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

2. 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

3. 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?

4. 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%

5. 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
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

6. 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.

7. 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

8. 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

9. 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

10. 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.

11. 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)

12. 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 p5
1. Procedure-After-care-and-Risks

13. 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.”

14. 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

15. 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),

16. 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.

17. 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. m

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

19. 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)

20. Infection

21. 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

22. 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.

23. 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.

24. Branding

25. 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.”

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

27. 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): 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

28. Scarification

29. 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)

30. 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 Springer Science and Business Media.
The Network for Public Health Law mmary.pdf

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

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

34. 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)

35. “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

36. References
Available on request!