Anatomy

Commonly pierced areas of the body include the ears, eyebrows, tongue, nose (i.e., ala, septum, and bridge), umbilicus, nipples, lips, and genitals. Each site carries unique risks. The physician needs to be cognizant of these risks when evaluating whether to pierce a specific location, and needs to counsel the patient accordingly.

Indications

• Cosmetic procedure

• No traditional medical indications

• The clitoral hood piercing may improve the sexual experience for women who have lost sensitivity

Contraindications

• Skin and systemic disorders: Medical contraindications to body piercing are related to external factors involving the skin and to systemic conditions. Local skin infection, a cyst, severe eczema, or any other significant skin disorder at the site is a contraindication to piercing. A history of keloid formation, not necessarily hypertrophic scarring, is also a condition that warns against piercing.

• Steroid use and coagulation disorders: Chronic steroid use or a coagulation disorder also precludes the procedure.

• Immunodeficiency syndromes: Patients with an immunodeficiency disorder, such as acquired immunodeficiency syndrome (AIDS), present unique difficulties. For many of these patients, body modification is an important part of life, and the piercing would benefit their overall sense of well-being. Although, theoretically, AIDS might be considered a contraindication to piercing, realistically, unless the patient’s T-cell levels are significantly compromised, piercing can be successfully accomplished in the patient with AIDS.

• Pregnancy: Clinicians should discuss pregnancy intentions with women seeking nipple or navel piercings because healing can take 2 to 4 months. Controversy exists regarding whether a nipple piercing affects lactation. There are 15 to 20 milk ducts in the nipple. Although scar tissue may occlude some ducts, a properly placed piercing with appropriate jewelry should not adversely affect breast function. Excessive scarring may lead to duct occlusion, which could cause decreased or absent milk expression, persistent breast engorgement, and increased risk of infection or abscess formation during lactation. Women interested in nipple piercings should be aware of the unknown and potentially adverse effects on the ability to breast-feed. Also, because the infant may aspirate the jewelry or develop metal allergies, the jewelry is removed during actual breast-feeding.

Navel piercings can take 6 to 10 months to heal. This should also be taken into consideration if a pregnancy is being considered. Navel piercings also tend to migrate. Tissue distortion that occurs during pregnancy can exacerbate this problem, and it may be necessary to remove the jewelry as gestation progresses.

Equipment

Jewelry

It is important to use the proper jewelry to avoid complications. Patients should wear only jewelry made of surgical-grade stainless steel (316 L [low carbon], 316 LVM [low carbon, volume melt]), titanium, niobium, platinum, solid white or yellow gold (14K or 18K), or Tygon. Gold-plated jewelry contains reactive metals such as nickel and can cause allergic reactions. Silver will tarnish in the moist environment of a new piercing or in contact with any mucosal surface.

The most common types of jewelry are bead ring, captive bead ring, straight barbell, circular barbell, and curved barbell (Fig. 233-1). Size is defined in terms of gauge and either diameter or length. If the jewelry is not provided by the physician’s office, patients should be advised to purchase the jewelry that is appropriate for the piercing they desire and bring it with them. Table 233-1 summarizes the initial jewelry commonly used for each location.

Figure 233-1 Jewelry styles: straight barbell (top), captive ring (left), circular barbell (center), curved barbell (right), and labret stud (bottom).

TABLE 233-1 Jewelry Selection

The bead ring and captive bead ring are opened and closed either by hand or with specialized ring-opening, ring-closing pliers. The use of other pliers may distort the shape of the ring. It is important to maintain the integrity and shape when opening and closing the ring.

Piercing Equipment

• Appropriate jewelry: sterilize in an autoclave.

• Antiseptic cleanser: use povidone–iodine (Betadine), Techni-Care, or ethyl alcohol.

• Ring-closing pliers: use with captive or bead rings; usually not needed if jewelry is annealed. (The annealing process allows jewelry to be manipulated more easily, particularly by hand.)

• Piercing needles: have various sizes available, including 10, 12, 14, 16, and 18 gauge. (For most piercings, the needle size should match the gauge of the jewelry being inserted [Fig. 233-2].)

• Needle-receiving tube: use for piercings involving the nostril, septum, penis, clitoral hood, and some parts of the ear cartilage (Fig. 233-3).

• Rubber bands: use to provide tension for piercing clamps.

