Body Modification The What, How, and Pitfalls Andrea Perry, RN, MSN, CEN, CNL

Objectives Discuss the potential medical pitfalls of body modification Understand the importance of extracting a full history from a patient in relation to injuries and foreign bodies

Healing Times for Piercing Ear lobe – 6 to 8 wks Ear Cartilage – 4 mos to 1 yr Eyebrow – 6 to 8 wks Nostril – 2 to 4 mos Nasal Septum – 6 to 8 mos Nasal bridge – 8 to 10 wks Tongue – 4 wks Lip – 6 – 8 weeks Nipple – 2 – 4 months Navel – up to 9 months Female Genitalia – 2 weeks to 4 months Male Genitalia- 3 – 9 months Really? Are young adults cleaning stuff for that long? http://www.aafp.org/afp/2005/1115/p2029.html

Piercing Complication Rates Ears: 35% had complications Lip/tongue piercings: 87.8% had complications Survey of 225 adolescents at urban hospital: Piercing infection-74% Bleeding-30% Allergic rxn-26% Keloids-19% http://www.ncbi.nlm.nih.gov/pubmed/20806097 http://www.aafp.org/afp/2005/1115/p2029.html

Complications Dependent on the site! Infection Nerve Damage Excessive bleeding Scar Tissue Airway issues Allergic rxn Ludwig’s Angina Cartilage piercings→ poor healing and more serious infection. Auricular perichondritis– inflammation of skin and tissue surrounding ear cartilage Can progress to chondritis, which requires the diseased cartilage to be removed Tx:Cipro http://www.ghorayeb.com/EarPiercingComplications.html Outbreak of Pseudomonas aeruginosa Infections Caused by Commercial Piercing of Upper Ear Cartilage, JAMA 2004:291;981-5 Cartilage is largely avascular– pseudomonas a common infection

Oral Piercings- Uvula High failure rate due to strength of gag reflex Risks of aspiration, airway edema, airway obstruction, snoring As your palate relaxes during sleep, it can create obstruction. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2606659/

Oral Piercings- Tongue Chipped/ fractured teeth Gingival recession Bone dehiscence Hepatitis Blood loss Trigeminal neuralgia Aspiration Trigeminal nerve innervates the face; if it’s injured you can have chronic and permanent pain

Male Genitalia Piercings Paraphimosis: Delayed tx →tissue ischemia → gangrene→ autoamputation of the distal penis. Uretheral injuries Infections Prolonged priapism Recurrent condyloma acuminata (HPV) High risk for significant complication because delay treatment due to embarrassment. Paraphimosis occurs in uncircumcised patients. Foreskin gets trapped behind the glans and causes constriction, like a rubber band

Life Threatening Piercing Complications Endocarditis Rate of endocarditis is increasing. 25 yo male presented with fever, chills, rigors, and SOB for 6 days. Temp of 38.9 and systolic and diastolic murmurs. Hx of aortic valvuloplasty at 8 for congenital stenosis. Tongue was pierced 2 months before, no signs of infection. His transthoracic echo was not conclusive, but transesophageal echo showed multiple vegetative lesions. He was positive for H. aphrophilus, as was his tongue stud. Aortic valve replacement was recommended after completion of his abx, but he did not return. Haemophilus aphrophilus Endocarditis after Tongue Piercing, Emerging Inf. Disease, Aug (8) 2002 http://wwwnc.cdc.gov/eid/article/8/8/01-0458_article#tnF1

Life Threatening Piercing Complications Abscesses Brain abscesses are possible due to peculiarities of venous drainage from the tongue. This is a girl who almost died from a brain abscess caused by a tongue piercing. She had to have a part of her skull removed to allow for swelling. The images are from a 22 year old male that developed multiple brain abcesses from his tongue piercing. He died from septic shock. http://www.doonsouthdental.ca/InfoAndLinks/TonguePiercing/Piercing.html

