, which should be no more than about 1–2 mm. Insertion of the needle beyond this limit could cause bleeding or pain. In addition, great care should be taken as the pigment can spread out if the ink is injected too deeply. For patients with very thin skin, the needle should penetrate less, while for patients with thicker skin, the needle can penetrate the skin more. Furthermore, if the dot-to-dot distance is too small, it can create an unnatural appearance. If the dot-todot distance is excessively small, the dots enlarge with slight spreading during follow-up and they appear to be connected to one another by bridges, making them appear very large or blurry.
Results On postoperative day 1, the treated sites were red which was caused by inflammatory reactions. The redness disappeared without leaving any infections or other adverse effects. The patients made follow-up visits at 2 and 6 weeks postoperatively. If necessary, minor retouches were performed during the visits in 11 patients (26 %) for focal loss of pigment after shedding of the crust. The indication for a touch-up procedure was loss of pigment of more than 10–20 %. The follow-up period ranged from 6 to 20 months, with a mean 10.3 months (Figs. 1, 2, 3, 4). The cosmetic appearance was markedly improved as judged by the patients and the surgeon. Only one patient, a 24-year-old female with FPHL Ludwig stage I, was dissatisfied with the results. One year after the procedure she said that she did not see a great improvement and disagreed with the surgeon’s assessment that the results were satisfactory. The other 42 patients were pleased with the results and reported that they were satisfactory. There were no incidences of complications such as infections, allergic reactions, or skin necrosis.
Discussion Tattoos have been around for over 4,000 years. The word ‘‘tattoo’’ was provided by Captain Cook (1776) from a Polynesian language and refers to the placement of black pigment under the skin [3]. Tattooing were performed in ancient Egypt to indicate worship to a god [10]. Even in recent times, micropigmentation has been used in various ways and in various areas, such as in nipple-areola reconstruction [1], eyebrows, eyelids, lips, and cleft lip and palate [13]. In 1987, a permanent eyeliner tattooing technique was reported for the first time by Patipa [7].
Aesth Plast Surg (2014) 38:199–204
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Fig. 1 A 38-year-old woman with female pattern hair loss. a Before micropigmentation. b Nine months after micropigmentation
Fig. 2 A 35-year-old man with MPB. a Before micropigmentation. b Eight months after micropigmentation
Fig. 3 A 38-year-old man with MPB. The patient had a history of two previous hair transplantation surgeries, of which the first session involved follicular unit transplantation (FUT) 3000 grafts and the second session involved follicular unit extraction (FUE) 5000 grafts.
However, the patient still felt that the density of the recipient site was insufficient. Although he wanted to have a third session to increase the density, the donor site was depleted due to the previous surgeries. a Before micropigmentation. b Nine months after micropigmentation
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Fig. 4 A 43-year-old man with noticeable donor scars due to previous hair transplantation surgery. a Before micropigmentation. b Six months after micropigmentation
Van der Velden et al. [12] reported the use of tattoos for medical purposes for the first time in 1990 with regard to dermatography. In 1998, van der Velden et al. [14] further reported experiences with tattoos for treating alopecia areata of the eyebrow. In 2001, Traquina [11] reported the results of micropigmentation performed in 62 patients with scalp scars; this was the first reported use of micropigmentation on the scalp. In 2009, Spyropoulou and Fatah [9] reported a case in which an artistic decorative tattoo was made to disguise a scar on the abdomen after performing a TRAM flap. In 2011, Kim et al. [5] described 32 cases of medical tattooing in Koreans who had scars at various sites, including alopecia scars, vermilion scars, and hypopigmented scars. Micropigmentation has been performed for a long time in various forms in the medical and aesthetic fields. However, there have rarely been medical reports describing micropigmentation to treat MPB or FPHL until recently. The pigments used for micropigmentation are mainly inert, nontoxic, nonallergenic, and tissue-stable and are injected with a needle about 6 lm in size. Iron