• Insertion taper: a solid metal rod that is larger at one end and gradually becomes smaller at the other end; gauge measurement is based on size of larger end; use to help transfer jewelry or for stretching; in a fresh piercing the taper’s gauge will be the same as the jewelry gauge. Transfer means to place the tip of the jewelry into the needle or taper and pass it into place in the hole previously made by the needle.

• Needle pusher/acrylic needle holder: helps pass the needle through skin.

• Tissue forceps: use Pennington, mini-Pennington, or ring forceps; slotted style is optional. (The forceps is tensioned with two rubber bands; this helps avoid clamping skin too tightly.)

• Surgical marking pen: use very fine point. (Sharpie Fine Point pens can be used.)

• Gentian violet: to mark tongue and oral cavity piercings.

• Toothpicks: to apply gentian violet.

• Cotton applicators: use to adjust the size or site of insertion marks at the piercing site; erase or fine-tune the marks with alcohol-soaked applicators.

• Gauze: to cleanse the site after piercing.

• Gauge wheel: confirm gauge of needle or jewelry.

• Caliper: confirm size of jewelry.

• Sterile barrier field: cover instrument tray.

• Cork: cover needle tip after insertion. (Protects against needle injury.)

• Ethyl alcohol (70%): can use as a skin cleanser. (Removes excess ink marks.)

Figure 233-2 Piercing needle. This is a hollow, tribeveled needle. Jewelry is held against the nonpointed end of the needle for passage through the skin. After passage, a cork can be placed on the needle tip to prevent needlestick injuries.

Figure 233-3 Needle-receiving tube. This is a hollow tube that is used in ear cartilage, nostril, and genital piercings. The needle is passed through the area being pierced into the tube. The tube protects adjacent structures from inadvertent injury.

Sterilization

Most piercing equipment can be sterilized in an autoclave (270° F under high-pressure steam for at least 10 minutes). Items that are reusable should be cleansed in an ultrasonic cleaner before sterilization. Those items that are heat sensitive can be cleansed with a broad-spectrum, environmentally safe germicidal that kills such organisms as human immunodeficiency virus (HIV), hepatitis (particularly B), and tuberculosis. When possible, piercing guns should be avoided because most cannot be properly sterilized. Those patients choosing to have a body piercing done at a piercing salon should be advised to search for members of the Association of Professional Piercers. In addition, the piercer should possess certifications for basic life support/cardiopulmonary resuscitation and blood-borne pathogens training.

Preprocedure Patient Education and Forms

Inform the patient of all possible complications of piercing in general and those specific to the location requested. Thorough documentation of the informed consent is mandatory. All patients younger than 18 years of age need legal guardian consent. Patients should anticipate the average healing time depending on the location of the piercing (Table 233-2). (See the sample patient education and consent forms online at www.expertconsult.com.)

TABLE 233-2 Average Healing Times for Piercing Locations

Location	Healing Times
Ear lobe	4–6 wk
Ear cartilage	2–3 mo
Eyebrow	6–8 wk
Nostril	2–3 mo
Nasal septum	4–6 wk
Tongue	4–6 wk
Labret	6–8 wk
Nipple (female)	2–3 mo
Nipple (male)	2–3 mo
Navel	6–10 mo
Clitoral hood	4–6 wk
Penis (Prince Albert)	4–6 wk

Technique

Universal precautions should always be followed. Instruments and jewelry need to be appropriately sterilized. In rare circumstances, certain jewelry will need to be soaked in an antiseptic solution for 30 minutes. This solution is removed with alcohol before insertion. Anesthesia is usually not indicated for these procedures. However, for sensitive areas such as the genitals and mucosa, topical anesthetics like topical lidocaine (EMLA cream) or benzocaine (Hurricaine) can be applied before the procedures.

Navel Piercing

1 Prepare the sterile instrument tray (Fig. 233-4).

2 Clean the navel and the surrounding abdominal wall with an antiseptic solution (sterile preparation).

3 Mark entry and exit points with the surgical marker (Fig. 233-5). Confirm acceptability of location with the patient before proceeding. Use the crest of the navel fold as a guide. On the abdominal wall, mark the entrance site at a distance half the length of the curved barbell or the diameter of the ring from the edge of the skin fold. On the undersurface of the navel skin fold, mark the exit site at the same distance from the edge of the fold as the entrance site. This is above the deep, flat base of the umbilicus. Have the patient lie, sit, stand, protrude, and retract the abdomen to evaluate placement of the markings as they vary with each position. Make adjustments in the markings if needed. If an umbilical hernia or other anatomic variants are present, a navel piercing should be avoided.