CONTINUING EDUCATION
Body Art and the Perioperative
Process 2.3
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DEBRA DUNN, MSN, MBA, RN, CNOR
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Purpose/Goal
To provide the learner with knowledge of best practices related
to safe perioperative care for patients with various forms of
body art.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
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Conflict-of-Interest Disclosures
Debra Dunn, MSN, MBA, RN, CNOR, has no declared
affiliation that could be perceived as posing a potential conflict
of interest in the publication of this article.
The behavioral objectives for this program were created by
Kristi Van Anderson, BSN, RN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC,
director, Perioperative Education. Ms Van Anderson and
Ms Bakewell have no declared affiliations that could be
perceived as posing potential conflicts of interest in the
publication of this article.
Objectives
Sponsorship or Commercial Support
1. Discuss societal acceptance and prevalence of body art.
2. Identify different types of body art.
3. Describe cultural and perioperative considerations for
patients with body art.
No sponsorship or commercial support was received for this
article.
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AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
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http://dx.doi.org/10.1016/j.aorn.2016.07.011
ª AORN, Inc, 2016
326 j AORN Journal
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Body Art and the Perioperative
Process 2.3
www.aornjournal.org/content/cme
DEBRA DUNN, MSN, MBA, RN, CNOR
ABSTRACT
Body modification, also known as body art, has been a common cultural practice for thousands of
years and includes body piercings, transdermal and subdermal implants, tattoos, scarification, body
stretching and sculpting, dental grills, and nail art. Perioperative nurses must learn more about body
art to provide nonjudgmental, nonprejudicial care and to ensure patient safety when they prepare
patients for surgery. A welcoming environment engages patients and fosters communication so that
patients are more likely to share hidden body art. It is also necessary for the preoperative nurse to
communicate with the perioperative team about patients’ body art to avoid airway complications,
tissue trauma, pressure ulcers, burns, postoperative surgical site infections, or distorted fluoroscopy or
magnetic resonance images. Identifying patients’ body art in advance allows the perioperative team to
be better prepared to deliver safe care. AORN J 104 (October 2016) 327-337. ª AORN, Inc, 2016.
http://dx.doi.org/10.1016/j.aorn.2016.07.011
Key words: piercing, tattoo, body art, body modification, implants.
B
ody modification has been practiced throughout
history by men, women, and children around the
world.1,2 Some body modification practices that
originated in ancient communities are considered mainstream
today. Since the 1990s, body piercings, tattoos, and scarification have become increasingly popular.3,4 Perioperative
nurses must be familiar with the body modifications their
patients could potentially have to ensure surgical safety.
Piercings, transdermal and subdermal implants, tattoos, scarification, body stretching and sculpting, dental grills, and nail
art affect the nursing care provided in perioperative areas.
Nurses must provide culturally sensitive care, which requires
an understanding of these various types of body art.
People pursue different forms of body art for a variety of
reasons, including
displaying individualized self-expression and uniqueness,
where bodies are viewed as outer reflections of inner selves;
feeling addicted to the adrenaline rush and release of endorphins associated with the act of being pierced or tattooed;
following fashion trends;
seeking social acceptance and belonging;
breaking or rebelling against family expectations;
enhancing how they look and feel;
pursuing a religious ritual;
demarcating an important life event (eg, birthday, anniversary) or a rite of passage (eg, reaching sexual maturity);
honoring another person;
distinguishing themselves as officials or of royalty; and
symbolically reclaiming themselves after a traumatic or
painful experience.3,5,6
Body art may be visible (eg, on the face), visible only when
clothing permits (eg, tattoo on lower back), or not visible
(eg, genital piercing). Approximately 72% (N ¼ 492) of adults
who have tattoos do not display them.7 Today, tattoos and
piercings are the most common forms of body art. The Harris
Poll demonstrated that approximately one in five adults
(N ¼ 2,016) has at least one tattoo.8 Approximately 40% of
18- to 29-year-old Americans (N ¼ 830) have a tattoo;2,7 50%
of those have two to five tattoos, and 18% have six or more.7
http://dx.doi.org/10.1016/j.aorn.2016.07.011
ª AORN, Inc, 2016
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AORN Journal j 327
Dunn
Piercings are also very popular: according to one report,
approximately 83% of Americans have had their earlobes
pierced, 14% have a piercing in a place other than the earlobe,
and 72% of Americans with a body piercing anywhere on the
body are women.9 Almost 25% (N ¼ 830) of 18- to 29-yearold Americans have a piercing in a place other than the
earlobe, which is a rate six times that of older adults.7
Nurses must communicate about their patients’ body art
preoperatively with the perioperative team, including the
anesthesia care provider and surgeon. The anesthesia care
provider, for example, must know about hardware or jewelry
found in and around the oral cavity or tattoos placed in the
lumbar region that could affect spinal or epidural needle
placement. The nurse and surgeon should discuss body art
that may affect positioning decisions or cause tissue trauma,
pressure ulcers, infections, or burns if not removed. It is best
to share information about the patient’s body art with the
surgical team before the patient arrives in the OR so that the
team will be better prepared for delivering safe care. In addition, delays and cancellations related to lack of preparation for
handling body art (eg, not having proper tools to remove
certain jewelry) can be avoided.
TYPES OF BODY ART
Body piercings, transdermal and subdermal implants, tattoos,
scarification, body stretching and sculpting, dental grills, and
nail art are the types of body art described in this article in
relation to the perioperative process.