oxide has been the most commonly used agent. The pigment substances differ slightly depending on the color required. For example, cinnabar and mercuric sulfate are used for red, iron oxide is used for black and brown, and cadmium sulfide used is used for yellow [3]. Although most of these substances are known to be safe, it should be noted that there have been reports of incidences of infections, tattoo allergies, and basal cell carcinoma at the tattoo sites where these substances were used [2–4]. The most certain treatment method at the current time for disguising alopecia or scalp scars is hair transplantation. Hair transplantation involves surgery to harvest hairs that will not fall out permanently from a limited safe donor area at the back of the head and implanting the hairs into the area that requires hair. However, in cases when the donor site is depleted because of several repeated hair transplantation surgeries, when patients have a phobia for the surgery itself, when the donor site is not good for harvesting for some reason, and when it is difficult for the
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patient to undergo surgery because of social activities, other options are required. Micropigmentation can be a good therapeutic method for FPHL. Unlike in MPB, in the overall hair density is reduced without the hairline retreating. The reduction in hair density is consequently noticed when the scalp is seen through the hair, commonly referred to as a ‘‘see-through appearance.’’ In such cases, micropigmentation can decrease the ‘‘see-through appearance’’ and is a great help in camouflaging the intensity of the hair loss. The treatments for FPHL can be classified into medication treatments, conservative treatments, topical agents such as minoxidil, and hair transplantation. However, none of these methods alone can provide a definite resolution. Therefore, performing micropigmentation alone or in addition to hair transplantation can bring about very good improvements. Micropigmentation also produces good results for scalp scars. Scalp scars can result from various causes, including aesthetic surgery for trauma, neurosurgery, and facelifts. Micropigmentation is also very effective for hiding donor scars created by previous hair transplantations. In addition, micropigmentation can bring about even better outcomes than hair transplantation when the scars are composed of very hard fibrous tissues. Of course, the use of micropigmentation to improve the look of the hair density after hair transplantation for scalp scars can have very good effects. In Western countries, many people easily adapt to the skinhead look and micropigmentation is widely applied to scalp scars as well [6]. However, in Asia, and especially in Korea, the indications for micropigmentation are somewhat different. FPHL is considered to be one of the best indications for the use of micropigmentation in Asians. In cases with FPHL, even if hair loss continues, the hairline does not retreat, unlike with MPB, so there is no possibility of the micropigmentation becoming exposed, enabling a safer performance of the procedure. In addition, because the procedure can be performed without cutting the hair short, patients can undergo the procedure comfortably without interrupting their daily life. Both men and women have shown good outcomes with micropigmentation in the vertex area. Patients with MPB
Aesth Plast Surg (2014) 38:199–204
should be warned in advance that micropigmentation can become exposed as the hair loss continues. In addition, the use of finasteride (hair-growth-promoting medication) should be encouraged. Although it is possible to remove micropigmentation at a later time, the potential complications of doing so should be considered, including the possibility of needing several removal attempts and scarring. Micropigmentation is also a good option for camouflaging scalp scars. When the area without hair is too wide, it would look awkward with micropigmentation alone. In such cases, hair transplantation followed by additional micropigmentation can possibly lead to synergic effects. Factors affecting micropigmentation include the penetration depth, the length of time that the needle is inside the skin, types and conditions of the ink, and thickness, elasticity, and laxity of the skin. Among these, the most important factors are the penetration depth of the needle and the length of time the needle is inside the skin. The optimum penetration depth is about 1.5 mm (range 1–2 mm), where the upper and midpapillary dermis