Restorative micropigmentation of scars: a narrative review, scar-type indication matrix and referral protocol for physicians, plastic surgeons and dermatologists

Objective. To summarise the evidence on restorative micropigmentation as a colour-camouflage technique for scars of different aetiologies and to propose an indication matrix and a referral protocol for physicians, plastic surgeons and dermatologists. Methods. Narrative review of the biomedical literature (PubMed, Google Scholar) on medical tattooing, dermatography and micropigmentation of scars, skin grafts and flaps, and of international scar-management recommendations. Proposals lacking specific evidence are identified as the authors' opinion. Results. Evidence comes from case series, retrospective studies and reviews (levels III–IV). A systematic review of 18 studies reports high satisfaction across indications, including incision, laceration and burn scars. In the head and neck, dermatography of scars and grafts was associated with better perceived appearance and quality of life. The technique modifies colour, not relief or texture; its limitations are fading, unpredictable pigment retention in scar tissue and skin reactions. The most favourable indication is a mature, flat, hypopigmented scar; immature, hypertrophic or keloid scars must be treated or stabilised first. Conclusions. Micropigmentation complements scar treatment; it does not replace it. Its outcome depends on scar type, scar maturity and operator training. An indication matrix, a referral algorithm and a patient information sheet are proposed. Preprint not peer reviewed. Conflict of interest: both authors hold management positions at the Instituto Nacional de Micropigmentación, a centre that performs the procedure described. A Spanish version of this paper is available (see related identifiers).