48Accid Emerg Med 1999;16:418-421

Body piercing in the accident and emergency

department

Rakesh Khanna, S Sathish Kumar, B Srinivasa Raju, A V Kumar

AbstractRecently an increasing number ofpatientswith complications related to piercedbody jewellery have been seen. Oftenremoval of the jewellery is indicated.Removal of these items may also berequired for radiological purposes. If thedoctor is familiar with the opening mech-anism of the item, removal is not usuallydifficult. Uninformed attempts at removalmay cause unnecessary trauma and dis-tress. In a survey of 28 accident and emer-gency doctors, only six were ableaccurately to describe the opening mecha-nisms of all three commonly used types ofjewellery. Descriptions ofthe types ofjew-ellery currently used are not available inthe medical literature. The aim of thisarticle is to familiarise doctors with thetypes of jewellery used, describe theiropening mechanisms, and suggest tech-niques for their removal. The complica-tions ofbody piercing and the indicationsfor the removal ofbody jewellery are alsooutlined.(7Accid Emerg Med 1999;16:418-421)

Keywords: body piercing; jewellery

Accident andEmergencyDepartment,Staffordshire DistrictHospital, StaffordR KhannaS S KumarB S RajuA V Kumar

Correspondence to:Rakesh Khanna, SpecialistRegistrar in Accident andEmergency, 289 BirminghamRoad, Sutton Coldfield B72IED.

Accepted 28 July 1999

Over the last few years body piercing hasbecome an increasingly popular expression ofbody art. Increasingly the vogue is for piercingand placing body jewellery in unconventionalparts of the body such as the tongue, lips, labia,and even through the erectile tissue of thepenis, nipple, and clitoris. These patients maypresent to the accident and emergency (A&E)department with a variety of complications andit may be necessary for the jewellery to beremoved in the department. Because the jewel-lery is radio-opaque removal may be requiredfor standard radiography. This is especiallyimportant when cervical spine views arerequired in a patient with a "lingual bar" whichmay obscure the odontoid peg. They may alsorequire removal to prevent scattering ofcomputed tomographic scans and disturbanceof the magnetic field when performing mag-netic resonance imaging.There are several reports of the complica-

tions of body piercing in medical literatureincluding local and systemic infections,' 2 thepossible transmission of hepatitis B and HIV,3Ludwig's angina,5 and toxic shock syndrome.6Dental journals have documented the compli-cations of intraoral piercing.' 8 There have alsobeen reports on significant local granuloma-tous reactions.9'-1 The commonest complica-tions are almost certainly bleeding, local infec-

tion, and oedema of surrounding tissuesleading to embedding of the jewellery.We have seen a number of patients in our

department with a variety of minor complica-tions relating to body jewellery requiring itsremoval (box 1). Some difficulty was experi-enced in effecting this, prompting us toresearch this area. In the medical literature,there did not appear to be any detaileddescriptions of the various types of studs andrings used by practitioners of this art nor oftheir opening mechanisms. The aim of thisarticle is to outline the various types of bodyjewellery in use today, describe their openingmechanisms, review the potential complica-tions of this "art form", and to suggest appro-priate techniques to remove them in some ofthe different situations that may be encoun-tered in an A&E department.Out of 28 A&E doctors surveyed, only six

were able accurately to describe the openingmechanism of the three common types of jew-ellery shown in fig 1. Four doctors suggestedunnecessary procedures such as incising of thesurrounding tissue. This article addresses thisdeficit in information.We interviewed four licensed body piercing

practitioners who we questioned with regard totheir licensing requirements and techniquesused. We also procured a range of stainlesssteel body jewellery to dismantle, study, andphotograph. The medical literature was re-viewed in Medline using the OVID interfacefrom 1986 to January 1999 for all entries relat-ing to body piercing.

Techniques used by "professionalpiercers"Licensed ear piercers usually carry out bodypiercing in the UK. The environmental depart-ment of the local council, which accesses thetraining of the applicant, vets them. The BodyPiercing Association conducts trainingcourses. After inspecting the proposedpremises and ensuring that arrangements are

Figure 1 Example of types of body jewellery. (A) Barbellstud; (B) labret stud; (C) captive bead.

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in place for safe disposal of sharp instrumentsthe council may issue a licence for ear piercing.The studios appear to perform a wide varietyof procedures under this licence.