are [3]. If the penetration is too deep or too long, the size of the dot becomes too large over time, the dot-to-dot distances become smaller, and the dots appear to be connected, creating a phenomenon that resembles spreading of the coloration. This should be avoided because it makes it obvious that the person had the procedure. Peters et al. [8] reported complications of extensive spread of lower-eyelid pigment after performing blepharopigmentation. Therefore, it is better to perform the procedure with a light sense of touch. On the other hand, if the needle insertion is too shallow (\1 mm) or is in the skin for too short a time, the pigment may not remain inside the skin but instead disappear by extrusion together with the crust [3]. In cases in which the procedure is performed too superficially, the dot is visible immediately after the operation but disappears and is invisible at the 2-week follow-up visit. Therefore, the patient should be checked 2 weeks after the procedure and touch-up enhancement procedures should be performed if required at that time. Gauging needle penetration depth is a highly sensitive technique and comes from experimentation and the surgeon’s digital sensation. Therefore, it is recommended that the dot-to-dot distance be reduced as the surgeon’s technique improves. In theory, the patient’s original density of follicular units is the ideal dot density or distance. To control the distance, a surgeon should wear a 59 magnification loupe at minimum. The dots should never be put in a continuous line; instead, they should be placed in an irregular pattern, ensuring that the distances between individual dots are maintained. The fact that the natural hair may turn gray
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over time should also be explained to the patient. If there are too many gray hairs, it may be necessary dye the hair a dark color on a continuous basis. Micropigmentation is not recommended for individuals who change their hair color frequently. Patients should be informed about the possibility of the pigment fading over time, and that they may need to undergo an additional procedure to enhance the color in the future. Patients must also be advised of the difficulty in removing the micropigmentation at a later time and the possible risks of hair loss and scarring. Furthermore, patients should be informed that additional micropigmentation procedures may be needed if the hair loss becomes worse in the future. The use of the procedure for scar tissue is very challenging and complicated, and it is difficult to predict the outcome. If the penetration of the needle is just slightly deeper than it is supposed to be, the pigment can spread out to the ambient tissues, but if it is just slightly shallower, the pigment may not be retained. Therefore, a lot of experience is needed in using this technique. It is important that surgeons anticipate having to perform touch-up procedures from the beginning and should not attempt to overintroduce the pigment, which can subsequently result in deep penetration. If there is good surgical planning, high-yield results are achievable, even in problematic scar sites. Gauging needle depth in scars is challenging, and developing one’s skills with MPB and FPHL cases is highly recommended before attempting the procedure on a scar field. In addition, surgeons should not attempt to perform micropigmentation on tufted areas before accumulating experience. In the beginning, the procedure should be performed with a certain dot-to-dot distance to avoid the dots looking like they are connected by bridges when the dot size becomes slightly bigger over time. Supplementation between the dots while performing touch-up procedures might be necessary.
Conclusions Micropigmentation is considered to be one of the effective methods for camouflaging MPB, FPHL, and scalp scars. Conflict of interest The authors declare that they have no conflicts of interest to disclose.
References 1. Becker H (1986) The use of intradermal tattoo to enhance the final result of nipple-areolar reconstruction. Plast Reconstr Surg 77:673–676 2. Earley MJ (1983) Basal cell carcinoma arising in tattoos: a clinical report of two cases. Br J Plast Surg 36:258–259