Piercing
Body piercing has been performed for thousands of years
(Supplementary Sidebar 1) and continues to be popular
today. The most common piercing site for both men and
women is the ear; the next most common site for women is
the navel. Although both sexes are less likely to pierce the
tongue, nipple, lip, eyebrow, or genitals than the ear or
navel, these sites are more commonly pierced today than in
years past.5,10,11 Body piercings are considered a semipermanent form of body art because removing the jewelry
does not guarantee the hole will close without defects or
visible changes in the skin. Piercings generally heal within 4
to 36 weeks, depending on the location of the piercing and
tissue vascularitydthe more vascular the tissue, the quicker
it heals (Supplementary Table 1).12 Jewelry can be made
from many different materials, including various metals,
plastics, and wood. Table 1 lists common types of jewelry
(also called hardware), and Figure 1 shows illustrations of
several types of jewelry.
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Perioperative nurses should assess patients preoperatively for
piercings and be aware of the following medical problems that
can be associated with them:
allergic reactions;
inflammatory reactions;
angioedema;
rejection of the hardware material;
infection;
acute pain, lingering pain, and trigeminal neuralgia;
superficial nerve damage;
migration of the hardware;
scarring or keloid formation;
persistent bleeding;
trauma around the pierced site;
tooth injuries (oral piercing);
Ludwig’s angina (oral piercing);
perichondritis;
granulomas;
pelvic inflammatory disease (navel piercing);
secondary infections (eg, endocarditis, acute poststreptococcal
glomerulonephritis, streptococcal septicemia, staphylococcal
toxic shock syndrome, tetanus, pseudomonas abscesses); and
bloodborne infections (eg, HIV and hepatitis related to poor
technique or inadequate cleaning and sterilization of
instruments).3,4,6,10,12-14
Ear
The most common piercing site is the earlobe, which may have
multiple piercings. Another type of earlobe piercing, gauging,
begins with a pierced hole that is slowly stretched. The piercing
technologist uses a punch tool to remove the central tissue.
After the site heals, the circumference is then stretched over
time with an ear taper (a cone-shaped plug), which is gradually
increased in size. This site can hold larger hardware such as
colorful plugs, rings, curly tapers, and straight tapers that can be
solid or an open-tunnel style. Gauging in the ear cartilage is
called stretched cartilage, and it can hold heavy jewelry pieces.
Select ear piercings are shown in Figure 2.
Face
Facial piercings can include cheek, lip, chin, eyebrow, nasal, and
tongue piercings (Figure 3). Nasal piercings can involve a nostril
screw or a captive bead hoop that is used on the nares. Cheek
piercings involve a ball on the external surface and a flat disk on
the interior, which is called a flat-backed labret.3,15 Straight
barbells are commonly used for tongue piercings, which are
usually anterior to the lingual frenulum and at the midline.3
Tongue piercings are usually positioned approximately one inch
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Body Art and Perioperative Care
Table 1. Common Types of Body Modification Jewelry
1-4
Jewelry
Description
Barbell (ie, banana bar)
A post with balls on both ends. One or both balls unscrew from the post; the threaded
part can be inside the ball or outside on the post, or the ball can be pulled off the bar
(ie, press-fit barbell). The post can be straight, curved, L-shaped, or semicircular; the
end jeweled piece can be glued in place. Barbells are more commonly used on the
ear, eyebrow, tongue, navel, and genitals.
Belly chain, navel bar
A chain that connects two pierced areas of the navel. It can also attach to the pierced
navel and travel around the waist or hip and connect back to the initial piercing.
A navel bar (ie, navel barbell) is a straight or curved bar with a ball at one end and
jewelry at the other end. Jewelry may also be present at both ends.
Captive bead (ie, captive ring,
capture ball ring, bead ring,
tension hoop)
An incomplete circle of metal accompanied by a decorative bead with two indentations
(dimples). The two opposing ends of the circle hold the bead with pressure, which is
removed by inserting the tip of a fine-pointed plier or a ring-expander plier into the
ring. Spreading the pliers open to release the tension on the bead allows the bead to
fall out. The captive bead is more often used on the nipple, eyebrow, navel, or
genitalia.
Dermal anchor
The subdermally placed anchor into which external jewelry is screwed.
Earlobe plug
A plug that pops out or unscrews from one side.
Implant
Jewelry made of silicone, metal, or polytetrafluoroethylene (ie, Teflon, which does not
interfere with medical equipment). Implants are usually found in areas without a lot of
fatty tissue, such as across the forehead, in the wrist, or along the breastbone.
Labret
A straight bar with one fixed flat end and one threaded end onto which a ball can be
screwed. It can also have a jeweled end that is glued in place.
Nostril screw
A straight post with a unique bend along the length of it to secure the hardware into
place; lies flat against the nasal mucosa.
Safety pin
A safety pin in the pierced hole.
Straight post
A straight post that is inserted through a pierced hole. It may have an accompanying
curved clasp that uses tension to lock onto the post and hold it in place.
Stud
A post with jewelry at one end. The other end has either a ball or a clasp to hold the
jewelry in place.
Taper
A cone-shaped plug that is gradually increased in size to stretch the ear over time.
