Scalp Micropigmentation (SMP): Semantics, Terminology, and Standards
Scalp Micropigmentation (SMP) is a procedure that is used to create the illusion of shaved hair, stubble, or greater density in hair-bearing areas that have lost hair or require augmentation. It is becoming more popular around the world, and its value to hair restoration surgeons is demonstrated by the ISHRS including it alongside Follicular Unit Excision (FUE) and Follicular Unit Transplantation (FUT) at the Triple Crown World Live Surgery Workshop in November. SMP is a relatively new technique and along with the methodology, the terminology is evolving.
Authors of this article:
Dr. Greg Williams, MBBS, FISHRS, Hair Transplant Surgeon in London, England
Dawn Forshaw, Hayward Heaths, England, UK*
*Disclosure: Dawn Forshaw is founder of the Finishing Touches Group and has financial interests in companies that manufacture SMP needles, machines, and pigment colours as well as in SMP training.
Although it is different from Permanent Makeup (PMU) and Semi-Permanent Makeup (SPMU), it has evolved from these procedures. As in other parts of the world, the number of practitioners and salons/clinics offering SMP in the United Kingdom is rapidly increasing. In March 2019, the British Association of Hair Restoration Surgery (BAHRS) recognised the importance of these professionals by creating a specific affiliate membership category for Scalp Micropigmentation Practitioners (SMPPs).
In doing so, it was recognised that there were no professional standards for SMPPs in the UK and, even amongst experts in the field, there was confusion about semantics and terminology. A document was therefore required to provide guidance to the BAHRS membership so that communication could be standardised. The first item to clarify was the relationship between the terms “scalp micropigmentation” and “tattoo” since both are used to identify the same procedure—the implantation of ink or pigment colours into the scalp skin. However, differences have been suggested based on the equipment and medium used.
People use the terms “semi-permanent micropigmentation” and “micropigmentation tattooing” even though the word “micropigmentation” does not yet exist in the Oxford Dictionary and “pigmentation” is classified as a mass noun and defined as “the natural colouring of animal or plant tissue.” Since the words “pigment” and “tattoo” can be used as either a noun or verb, could the word “micropigment” also be used as a noun or a verb? The Oxford Dictionary defines the verb “tattoo” as “mark (a part of the body) with an indelible design by inserting pigment into punctures in the skin.” Although the Oxford dictionary defines “indelible” as “making marks that cannot be removed,” we know from clinical practice that tattoos are not, in fact, indelible because they can be removed with laser treatment. So is it still a contradiction to say “semi-permanent tattoo”?
In the UK, different insurance coverage is required to perform SMP than to tattoo, and insurers make the differentiation based on the equipment used according to the manufacturer’s instructions. This separation will become more difficult with the development of hybrid machines. In English vernacular, tattooing (as done for artistic body adornment) tends to imply a permanent procedure whereas micropigmentation can be performed to achieve a short, medium, or long-term result. Matters are further confused as tattoo mediums are often called “inks” whereas micropigmentation mediums are called “pigments” or “pigment colours.” However, there is no scientific basis to this. The medium used, that is, the ink or pigment colour, may affect the permanency of the treatment although depth of insertion and particle size can also affect whether the scalp colour will fade. Mediums referred to as “inks” are often carbon-based products that can be diluted to the required shade for the particular patient treatment. They are more resistant to ultraviolet (UV) light, so might remain visible in the scalp longer.
Carbon-based mediums are referred to as “organic” and they are generally thought to have smaller particle sizes compared to “inorganic” mediums. Both organic and inorganic mediums are taken up by macrophages resulting in retention in the skin. In this context, organic versus inorganic has nothing to do with healthy lifestyle choices but is related to the chemical constitution of the medium used in SMP and tattooing. The majority of mediums referred to as “pigments” are metallic-oxide-based products with multi-layered colour compounds to generate the different tones. The mixed pigment colours created for micropigmentation are less resistant to UV light and this can contribute to the scalp colouration changing or fading over time. “Inorganic” refers to products made of metallic compounds and salts such as chromates, sulphates, and metallic oxides including iron oxides.
In practice, both organic and inorganic mediums can be used in tattoo machines and SMP machines. Matters are further confused with the practice of mixing organic and inorganic mediums. There are also differences between the needles used for SMP and tattoos and cartridges should be used that prevent the potential backflow of blood.
The next issue for the BAHRS to define was the training required for a BAHRS SMPP affiliate member. Since SMP requires knowledge about the scalp and diseases, it was agreed that training in micropigmentation to other body areas would not be adequate and an awarding organisation (AO) accredited Level 4 qualification specifically in SMP would be required.
Since SMP in the UK is most often done by people with no medical training, applicants are required to have completed a Blood Borne Pathogen Course, or the equivalent, to have a certificate in First Aid, to have a certificate in Basic Life Support, and to keep themselves up to date with developments in the field by reading relevant publications and discussions with colleagues, as well as to participate in, and be aware of, audits in the practice where they work. Another reason why a specific SMP Level 4 course is required is because the BAHRS did not want traditional artistic tattooists to be eligible for membership, even if they were extremely experienced, without additional training.
In the UK, there are overlaps and differences in the statutory regulations to do with tattooing and micropigmentation. The relevant work-based regulations that must be followed and the professional and practice standards that must be complied with are listed in the BAHRS Professional Standards for Scalp Micropigmentation Practitioners.
SMPP affiliate members sign a Code of Conduct agreeing to abide by these professional standards. If male and female pattern hair loss, as well as other non-scarring and scarring alopecias, are considered medical conditions, then it follows that SMP should be considered a “medical” procedure. Furthermore, there is a real chance of blood borne disease transmission if incorrect needles and machines are used. In addition, there are other health risks when hazardous inks and dyes are used.
In the UK, therefore, we are encouraging a “Safety in Micropigmentation” campaign to highlight for both professionals and patients what is required for safe practice. Holding a medical or nursing degree does not obviate the need for specific training in SMP, and doctors and nurses who perform SMP should comply with the same standards as non-medical SMPPs. A different clinic license may also be required to perform SMP from that required to perform hair transplant surgery.