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204 3. Garg G, Thami GP (2005) Micropigmentation: tattooing for medical purposes. Dermatol Surg 31:928–931 4. Goldberg HM (1996) Tattoo allergy. Plast Reconstr Surg 98:1315–1316 5. Kim EK, Chang TJ, Hong JP, Koh KS (2001) Use of tattooing to camouflage various scars. Aesthetic Plast Surg 35:392–395 6. Park JP, Rassman WR (2011) Scalp micropigmentation (SMP): novel applications in hair loss. Hair Transplant Forum Int 21(181):186–187 7. Patipa M (1987) Eyelid tattooing. Dermatol Clin 5:335–348 8. Peters NT, Conn H, Coˆte´ MA (1999) Extensive eyelid pigment spread after blepharopigmentation. Ophthal Plast Reconstr Surg 15:445–447 9. Spyropoulou GA, Fatah F (2009) Decorative tattooing for scar camouflage: patient innovation. J Plast Reconstr Aesthet Surg 62:e353–e355
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Aesth Plast Surg (2014) 38:199–204 10. Steinberg JD, Winkelman FJ (2001) Permanent skin pigmentation for decorative and reconstructive purposes. Dermatol Ther 14:237–245 11. Traquina AC (2001) Micropigmentation as an adjuvant in cosmetic surgery of the scalp. Dermatol Surg 27:123–128 12. van der Velden EM, Wittkampf AR, de Jong BD, van der Putte SC, van der Dussen MF (1992) Dermatography, a treatment for sequelae after head and neck surgery. J Craniomaxillofac Surg 20:273–278 13. van der Velden EM, van der Dussen MF (1995) Dermatography as an adjuvant treatment for cleft lip and palate patients. J Oral Maxillofac Surg 53:9–12 14. van der Velden EM, Drost BH, Ijsselmuiden OE, Baruchin AM, Hulsebosch HJ (1998) Dermatography as a new treatment for alopecia areata of the eyebrows. Int J Dermatol 37:617–621
ORIGINAL ARTICLE
NON-SURGICAL AESTHETIC
Micropigmentation: Camouflaging Scalp Alopecia and Scars in Korean Patients Jae Hyun Park • Jae Seong Moh • Seung Yong Lee Seung Hyun You
•
Received: 18 March 2013 / Accepted: 17 November 2013 / Published online: 24 December 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Abstract Background The aim of this study was to identify the usefulness of micropigmentation as a technique for alopecia and scalp scar camouflage in Korean patients. Methods Micropigmentation was performed in 43 Korean patients from November 2011 to October 2012. There were 23 female patients with female pattern hair loss (FPHL), 14 male patients with male pattern baldness, and 6 patients with scalp scars. Results The results for one patient with FPHL Ludwig stage I were satisfactory according to the physician’s assessment, but the patient was dissatisfied because she did not notice any remarkable changes after the procedure. The results for the other 42 patients were highly satisfactory and there were no adverse effects or complications. Conclusions Micropigmentation appears to be a good method for camouflaging hair loss and scalp scars. Level of Evidence IV 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. Keywords Micropigmentation Male pattern baldness Female pattern hair loss Scalp scar
J. H. Park (&) J. S. Moh S. Y. Lee S. H. You Dana Plastic Surgery Clinic, Human Tower 11F, 20-9 Jamwondong, Seocho-gu, Seoul, Korea e-mail: [email protected]
Introduction Regardless of sex, hair loss is a factor that causes a person to appear older than their actual age and thus less attractive. Recently, hair transplantation surgery and medications have shown improved therapeutic effectiveness for hair loss in men and women and are beginning to be recognized as standardized treatment methods. Some patients develop surgery phobia after multiple hair transplantation procedures and decide not to pursue surgical options despite their hair loss. Camouflaging hair loss by methods other than surgery, e.g., wearing a wig or spraying black powder regularly, is another possible course that some patients pursue. However, wearing a wig can be challenging when performing outdoor exercises or using public bath facilities (popular and generalized in Korean society), and many patients complain about the high temperatures and the sweating on the scalp when wearing a wig in the summer. Use of black powder spray is also quite cumbersome as it has temporary effectiveness and should be applied for every outing, and it looks bad if it gets wet. Furthermore, hair transplantation onto scalp scars often produces disappointing outcomes based on the low hair survival rate. Scarring causes a whitish skin color and leads to greater contrast against black-colored hair, thereby making the ‘‘see-through appearance’’ of the scalp much more noticeable. Many patients choose micropigmentation as a primary treatment option because of their surgery phobia. In these cases, micropigmentation can be a good option for camouflage. Here we report our experiences with micropigmentation for treating scalp alopecia and scars in Koreans together with the results of a literature review.