Tube, flared eyelet, flesh tunnel
A ring inserted into a pierced hole, usually in the ear, with the goal to enlarge the
pierced hole. It stays in place with an O-ring at the back of the ear.
Editor’s note: Teflon is a registered trademark of The Chemours Company, Wilmington, DE.
References
1. Halliday KA. Body piercing: issues and challenges for nurses. J Forensic Nurs. 2005;1(2):47-56.
2. Larkin BG. The ins and outs of body piercing. AORN J. 2004;79(2):333-342.
3. Marenzi B. Body piercing: a patient safety issue. J Perianesth Nurs. 2004;19(1):4-10.
4. Mudderman NR. What every nurse needs to know about body piercing. J Contin Educ Nurs. 2006;37(5):198-199.
from the tip of the tongue and in the center to avoid the two
deep lingual veins because the tongue is a vascular tissue that
bleeds and swells easily.3 A tongue piercing may be placed
horizontally or vertically.15
Torso and limb
Jewelry for a navel piercing is usually a captive bead or curved
barbell. The navel can be pierced in the skin above or below it; a
horizontal piercing can also be made through the skin
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surrounding the navel. Nipple piercings cross the nipple base
and may or may not go through the areola. Sometimes a nipple
shield is also included, which is a decorative metal disk that is
held in place over the areola with the barbell jewelry set through
the nipple piercing. Nipple piercing may be performed to increase a person’s ability to experience sexual pleasure.3,12 Surface
piercings can be found in anatomically flat locations such as the
neck, chest wall, forearms, pubis, arms, legs, and sternal notch.
Figure 4 shows an example of a surface piercing of the wrist.
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minora, clitoris, or clitoral hood. Most commonly, a captive
bead or semicircular barbell is used on the clitoral hood or
areas surrounding the clitorisddirect clitoral piercings are rare
and painful.3,12 Paradoxically, these piercings originated as
both a form of chastity and a means to enhance erotic feelings.15 More recently, female genital piercings have been
chosen by women overcoming past trauma, such as dysfunctional sexual relationships, sexual violence, or divorce. In this
way, women “reclaim their body parts [that] they psychologically separated from themselves during the traumatic
event.”12(p131) Sexual negation also may occur, where the ring
piercings of the labia majora are hooked together to “close” the
vaginal opening.12
print & web 4C=FPO
Male genital piercings have been documented throughout
history. Piercings of the glans may or may not transect the
urethra, and may include the
Figure 1. Select types of jewelry and hardware.
Illustration by Kurt Jones.
Genital
Scrotal piercings include the guiche (perineum) and hafada
(anywhere on the scrotum). Frenum piercings are on the
underside of the penis near the glans where it meets the shaft.
Variations include the lorum (placed at the base of the shaft)
and the ladder (a row of piercings on the underside of the
print & web 4C=FPO
People may choose to have genital piercings to increase their
ability to experience sexual pleasure, increase the intensity of
sexual stimulation, or provide pleasure to a partner.3,5,12 Sites
of female genital piercings include the labia majora, labia
Prince Albert (through the urethra and out the inferior
surface of the glans),
reverse Prince Albert (through the urethra and out the
superior surface of the glans),
apadravya (vertical through the glans),
ampallang (horizontal through the glans), and
dydoe (through the ridge of the glans).
Figure 2. Multiple types of ear piercings. Illustration by Kurt Jones.
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Figure 4. A surface piercing of the wrist. Photo courtesy of FreeImages.com.
Tattoos
Figure 3. Select types of facial piercings. Illustration by
Kurt Jones.
penis).16 Similar to female piercings, male genital piercings
were initially performed for both chastity and sexual stimulation.15 Figure 5 displays select male genitalia piercings.
Transdermal and Subdermal Implants
Transdermal implants (ie, microdermal, single-point piercings)
are semipermanent implants in which the skin is pierced to
create a one-way hole through which a small anchor is placed
beneath the skin. Attached to the embedded anchor is a step
(or top) that protrudes from the skin; a step is a post with a
threaded end into which jewelry is screwed. If the person
decides to remove the piercing, the transdermal piece needs to
be surgically removed.2,6
Subdermal implants are semipermanent, decorative hardware
that come in various shapes and are placed completely under
the skin. The hardware itself is not visible but creates raised
designs that are visible at the skin level. Similar to implanting a
pacemaker battery or spinal stimulator, the hardware is
implanted into a subcutaneous pocket and the skin is stitched
closed. The implant may be made from silicone, polytetrafluoroethylene (ie, Teflon), or metal.17 Risks include infection,
scarring, and migration.2,6,14 A subset of subdermal implants
is pearling, or genital beading, in which small objects composed
of various materials are placed beneath the labia or the shaft or
foreskin of the penis.14
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Tattooing is the depositing of ink pigment along a needle track
into the epidermis and dermis (skin penetration is 0.6 to 2.2
mm deep). Only the ink deposited into the dermis is
permanentdthe epidermal layer flakes and sloughs off as it is
replaced with new cells.4 Over time, however, tattoo colors
invariably fade.2 Today, this art form increasingly is moving
into mainstream culture. Approximately 15,000 tattoo parlors
operate in the United States.2 Supplementary Sidebar 2 provides historical information on tattooing practices.
Tattoo ink always contains at least one pigment color, plus a
carrier to transport the ink. There are several safety concerns
associated with tattoo inks. First, many pigments found in
tattoo ink have not been approved for injection into the skin,
or even for contact with the skin.18 Pigments used in tattoo
ink are considered cosmetics by the US Food and Drug
Administration and are subject to premarket approval.