Currently in the UK body piercers are notallowed to use injectable local anaesthetics.The piercers we talked to were aware of theavailability of effective topical local anaesthet-ics such as Emla. They do not stock it but canadvise a patient to request their generalpractitioner for a prescription. Almost all oftheir work is done without any form ofanaesthesia or occasionally with ethyl chloridespray. As a significant number of piercings cur-rently performed are intraoral, this techniquehas very limited application. There appears tobe awareness of the obvious complicationssuch as bleeding, local swelling, and infection.Usually a larger size ofjewellery is initially usedto allow for the anticipated swelling and to pre-vent embedding. After a period of four to sixweeks this is changed to a smaller size.The standard technique employed is to

pierce the body with a large bore intravenoustype cannula, remove the needle, pass theopened jewellery into the lumen of thecannula, and withdraw the cannula backthrough the tissues. A variety of propriety"guns" are also available but their use is limitedmostly to ear piercing.

Types ofjeweliery usedThere are three basic types of jewellery in cur-rent use, although there are many variations ofthese designs.

(1) BARBELL STUDS (FIG 1A)These are straight bars with a ball threadedonto both ends. The commonest site of usageis through the tongue. Smaller studs of thistype are also passed through the glans penisand clitoris. These bars may be curved (bananatype) or even form an incomplete circle for usearound the navel, eyebrow, and nipple.

(2) LABRET STUDS (FIG IB)These are straight bars with a ball threaded onone end and a disc permanently fixed onto theother. They are used mostly for lower lip andoral piercings with the ball usually beingexposed to the exterior and the flat disc

Figure 2 Examples shown in fig 1 with beads detached. In(A) and (B) they have been unscrewed; (C) requireddistraction of the ring.

retained intraorally. These may be removed byunscrewing the ball (fig 2B).

(3) CAPTIVE BEAD RING (FIG IC)These consist of a bead with small dimples onopposite sides which is held "captive" bytension from both sides of an incomplete ring.Removal is achieved by distracting the ringusing two clips. The manufacturers claim thatthey are easy to insert and remove, although wedid not find it so. A variation of this is the"bead ring", in which one bead is coupled per-manently to one end, opening being effected byremoving the free end of the ring.

Indications for removalThe commonest complications are localoedema (leading to embedding of the jewel-lery), infection (local, regional, and systemic),and bleeding. The frequency of these compli-cations does not appear to have been deter-mined, although we understand from ourdiscussions with body piercers that this maybeup to 30%. Removal may also be required forradiological purposes in the conscious orunconscious patient. Local trauma to thepierced site may require removal for immediatemanagement of tissue damage. While remov-

ing any form of intraoral jewellery the risk ofaccidental aspiration must be considered.

Suggested techniques for removalUsually patients will be able to remove the jew-ellery themselves, but this may not be possiblein the presence of significant tissue oedema,infection, or in difficult positions such as in themouth.Removal of the barbell, its variants, and

labret type studs may be effected by holdingthe bar with an artery forceps and unscrewingthe bead with another (fig 2A and B). Wherethis type of jewellery is embedded (fig 3) it isbest to compress the oedematous tissue, push

Box 1Case reportsPatient 1: A teenage girl attempted suicideby partial hanging. She was in cervicalimmobilisation. Clinically she had decorti-cate rigidity suggestive of anoxic brain dam-age. The radiographer requested removal ofa lingual bar to visualise the odontoid pegand to facilitate computed tomography. Itwas removed by the technique illustrated infig5.Patient 2: A young man presented with a selfdiagnosis of "hernias in both groins".Examination revealed bilateral inguinallymph nodes associated with an infectednavel ring. Removal of the ring with a shortcourse of antibiotics resulted in a rapidresolution of symptoms.Patient 3: A teenage boy attempted to piercehis eyebrow with a copper wire, which heintended to use to draw some body jewellerythrough the tissues. The wire fractured anda piece of it was retained in the soft tissuesof his forehead.

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420 Khanna, Kumar, Raju, et al

Figure 3 A barbell stud embedded in oedematous tissue.

Figure 4 The same patient; stud has been exposed bycompressing the oedematous tissues and pushing the studfrom below making removal easier.

.I.Figure 5 Suggested technique for removing lingual bar inan unconscious patient with or without cervicalimmobilisation.

the jewellery through it to expose the bead sothat it can be grasped, and removed withforceps (fig 4). It should very rarely benecessary to incise any tissue.

T'he captive bead ring and its variants maybe removed by holding the ring on either sideof the captive bead and releasing the tension onthe bead (fig 2C). In the unconscious patientwe suggest that lingual barbells be removed byexteriorising the jewellery if possible and plac-ing a swab behind the bead as it is unscrewedto prevent possible aspiration (fig 5).