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Materials and Methods A total of 43 Korean patients who visited our clinic for alopecia or scalp scar treatment from November 2011 to October 2012 underwent micropigmentation. Among these patients, 23 had female pattern hair loss (FPHL), 14 had male pattern baldness (MPB), and 6 had scalp scars. Of the FPHL patients, seven were Ludwig stage I, 14 were stage II, and two were stage III. Their age range was 21–58 years, with a mean age of 38 years. For the MPB patients, eight were Norwood class III vertex, three were class IV, two were class V, and one was class VI. Their age range was 21–43 years, with a mean age of 36 years. Of the six patients with scalp scars, five had hair transplantation surgery donor scars and one had a post-traumatic scar from an accidental fall 5 years earlier. We performed scalp micropigmentation and reviewed the medical records retrospectively. All 43 patients were Koreans with black hair. Patients with bright brown hair or underwent frequent hair coloring were removed from the list. Most Koreans have dark black hair and only black ink was used for micropigmentation. Because of the variety in hair color and density, subtle tonal adjustment of the ink was essential and achieved by mixing it with normal saline. Five of the 23 patients with FPHL and six of the 14 patients with MPB had a previous history of hair transplantation. The average area affected by the procedure was 104 cm2 for scalp alopecia and 9.2 cm2 for scalp scars. For FPHL, the smallest size was 4.5 9 9 cm (40.5 cm2), the largest size was 15 9 18 cm (270 cm2), and the mean procedure area was 112 cm2. For MPB, the smallest size was 6 9 7 cm (42 cm2), the largest size was 12 9 15 cm (180 cm2), and the mean area was 92 cm2. The actual scar area ranged from 1 9 3 cm (3 cm2) to 1 9 28 cm (28 cm2), with a mean area of 9 cm2. Initially, the area to undergo the procedure was indicated with a marker pen based on preoperative consultations, and the local anesthetic EMLA cream (5 % lidocaine topical cream; AstraZeneca, Sweden), was applied. After application of the EMLA cream, we waited for 20–30 min and then draped the area in a sterile manner. A local anesthetic injection was not used in most cases, except for two patients who were very sensitive to pain. We used a professional tattoo machine with ink cartridges. This machine had the advantage in that an ink cartridge could be used to select various needle liners depending on the shape and size of the surgical site. We chose the most appropriate needle, mainly from the 1, 3, 5, and 7 liners, based on the surgical site and size. A loupe of 5.59 magnification was used for the procedure. While using the thumb and index finger to stretch the site to be treated, we inserted the needle holder as one
123
Aesth Plast Surg (2014) 38:199–204
holds a pen, ensuring that its angle was 90° to the skin surface. The procedure should be performed with caution with respect to the depth that the needle penetrates the skin, which should be no more than about 1–2 mm. Insertion of the needle beyond this limit could cause bleeding or pain. In addition, great care should be taken as the pigment can spread out if the ink is injected too deeply. For patients with very thin skin, the needle should penetrate less, while for patients with thicker skin, the needle can penetrate the skin more. Furthermore, if the dot-to-dot distance is too small, it can create an unnatural appearance. If the dot-todot distance is excessively small, the dots enlarge with slight spreading during follow-up and they appear to be connected to one another by bridges, making them appear very large or blurry.
Results On postoperative day 1, the treated sites were red which was caused by inflammatory reactions. The redness disappeared without leaving any infections or other adverse effects. The patients made follow-up visits at 2 and 6 weeks postoperatively. If necessary, minor retouches were performed during the visits in 11 patients (26 %) for focal loss of pigment after shedding of the crust. The indication for a touch-up procedure was loss of pigment of more than 10–20 %. The follow-up period ranged from 6 to 20 months, with a mean 10.3 months (Figs. 1, 2, 3, 4). The cosmetic appearance was markedly improved as judged by the patients and the surgeon. Only one patient, a 24-year-old female with FPHL Ludwig stage I, was dissatisfied with the results. One year after the procedure she said that she did not see a great improvement and disagreed with the surgeon’s assessment that the results were satisfactory. The other 42 patients were pleased with the results and reported that they were satisfactory. There were no incidences of complications such as infections, allergic reactions, or skin necrosis.
Discussion Tattoos have been around for over 4,000 years. The word ‘‘tattoo’’ was provided by Captain Cook (1776) from a Polynesian language and refers to the placement of black pigment under the skin [3]. Tattooing were performed in ancient Egypt to indicate worship to a god [10]. Even in recent times, micropigmentation has been used in various ways and in various areas, such as in nipple-areola reconstruction [1], eyebrows, eyelids, lips, and cleft lip and palate [13]. In 1987, a permanent eyeliner tattooing technique was reported for the first time by Patipa [7].
Aesth Plast Surg (2014) 38:199–204
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Fig. 1 A 38-year-old woman with female pattern hair loss. a Before micropigmentation. b Nine months after micropigmentation
Fig. 2 A 35-year-old man with MPB. a Before micropigmentation. b Eight months after micropigmentation
Fig. 3 A 38-year-old man with MPB. The patient had a history of two previous hair transplantation surgeries, of which the first session involved follicular unit transplantation (FUT) 3000 grafts and the second session involved follicular unit extraction (FUE) 5000 grafts.