However, the US Food and Drug Administration has not
traditionally regulated the pigments in tattoo ink because of
competing public health priorities and lack of evidence of
harm.18 Second, tattoo artists sometimes use industrial inks,
such as printer’s ink or automobile paint, either alone or in
tandem with other pigments, decreasing the tattooed person’s
ability to learn about his or her ink composition.14,18 Third,
there are pigments used in tattoo ink that contain potentially
hazardous carcinogenic substances (eg, polycyclic aromatic
hydrocarbons) and metallic salts (eg, cadmium, lead, mercury),
which, depending on the amount, could be toxic when
absorbed by the body.19-21
Aside from the dangers inherent in tattoo ink, other risks
associated with tattoos include
pain;
bleeding;
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images are burned and imprinted onto the body. Branding can
be performed with any of the following:
an electrocautery knife (also called hyfrecator branding),
a laser,
hot metal (known as strike branding),
cold metal (using liquid nitrogen),
chemicals (caustic, corrosive), or
a tattoo gun without ink.
print & web 4C=FPO
A scab forms and is scraped off repeatedly or the wound is
irritated with chemicals until it leaves a visible etching.2,6,25
Figure 5. Male genitalia piercings. Illustration by Kurt
Jones.
localized trauma;
inflammatory reactions;
allergic reactions to the metals, pigments, or dyes;
local cutaneous reactions such as lichenoid, granulomatous,
eczematous, and pseudolymphomatous reactions;
local infection with pustular lesions;
infections such as hepatitis B and C, HIV, pseudomonas,
staphylococcus, malaria, leprosy, tetanus, tuberculosis,
mycobacterium, and syphilis;
potential risk of melanomas and basal cell carcinomas;
blood poisoning;
scarring; and
secondary infections (eg, infective endocarditis, liver
inflammation).4,6,14
Tattoo pigment also has been found to have traveled from the
tattoo site into the lymph nodes and then mistaken for metastatic disease or tumors.22,23 Tattoo removal, which can be
tedious and painful, also has inherent risks, including scarring,
pigment changes, and blistering.6,24
Skinning is another form of scarification in which single-line
cuts are made into the skin to be removed or peeled off.
Hatching is a practice in which a blade is used to sketch on the
skin to create the appearance of shadows or shading. Layers of
skin also can be removed with an inkless tattoo device or an
object that causes friction, like sandpaper; this is called abrasion.25 A final form of scarification is called scarring moxibustion,
which involves placing incense on the skin and allowing it to
burn until extinguished inside the flesh.25 All forms of scarification can lead to infections and excessive scarring. In addition,
the end result of the image may not be what the person wanted
or expected, because scars develop unpredictably.
Body Stretching
With stretching, a body part is stretched beyond its normal
limit or size. The most popular body part that is stretched is
the earlobe. Either larger implants are inserted to stretch a hole
made by piercing or the weight of the hardware that is inserted
in the hole fosters the stretching process. Risks associated with
stretching include skin blowout and excessive scarring with
keloid formation.6
Body Sculpting
Sculpting requires the body part to be permanently altered.
Examples of this practice include cutting off the top cartilage
of the ear and sewing it back on to form a point (resembling
elf ears) and tongue splitting. Tongue splitting involves cutting
the middle of the tongue from the tip back. Splitting the
tongue causes speech defects and can result in a large amount
of blood loss. Sculpting is painful when performed without
anesthesia, and infection is a possible complication.6
Scarification
Dental Grills
Scarification is performed by scratching, etching, or cutting
designs into the skin with a blade and allowing a scar to form
into a permanent design (Figure 6). A common methodology
includes branding, an extreme form of scarification where
Dental grills are decorative covers that can either slip temporarily onto or be permanently affixed to the teeth. They may
be made of solid gold or a mixture of gemstones (eg,
diamonds) and metals. Possible complications that may be
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Body Art and Perioperative Care
body art when they feel accepted.3 Cultural awareness, which
includes a self-examination of prejudicial thoughts and personal biases, therefore, is paramount.3,11
print & web 4C=FPO
Discussion of body art should begin with the preadmission
testing process, with the preoperative phone call, or on
admission to the preoperative area on the day of surgery; any
issues should be addressed before the patient enters the OR
suite. Effective communication during the perioperative
process is imperative to creating a receptive environment in
which perioperative staff members can provide safe care.
When preparing patients for surgery, one of the nurse’s main
concerns is to be respectful of his or her patient’s cultural
beliefs and preserve the patient’s body image while promoting safety.