Dermal Implants Also called “single point piercings” Anchors are implanted under the skin using either a dermal punch or piercing needle. Jewelry is then screwed on and is interchangeable once healed (8-12 weeks later)

Dermal Implant Complications Same as other piercings, but includes: Damage to nerves/vessels in the dermis Embedding or migration Rejection (like with any implant!) Ocular: blindness, bleeding beneath the conjunctiva, perforation of the eye, conjunctivitis Embedding: layers of skin pulled together Migration: body forces anchor out http://tattoo.about.com/od/piercingsgeneralinfo/ss/dermalanchors.htm#ste p5 1. http://emedicalhub.hubpages.com/hub/Dermal-Piercing-Types-Pictures- Procedure-After-care-and-Risks

Body Suspension It’s Saturday night at 0300 and a 24-year-old heavily pierced man presents to triage with multiple lacerations on his arms and legs. In obtaining the initial history, it is found that he was undergoing a body suspension at a local club and the “hooks ripped out.”

Body Suspension Has been practiced in multiple cultures for thousands of years Gaining popularity in Western culture Why? Rite of passage Adrenaline rush Performance art Sterilized deep sea fishing hooks with the barbs removed

Body Suspension Associated risks? Bruising Fainting (most commonly vasovagal in origin from pain, seeing the needle, or seeing blood) Excessive bleeding Falls Infections/pain Post-suspension depression (fairly common) Bleeding more common when hooks are removed Falls more commonly related to hoist failures than hooks ripping PSD: unclear what causes it, but might be related to chemical withdrawal from the endorphins and loss of the psychological high DeBoer, S., Falkner, A., Amundson, T., Armstrong, M., Seaver, M., Joyner, S., & Rapoport, L. (December 2008). Just hanging around: Questions and answers about body suspensions. JEN 34 (6), 523-529. http://www.jenonline.org/article/S0099-1767(07)00643-5/pdf

Tattoos Tattoo Regulation? No national regulation. California law delegates supervision to the county. Most artists are unlicensed & have learned via informal apprenticeship. No formal training in anatomy, infection control, or universal precautions.

Tattoo Ink 50+ pigments and shades employed None are FDA approved for skin injection Some are industrial grade printers ink or automobile paint 2014: batch of contaminated ink and needles identified by FDA; research is ongoing. No laws for ink sterility Infections with M. Chelonae caused by contaminated ink have been reported around the world Per FDA in 2009: inks are subject to tattoo regulation, but due to other priorities and lack of evidence of safety concerns, they haven’t been tested. http://articles.latimes.com/2012/aug/23/news/la-heb-tattoo-ink-infection- 20120823 http://www.fda.gov/Cosmetics/ProductsIngredients/Products/ucm408557.ht m

Operator Health Concerns Unhygenic practices Cross Contamination Artist/client Client/client Equipment/client “Sterile” equipment

Tattoo Complications Blood Borne Diseases Skin Infections Hep B, C HIV Syphilis Tetanus Skin Infections HSV Mycobacterium Staph aureus MRSA Other Severe Risks Nerve Damage Hemorrhage (hemophilia or extreme body modification) Allergic rxn (ink/injections, jewelry, latex)

Infection

Infection A study of 766 college students: Infection-45% Local skin rxn-39% 2 cases of Hepatitis Commercially acquired tattoos accounted for more than twice as many hep C infections as injection-drug use. People with several tattoos or complex/large tattoos have increased risk Consider infective endocarditis in a febrile pt without a source and a recent tattoo: MRSA, MSSA, S. epi, strep viridans, haemophilus, and neisseria

Other Complications Granulomas Keloids MRI complications Swelling/burns MRI– 1st and 2nd degree burns from components used in ink since there are no FDA regulations. Red is most common since the ink can contain iron. http://www.livescience.com/32801-do-mri-machines-affect-tattoos.html

Removal techniques Laser Dermabrasion Salabrasion Scarification Surgical removal camouflaging Salabrasion: using water and salt or a salt like substance to peel aware the upper layers of skin. “ sand away the upper most layers of skin to a point past bleeding.” Several sessions are necessary.