DiscussionOver the last few years body piercing hasbecome very popular within a large proportion

of tepplto.Fgrsrgrigispea

andre Stafforshied areasnqu alonethremvn ligare over 20studcnsiousoffeieng bihody piercing service.all h

studios we contacted reported excellent busi-ness, some with lengthy waiting lists. Thereasons behind its popularity are complex andbeyond the scope of this article but have beendealt with elsewhere." As several popularpersonalities have taken to wearing body jewel-lery (especially lingual bars), its popularity canbe expected to increase. There have been a fewreports in the medical literature about theobvious complications of such procedures suchas oedema and local infection.' 12 From ourdiscussions with body piercers and wearers webelieve these to be very common problems.None of the body piercers we spoke to wereaware that invasive intraoral procedures shouldonly be carried out under antibiotic cover inpatients with cardiac murmurs. Surprisinglythere has not been a single case report in theliterature regarding this or other obviouspotential complications such as excessive localbleeding or nerve damage.The medical profession must, we believe, be

concerned about the vogue in "extreme" pierc-ing, which includes in males piercing of thedistal urethra (the so called "Prince Albert"),scrotum, frenulum, and through the glanspenis itself. In females both the labia minoraand majora, the clitoral hood, and clitoris itselfmay be pierced. There are many variations ofthese basic themes involving the use of chainsand locks in addition to the body jewellery.Descriptions of these are beyond the scope ofthis article but the curious can easily finddetails of all these by searching the world wideweb using the words "body piercing" on anysearch engine. Under UK law female genitalmutilation is specifically prohibited. Althoughthis legislation was designed to prevent femalecircumcision, such extreme piercings may wellbe considered to be a form of mutilation. TheBritish government appears to have takennotice of these issues and at the time of writinghad announced that it proposes to introducelegislation to regulate body piercing. The scopeof the proposed legislation has not yet beenannounced.A doctor may be requested to remove body

jewellery by a wearer for a variety of medicaland social reasons. In some circumstances, asdescribed, it may be medically necessary toremove the jewellery in the conscious orunconscious patient. If the doctor is not famil-iar with the design of the item this may provedifficult to do. We hope that this article willprove useful to medical professionals in thisarea.

We would like to Mr Kevin Jukes, professional body piercer,Stafford, for his help in the preparation of this article. We wouldalso like to thank Mr Alistair Rose, medical photographer, Staf-fordshire District Hospital for preparing the photographs.

Funding: none.

Conflict of interest: none.

ContributorsRakesh Khanna initiated and participated in the design of thestudy, discussed core ideas, conducted the survey, interviewedprofessional body piercers, participated in data collection andwriting of the paper. S Sathish Kumar discussed core ideas, par-ticipated in data collection, coordinated the artwork, andparticipated in the writing of the paper. B Srinivasa Rajudiscussed core ideas, interviewed professional body piercers,participated in data collection and writing of the paper. A V

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Kumar discussed core ideas, participated in the design of thestudy, contributed to and participated in the writing of thepaper.

Rakesh Khanna is the guarantor for the article.

1 Cumberworth VL, Hogarth TB. Hazards of ear piercingprocedures which traverse cartilage: a report of pseu-domonas perichondritis and review of other complications.BrJ Clin Pract 1990;44:512-13.

2 Tweeten SS, Rickman LS. Infectious complications of bodypiercing. Clin Infect Dis 1998;26:735-40.

3 Hvolris JJ. [Hepatitis transmitted by ear piercing] [Danish].Ugeskr Laeger 1991;153:119.

4 Pugatch D, Milerno M, Rich JD. Possible transmission ofhuman immunodeficiency virus type 1 from body piercing.Clin Infect Dis 1998;26:767-78.

5 Perkins CS, Meisner J, Harrison JM. A complication oftongue piercing. Br DentJ 1997;22:147-8.

6 McCarthy VP, Peoples WM. Toxic shock syndrome after earpiercing. Pediatr Infect Dis J 1998;7:741-2.

7 Cobb DS, Denehy GE, Vargas MA. Adhesive compositeinlays for the restoration of cracked posterior teeth associ-ated with a tongue bar. Practical Periodontics and AestheticDentistry 1998;10:453-60.

8 Boardman R, Smith RA. Dental implications of oralpiercing. Journal of the Californian Dental Association 1997;25:200-7.

9 Zilinsky I, Tsur H, Trau H, et al. Pseudolymphoma of theear lobes due to ear piercing. Journal of Dermatology andSurgical Oncology 1989;15:666-8.

10 Ng KH, Siar CH, Ganesapillai T. Sarcoid like foreign bodyreaction in body piercing: a report of 2 cases. Oral Surg OralMed Oral Path Oral Radiol Endod 1997;84:28-31.

11 Wright J. Modifying the body: piercing and tattoos. NursingStandard 1995;10:27-30.

12 Turkeltaub SH, Habal MB. Acute pseudomonas chondritisas a sequel to ear piercing. Ann Plast Surg 1990;24:279-82.

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