Figure 6. Cranial scarification. Photo courtesy of
FreeImages.com/Eddie Roman.
experienced by a person wearing a grill long-term include
tooth decay, gum disease, worn enamel, and halitosisdall
because of the tendency for bacteria to collect under the grill.26
Nail Art
Nail polish can be adorned with sparkles, glitter, decals, and
pieces of foil with gel superimposed. Nail art can even be
three-dimensional. People may attach plastic bows, figurines,
flowers, jewels, or charms to their nails.2
PERIOPERATIVE PATIENT CARE
Body art may have cultural or emotional significance for a
patient. A prerequisite for providing nursing care to patients
with unfamiliar body art is to communicate with them in a
nonjudgmental and culturally sensitive manner.3,10 The first
step is for nurses to become familiar with the various forms of
body modification so they may provide care with empathy. It
is critical that the patient feels accepted by the nurse, which
requires the nurse to minimize or eliminate expressions of
disgust or surprise toward the patient’s body. Conscious or
subconscious expressions of negativity toward the patient can
result in alienation and the inhibition of communication
between the nurse and patient. Patients will be more likely to
be engaged in their care and to share the location of hidden
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Discovering body modifications in the OR after the nurse
uncovers the patient for positioning and prepping can result in
unexpected delays or procedure cancellations. Learning about
body art in the preoperative area allows time for the team to
inspect the body art for debris or infection, determine whether
the location of the body art is problematic, and learn of its
composition so that an appropriate plan of care can be
developed that reduces risks of complications, such as pressure
ulcers, electrosurgical or chemical burns, and infections.5,17
Jewelry Removal
According to AORN, all jewelry and hardware should be
removed before surgery.27 All patients should be instructed by
the surgeon’s office or the surgical facility to remove all jewelry
before the day of surgery. On the day of surgery, perioperative
nurses should remind patients to remove their jewelry and give
it to a family member. Alternatively, the item(s) can be placed
in a closed container, labeled with the patient’s name and
account number, and given to a staff member designated to
take responsibility for the item(s). Jewelry that is given to a
family member or staff member should be documented.
Nurses should ascertain enough information about piercings
preoperatively to ensure patient safety is maintained. Nurses
should determine
the age of the piercing, because fresh piercings could become
infected and spread to the surgical site; alternatively, if the
surgical site becomes infected it could spread to the pierced
site;
that there is no crust, debris, dirt, or infection at the pierced
site;
the jewelry’s location relative to the surgical site, because no
jewelry should be worn near the incision site or the active/
return electrode pathway;
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whether the patient is wearing jewelry in or near the genitalia
in the event a urinary catheter is required;
that mouth, cheek, and nasal jewelry have been removed
because of the potential airway problems that anesthesia care
providers may encounter; and
whether the patient refuses or is unable to remove jewelry; in
these instances, the surgeon may decide to cancel the procedure, or the jewelry must be insulated with surgical tape.4,15
Patient education includes providing the rationale for removing
jewelry and notifying the patient that it is his or her responsibility to remove jewelry before surgery. Information that
should be shared with patients when discussing reasons for
removing jewelry and hardware includes that the jewelry could
become a foreign body or be lost if it disengages during
surgery;
be a source of infection;
cause a burn if it is metal;
become caught on linen or drapes;
become damaged;
become difficult or impossible to remove without damage if
edema develops at the site, in which case it may need to be
cut;
impair incision healing when the jewelry is located near the
incision site; or
cause negative outcomes (eg, a bleeding tear from a tongue
stud can result in laryngospasm, airway obstruction, or acute
hypoxia).11
Patient and family education should be documented along
with the nurse’s assessments of the pierced site.
Patients should remove and reinsert their own jewelry whenever possible. Some patients, however, may not be able to
remove their own jewelry, may refuse to have their jewelry
removed, or may be unconscious when brought to perioperative services. Nurses, therefore, need to know how to safely
remove all types of jewelry and hardware. Patient safety takes
precedence over the patient’s desire to keep jewelry in place. If
the procedure is not emergent or urgent, it can be delayed
until this issue is resolved. Cutting the jewelry is a last resort
because it can cause tissue injury and ruin the jewelry.10 If a
policy does not exist regarding a patient’s refusal to remove
jewelry or hardware, the nurse should contact the risk manager
for guidance on an immediate situation, and a policy should
be written to avoid future issues.
Jewelry or hardware may be removed by using straight or rotary
movements to unscrew when threaded. Gauze can be used to
effectively grasp the jewelry when pulling it apart or unscrewing
it. If removal by hand is not possible, jewelry pliers or
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ring-opening pliers can be used.28 Before removing oral jewelry,
place gauze in the front of the throat to prevent jewelry from
being aspirated.1,28 The nurse must document jewelry removal
and provide a skin assessment before and after removal.