Branding

Branding Branding is scarification usually done through the application of a heated material (usually metal) making 3rd degree burn that eventually becomes a scar. “The tools must be hot enough to do sufficient damage to the tissue so as to form a permanent scar… it can be anything from a propane torch to a lowly candle… most experienced artists lean toward a propane torch.” http://wiki.bme.com/index.php?title=Strike_Branding

Branding Methods Strike Branding Electrocautery Electrosurgery (laser) branding Cautery pen “Freeze branding” (with liquid nitrogen!) Strike branding: like using stamps

Branding Complications Infection (septic shock, splenic abscesses) Blood borne pathogens Allergic rxn Sequelae arising from 3rd degree burns Also assoc. with substance abuse and high risk behaviors Cavernous Sinus thrombosis (caused by staph infection; blood clot in the CS, cavity at the base of the brain J Burn Care Res. 2006 Jan-Feb;27(1):108-10. Aesthetic skin branding: a novel form of body art with adverse clinical sequela. Karamanoukian R1, Ukatu C, Lee E, Hyman J, Sundine M, Kobayashi M, Evans GR. Journal of Medical Case reports 2009, 3:25. Adverse clinical sequelae after skin branding: a case series Shahzad Raza1*, Khalid Mahmood2, Abdul Hakeem3, Sylvie Polsky4, Anna Haemel5,Soniya Rai6 and Mahadi Ali Baig7

Scarification

Scarification “Typically the goal of scarification is to get raised scarring, preferably keloid scarring.” Cutting- 3 mm in depth Chemical Dremel Tattoo Gun Skin removal Ash rubbing Cutting: surgical blade/scalpel used Chemical: cut the design with a scalpel, then use a chemical irritant to create heavy scarring (like soap or formaldehyde) Dremel: layers of skin are ground away using the rotating abrasive tip of a rotary tool Tattoo gun: over tattooing an area using no ink or aa abrasive formula Skin Removal: Cut the design using a scalpel, then use dissection clamp to remove skin section. Ash rubbing: rub ashes into fresh wound. Can increase amount of scarring, discolor similar to ink, allow emotional significance (rubbing loved ones’ ashes into skin) http://wiki.bme.com/index.php?title=Scarification

Scarification Complications Infection Bleeding What if the cuts are too deep? Functional impairment depending on scarring “[California] State law does not expressly address scarification and definitions of other practices are too narrow to include it.” Dermatologic complications with Body Art: tattoos, piercings, and permanent makeup by Christa De Cuyper and Maria Luisa Cotapos c 2009. Springer Science and Business Media. The Network for Public Health Law https://www.networkforphl.org/_asset/vgntsm/State_Scarification_Laws_Su mmary.pdf

This “surgery” was performed by “body modification specialists.”

Tongue Bifurcation “Typically” done in a piercing shop under “sterile” conditions… but some people do it at home.

Bifurcation Complications Pain, swelling and infection Increased salivary flow Gingival injury/recession Interference with speech/mastication Prolonged bleeding Airway obstruction from edema Ludwig’s Angina Ludwig’s angina… swelling of the floor of the mouth (cellulitis)

“Bagel Head” Japanese trend. Inject about 13.5 oz of saline into a person’s forehead, the press your thumb into it and create an indent. The person can become somnolent toward the end of the procedure. Takes about 2 hrs and lasts less than a day. Complications: If someone accidentally uses hypertonic saline, it could lead to extreme dehydration. If the saline isn’t sterile, it could lead to infection. And, if ity’s done repeatedly, it could stretch the skin beyond it’s natural elasticity and leave you with a saggy forehead. Risk of neurovascular injury to trigeminal nerve, facial nerve http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3791963/

References Available on request!