However, the patient still felt that the density of the recipient site was insufficient. Although he wanted to have a third session to increase the density, the donor site was depleted due to the previous surgeries. a Before micropigmentation. b Nine months after micropigmentation
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Fig. 4 A 43-year-old man with noticeable donor scars due to previous hair transplantation surgery. a Before micropigmentation. b Six months after micropigmentation
Van der Velden et al. [12] reported the use of tattoos for medical purposes for the first time in 1990 with regard to dermatography. In 1998, van der Velden et al. [14] further reported experiences with tattoos for treating alopecia areata of the eyebrow. In 2001, Traquina [11] reported the results of micropigmentation performed in 62 patients with scalp scars; this was the first reported use of micropigmentation on the scalp. In 2009, Spyropoulou and Fatah [9] reported a case in which an artistic decorative tattoo was made to disguise a scar on the abdomen after performing a TRAM flap. In 2011, Kim et al. [5] described 32 cases of medical tattooing in Koreans who had scars at various sites, including alopecia scars, vermilion scars, and hypopigmented scars. Micropigmentation has been performed for a long time in various forms in the medical and aesthetic fields. However, there have rarely been medical reports describing micropigmentation to treat MPB or FPHL until recently. The pigments used for micropigmentation are mainly inert, nontoxic, nonallergenic, and tissue-stable and are injected with a needle about 6 lm in size. Iron oxide has been the most commonly used agent. The pigment substances differ slightly depending on the color required. For example, cinnabar and mercuric sulfate are used for red, iron oxide is used for black and brown, and cadmium sulfide used is used for yellow [3]. Although most of these substances are known to be safe, it should be noted that there have been reports of incidences of infections, tattoo allergies, and basal cell carcinoma at the tattoo sites where these substances were used [2–4]. The most certain treatment method at the current time for disguising alopecia or scalp scars is hair transplantation. Hair transplantation involves surgery to harvest hairs that will not fall out permanently from a limited safe donor area at the back of the head and implanting the hairs into the area that requires hair. However, in cases when the donor site is depleted because of several repeated hair transplantation surgeries, when patients have a phobia for the surgery itself, when the donor site is not good for harvesting for some reason, and when it is difficult for the
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patient to undergo surgery because of social activities, other options are required. Micropigmentation can be a good therapeutic method for FPHL. Unlike in MPB, in the overall hair density is reduced without the hairline retreating. The reduction in hair density is consequently noticed when the scalp is seen through the hair, commonly referred to as a ‘‘see-through appearance.’’ In such cases, micropigmentation can decrease the ‘‘see-through appearance’’ and is a great help in camouflaging the intensity of the hair loss. The treatments for FPHL can be classified into medication treatments, conservative treatments, topical agents such as minoxidil, and hair transplantation. However, none of these methods alone can provide a definite resolution. Therefore, performing micropigmentation alone or in addition to hair transplantation can bring about very good improvements. Micropigmentation also produces good results for scalp scars. Scalp scars can result from various causes, including aesthetic surgery for trauma, neurosurgery, and facelifts. Micropigmentation is also very effective for hiding donor scars created by previous hair transplantations. In addition, micropigmentation can bring about even better outcomes than hair transplantation when the scars are composed of very hard fibrous tissues. Of course, the use of micropigmentation to improve the look of the hair density after hair transplantation for scalp scars can have very good effects. In Western countries, many people easily adapt to the skinhead look and micropigmentation is widely applied to scalp scars as well [6]. However, in Asia, and especially in Korea, the indications for micropigmentation are somewhat different. FPHL is considered to be one of the best indications for the use of micropigmentation in Asians. In cases with FPHL, even if hair loss continues, the hairline does not retreat, unlike with MPB, so there is no possibility of the micropigmentation becoming exposed, enabling a safer performance of the procedure. In addition, because the procedure can be performed without cutting the hair short, patients can undergo the procedure comfortably without interrupting their daily life. Both men and women have shown good outcomes with micropigmentation in the vertex area. Patients with MPB
Aesth Plast Surg (2014) 38:199–204