Patients with fresh or recent piercings that are not yet healed
may be reluctant to remove the jewelry because of fear that their
pierced hole will close, especially in the genital and tongue areas,
where the tissue is vascular and heals quickly.12 Plastic barbells,
studs, or sterile sleepers are options to use as place holders,
although they are not radiopaque and may dislodge and become
a foreign body. Sleepers can be sterile sutures or thin plastic
tubing (eg, epidural IV catheter tubing). When plastic tubing is
used, it is slid over the jewelry to guide the tubing into the hole
as the jewelry is removed. Sleepers can prevent tears, burns (if
electrosurgery is used), and loss of metal jewelry or hardware
during surgery. Sleepers for tongue, mouth, or nasal rings are
not recommended because they can detach and get lost during
endotracheal tube insertion and could be aspirated.1,4,11
If jewelry that was not removed preoperatively is missing postoperatively and is suspected of being aspirated, swallowed, or
lost elsewhere in the body, radiographs will need to be taken. If
the lost item was not radiopaque and was located on the face, then
a fiber-optic endoscopy will need to be performed of the nasopharyngeal and oropharyngeal cavities, esophagus, larynx, and
trachea to validate that there is no foreign body left behind.4
Electrosurgery
Jewelry in or near the incision site must be removed before the
procedure to safeguard the patient. However, AORN and
other authors advocate removing all types of metallic jewelry as
a best practice because they can inadvertently reconcentrate a
current when electrosurgery is used, resulting in second-degree
burns.13,15,27 Despite the extensive safeguards manufacturers
have built into the mechanics of electrosurgery machines, all
metal objects in the pathway between the active electrode and
the dispersive pad must be removed before surgery to avoid the
risk of a burn. Burns can occur from
the jewelry accidentally coming into direct contact with the
activated electrode tip,
directed current that hits the metal found between the active
and dispersive electrodes,
heat conduction to the metal before the deactivated electrode completely cools down, or
leakage of current from the electrosurgery cord.17,27
In addition, the metal in jewelry can impede the return of
the electrical current to the dispersive pad, also causing a burn.17,27
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October 2016, Vol. 104, No. 4
If the patient’s jewelry cannot be removed and poses a risk for a
burn, bipolar electrosurgical technology should be considered, if it
is appropriate for the type of surgery being performed.17
The electrosurgical unit dispersive pad should not be placed
over tattoos or scars (either from surgery or body art).17,27,29
AORN guidelines specifically stipulate not to apply the
dispersive pad over a tattoo because the pigment in the ink
may contain metallic dyes. Evidence supporting this statement
comes from reports of adverse events related to the superheating of tattooed tissue during magnetic resonance imaging
(MRI) procedures.27,30 It is also important for the nurse to not
apply the pad on scar tissue (eg, sites where tattoos have been
removed, scarification body art) or over implanted metal
(eg, subdermal and transdermal hardware, implanted prostheses) because the scar and metallic object can impede or
divert the pathway of the electric current from the active
electrosurgery electrode to the dispersive pad.27
Anesthesia
Anesthesia care providers must be aware of piercings when
developing the anesthesia plan. Facial, nasal, and oral piercings
can get in the way of an effective mask seal during the delivery
of supportive oxygenation, even when regional anesthesia or
monitored anesthesia care is planned instead of general anesthesia.1,10 Prudent anesthesia care providers check a patient’s
oral airway and mouth for jewelry, dentures, and loose or
chipped teeth regardless of the type of anesthesia expected to
be employed. Tongue piercings, dental grill pieces, and any
other facial piercings near the mouth, chin, or nose can
detach and become a foreign body that could be swallowed
or inhaled and aspirated;
cause dental trauma, such as fractures and fissures, after the
patient is anesthetized and bites down on the jewelry; and
cause gum and soft tissue injury along with bleeding and
edema during intubation.
This jewelry must be removed both for patient safety reasons
and medical-legal risks to the anesthesia care providers and the
organization.1,4,5,10,13,15
The nurse also must inform the anesthesia care provider about
back implants and skin tattoos when planning for an epidural
block or spinal anesthesia. The hardware will need to be
avoided, and epidural and spinal injections need to be
performed with a bored needle when there are tattoos at the
site. Another method is to perform a cut-down to get beneath
the dermis and then insert the needle to avoid inserting ink
fragments into the body. The effect of sending retained tattoo
ink fragments into the epidural space or spinal canal are
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Body Art and Perioperative Care
unknown. Additionally, a Tuohy needle with a stylet can be
used to prevent the coring of the tattooed tissue.4
Finally, nail polish color or finish, decorations, and nail length
are also important details to share with the anesthesia care
provider. Nail art may impede the positioning and functioning
of the pulse oximeter. Pulse oximeters can be applied to the
earlobe when application over a nail will not suffice.
Fluoroscopy and MRI
Hybrid procedure rooms are common in modern ORs. These
OR suites can contain either a fluoroscopy unit (c-arm) or an
MRI machine. Tattoos have been shown to interfere with
fluoroscopy and MRI images, creating artifacts and tissue distortions that interfere with or obliterate the interpretations of
the images and the results or conclusions from the tests.3,14,27 It
has also been strongly suggested that tattoo pigments containing
metals (eg, iron) act as conductors during MRIs, causing a
burning sensation, pain, and potentially a superficial
burn.4,10,14,31 During an MRI scan, patients with tattoos have
reported a range of sensations, from slight discomfort and
stinging to severe pain. Metal jewelry creates an additional
problem in an MRI machine because the magnet can move or
dislodge the jewelry, causing trauma to the skin and discomfort
for the patient.31,32 Nail polish that contains tiny metallic
particles can also pose problems in a hybrid MRI OR suite.2
Defibrillation
Discovering that a patient has nipple or chest piercings, chest
tattoos, or torso scarification after the patient goes into cardiac
arrest is far from optimal. In such emergencies, there is no time
to remove the piercings, and determining the best location for
the defibrillator pads to avoid tattoos and scars can take up
precious seconds. Placing the pad on the tattoo or scar tissue can
cause the electrical current from the defibrillator to be diverted
or impeded from reaching the heart. This situation can decrease
the defibrillation effectiveness or cause secondary burns.3,13
Positioning
To eliminate potential nerve or tissue damage during a
procedure, the surgical team should ensure that any body art
hardware that cannot be removed is not compressed when
positioning patients. In instances when the hardware is not
removable, additional soft padding should be used around,
under, and over the hardware, and adjustments should be made
to the positioning or incision site as needed. Distribution of
pressure may need to be adjusted intraoperatively for surgeries
longer than 1.5 hours so to allow for capillary refill. An
assessment of preoperative skin integrity, including hardware
AORN Journal j 335
Dunn
October 2016, Vol. 104, No. 4
that was not removed, all body art, the patient’s position, and
personnel involved with the positioning, should be made and
documented.17 The appearance of the skin after the procedure
should also be documented.
Postoperative Concerns
After surgery, patients should replace their jewelry themselves
and only after they are fully awake. The person’s hands should
be clean and the jewelry should be disinfected before reinsertion. When the jewelry site is near the incision site (eg,
navel jewelry after laparoscopic surgery), it should not be
replaced until approved by the surgeon because it can increase
the risk for a surgical site infection or other adverse events.13
One source suggests waiting at least two days before reinserting such jewelry.11 When jewelry placement is near the
incision site, both the jewelry and incision site should be
observed for infection (eg, redness, warmth, pain, discharge)
for several days after reinsertion.11
CONCLUSION
Ear piercings and earlobe gauging, facial jewelry, genital and
nipple piercings, subdermal implants, and visible tattoos are
considered popular body modifications in today’s society.
Perioperative nurses may encounter scarification, body
sculpting, and stretching in patients less often. Perioperative
nurses must learn more about body modifications to ensure
patient safety when preparing patients for surgery. Nurses
need to become aware of any personal prejudices toward body
art and be more attentive and receptive toward patients who
express themselves through body art. Engaging patients to
learn more about their body art will help nurses understand
their patients more fully, which will enhance patient care.
SUPPLEMENTARY DATA
The supplementary material associated with this article can be
found in the online version at http://dx.doi.org/10.1016/
j.aorn.2016.07.011.
Acknowledgment: The author thanks Eleanor Silverman, MLS,
AHIP, medical librarian at St Joseph’s Healthcare System,
Paterson, NJ, for her assistance with researching this topic.
Editor’s note: Teflon is a registered trademark of The Chemours
Company, Wilmington, DE.
References
1. DeBoer S, McNeil M, Amundson T. Body piercing and airway
management: photo guide to tongue jewelry removal techniques.
AANA J. 2008;76(1):19-23.
336 j AORN Journal
2. Gordon SG. Expressing the Inner Wild: Tattoos, Piercings, Jewelry,
and Other Body Art. Minneapolis, MN: Lerner Publishing Group, Inc;
2014.
3. Halliday KA. Body piercing: issues and challenges for nurses.
J Forensic Nurs. 2005;1(2):47-56.
4. Mercier FJ, Bonnet MP. Tattooing and various piercing: anaesthetic considerations. Curr Opin Anaesthesiol. 2009;22(3):
436-441.
5. Larkin BG. The ins and outs of body piercing. AORN J. 2004;
79(2):333-342.
6. Currie-McGhee L. Tattoos, Body Piercings, and Teens. San Diego,
CA: ReferencePoint Press; 2014.
7. Millennials: a portrait of generation next. Confident. Connected.
Open to change. Pew Research Center. http://www.pewsocialtre
nds.org/files/2010/10/millennials-confident-connected-open-to-change
.pdf. Published February 24, 2010. Accessed June 29, 2016.
8. One in five U.S. adults now has a tattoo. The Harris Poll. http://www.the
harrispoll.com/health-and-life/One_in_Five_U_S__Adults_Now_Has_a_
Tattoo.html. Published February 23, 2012. Accessed June 29, 2016.
9. Body piercing statistics. Statistic Brain. http://www.statisticbrain
.com/body-piercing-statistics. Accessed June 29, 2016.
10. Mudderman NR. What every nurse needs to know about body
piercing. J Contin Educ Nurs. 2006;37(5):198-199.
11. Jacobs VR, Morrison JE Jr, Paepke S, Kiechle M. Body piercing
affecting laparoscopy: perioperative precautions. J Am Assoc
Gynecol Laparosc. 2004;11(4):537-541.
12. Young C, Armstrong ML. What nurses need to know when caring
for women with genital piercings. Nurs Womens Health. 2008;
12(2):128-138.
13. Diccini S, Nogueira A, Sousa VD. Body piercing among Brazilian
surgical patients. AORN J. 2009;89(1):161-165.
14. Boschert S. Tattoos, piercings can present problems. American College
of Emergency Physicians. https://www.acep.org/content.aspx?
id¼82882. Published December 2011. Accessed June 29, 2016.
15. Marenzi B. Body piercing: a patient safety issue. J Perianesth
Nurs. 2004;19(1):4-10.
16. Hudson KL. Male genital piercing guide. About Style. http://tattoo
.about.com/cs/beginners/a/blmalegenp.htm. Updated December
16, 2014. Accessed June 29, 2016.
17. Denholm B. Clinical issues: caring for surgical patients who have
subdermal implants. AORN J. 2013;97(3):372-375.
18. Tattoos & permanent makeup: fact sheet. US Food and Drug
Administration. http://www.fda.gov/cosmetics/productsingredients/
products/ucm108530.htm. Published November 29, 2000.
Updated August 22, 2012. Accessed June 29, 2016.
19. Regensburger J, Lehner K, Maisch T, et al. Tattoo inks contain
polycyclic aromatic hydrocarbons that additionally generate deleterious singlet oxygen. Exp Dermatol. 2010;19(8):e275-e281.
20. Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol.