should be warned in advance that micropigmentation can become exposed as the hair loss continues. In addition, the use of finasteride (hair-growth-promoting medication) should be encouraged. Although it is possible to remove micropigmentation at a later time, the potential complications of doing so should be considered, including the possibility of needing several removal attempts and scarring. Micropigmentation is also a good option for camouflaging scalp scars. When the area without hair is too wide, it would look awkward with micropigmentation alone. In such cases, hair transplantation followed by additional micropigmentation can possibly lead to synergic effects. Factors affecting micropigmentation include the penetration depth, the length of time that the needle is inside the skin, types and conditions of the ink, and thickness, elasticity, and laxity of the skin. Among these, the most important factors are the penetration depth of the needle and the length of time the needle is inside the skin. The optimum penetration depth is about 1.5 mm (range 1–2 mm), where the upper and midpapillary dermis are [3]. If the penetration is too deep or too long, the size of the dot becomes too large over time, the dot-to-dot distances become smaller, and the dots appear to be connected, creating a phenomenon that resembles spreading of the coloration. This should be avoided because it makes it obvious that the person had the procedure. Peters et al. [8] reported complications of extensive spread of lower-eyelid pigment after performing blepharopigmentation. Therefore, it is better to perform the procedure with a light sense of touch. On the other hand, if the needle insertion is too shallow (\1 mm) or is in the skin for too short a time, the pigment may not remain inside the skin but instead disappear by extrusion together with the crust [3]. In cases in which the procedure is performed too superficially, the dot is visible immediately after the operation but disappears and is invisible at the 2-week follow-up visit. Therefore, the patient should be checked 2 weeks after the procedure and touch-up enhancement procedures should be performed if required at that time. Gauging needle penetration depth is a highly sensitive technique and comes from experimentation and the surgeon’s digital sensation. Therefore, it is recommended that the dot-to-dot distance be reduced as the surgeon’s technique improves. In theory, the patient’s original density of follicular units is the ideal dot density or distance. To control the distance, a surgeon should wear a 59 magnification loupe at minimum. The dots should never be put in a continuous line; instead, they should be placed in an irregular pattern, ensuring that the distances between individual dots are maintained. The fact that the natural hair may turn gray
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over time should also be explained to the patient. If there are too many gray hairs, it may be necessary dye the hair a dark color on a continuous basis. Micropigmentation is not recommended for individuals who change their hair color frequently. Patients should be informed about the possibility of the pigment fading over time, and that they may need to undergo an additional procedure to enhance the color in the future. Patients must also be advised of the difficulty in removing the micropigmentation at a later time and the possible risks of hair loss and scarring. Furthermore, patients should be informed that additional micropigmentation procedures may be needed if the hair loss becomes worse in the future. The use of the procedure for scar tissue is very challenging and complicated, and it is difficult to predict the outcome. If the penetration of the needle is just slightly deeper than it is supposed to be, the pigment can spread out to the ambient tissues, but if it is just slightly shallower, the pigment may not be retained. Therefore, a lot of experience is needed in using this technique. It is important that surgeons anticipate having to perform touch-up procedures from the beginning and should not attempt to overintroduce the pigment, which can subsequently result in deep penetration. If there is good surgical planning, high-yield results are achievable, even in problematic scar sites. Gauging needle depth in scars is challenging, and developing one’s skills with MPB and FPHL cases is highly recommended before attempting the procedure on a scar field. In addition, surgeons should not attempt to perform micropigmentation on tufted areas before accumulating experience. In the beginning, the procedure should be performed with a certain dot-to-dot distance to avoid the dots looking like they are connected by bridges when the dot size becomes slightly bigger over time. Supplementation between the dots while performing touch-up procedures might be necessary.
Conclusions Micropigmentation is considered to be one of the effective methods for camouflaging MPB, FPHL, and scalp scars. Conflict of interest The authors declare that they have no conflicts of interest to disclose.
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