2012;13(4):e161-e168.
21. Forte G, Petrucci F, Cristaudo A, Bocca B. Market survey on toxic
metals contained in tattoo inks. Sci Total Environ. 2009;407(23):
5997-6002.
22. Peterson SL, Lee LA, Ozer K, Fitzpatrick JE. Tattoo pigment
interpreted as lymph node metastasis in a case of subungual
melanoma. Hand. 2008;3(3):282-285.
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October 2016, Vol. 104, No. 4
23. Chikkamuniyappa S, Sjuve-Scott R, Lancaster-Weiss K, Miller A,
Yeh IT. Tattoo pigment in sentinel lymph nodes: a mimicker
of metastatic malignant melanoma. Dermatol Online J. 2005;
11(1):14.
24. Khunger N, Molpariya A, Khunger A. Complications of tattoos and
tattoo removal: stop and think before you ink. J Cutan Aesthet
Surg. 2015;8(1):30-36.
25. Scarification. Medical Bag. https://www.themedicalbag.com/
bodymodstory/scarification. Published April 15, 2013.
Accessed June 29, 2016.
26. Grills. American Dental Association. http://www.mouthhealthy
.org/en/az-topics/g/grills. Accessed June 29, 2016.
27. Guideline for electrosurgery. In: Guidelines for Perioperative
Practice. Denver, CO: AORN, Inc; 2016:119-135.
28. Smith FD. Caring for surgical patients with piercings. AORN J.
2016;103(6):583-596.
29. Spruce L, Braswell ML. Implementing AORN recommended
practices for electrosurgery. AORN J. 2012;95(3):373-387.
www.aornjournal.org
Body Art and Perioperative Care
30. AST standards of practice for use of electrosurgery. Association of
Surgical Technologists. www.ast.org/uploadedfiles/main_site/
content/about_us/standard%20electrosurgery.pdf. Accessed
June 29, 2016.
31. Armstrong ML, Elkins L. Body art and MRI: tattoos, body piercings,
and permanent cosmetics may cause problems. Am J Nurs. 2005;
105(3):65-66.
32. Shellock FG, Spinazzi A. MRI safety update 2008: part 2,
screening patients for MRI. AJR Am J Roentgenol. 2008;191(4):
1140-1149.
Debra Dunn, MSN, MBA, RN, CNOR, is the OR
education specialist at Holy Name Medical Center,
Teaneck, NJ. Ms Dunn has no declared affiliation that
could be perceived as posing a potential conflict of
interest in the publication of this article.
AORN Journal j 337
EXAMINATION
Continuing Education:
Body Art and the Perioperative
Process 2.3
www.aornjournal.org/content/cme
PURPOSE/GOAL
To provide the learner with knowledge of best practices related to safe perioperative care for patients
with various forms of body art.
OBJECTIVES
1.
2.
3.
Discuss societal acceptance and prevalence of body art.
Identify different types of body art.
Describe cultural and perioperative considerations for patients with body art.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aornjournal.org/content/cme.
QUESTIONS
1. People pursue different forms of body art for a variety of
reasons, including
1. following fashion trends.
2. breaking or rebelling against family expectations.
3. displaying individualized self-expression and uniqueness.
4. seeking social acceptance and belonging.
5. distinguishing themselves as officials or of royalty.
6. symbolically reclaiming themselves after a traumatic or
painful experience.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
2. Approximately 40% of 18- to 29-year-old Americans have
a tattoo.
a. true
b. false
3. Perioperative nurses should assess patients preoperatively
for piercings and be aware of medical problems that can be
associated with piercings, including
1. allergic reactions.
2. infection.
3. persistent bleeding.
338 j AORN Journal
4. granulomas.
5. anemia.
a. 4 and 5
c. 1, 2, 3, and 4
b. 1, 2, and 3
d. 1, 2, 3, 4, and 5
4. Risks associated with tattoos include
1. jaundice.
2. hepatitis C.
3. blood poisoning.
4. HIV.
5. scarring.
6. melanoma.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6
5. The practice of using a blade to sketch on skin to create
shadows or shading is called
a. abrasion.
b. hatching.
c. branding.
d. skinning.
6. Tooth decay, gum disease, worn enamel, and halitosis are
possible complications of
a. dental grills.
b. lip piercings.
c. nasal piercings.
d. cheek piercings.
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October 2016, Vol. 104, No. 4
7. Concerns regarding body art should be addressed after
the patient enters the OR suite.
a. true
b. false
8. Nurses should ascertain enough information about a
patient’s piercings preoperatively to ensure patient safety
is maintained; this information should include
1. the presence of crust, debris, dirt, or infection at the
pierced site.
2. the jewelry’s location relative to the surgical site.
3. the patient’s motivation for getting the piercing.
4. whether the patient refuses or is unable to remove
jewelry.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
9. When electrosurgery is used on a patient with a metal
piercing, burns can occur from
1. the jewelry accidentally coming into direct contact
with the activated electrode tip.
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Body Art and Perioperative Care
2. directed current that hits the metal found between
the active and dispersive electrodes.
3. heat conduction to the metal before the deactivated
electrode completely cools down.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
10. Anesthesia care providers must be aware of the presence
of tongue piercings, dental grill pieces, and facial piercings near the mouth, chin, and nose because the jewelry
may
1. detach and become a foreign body that could be
swallowed or inhaled and aspirated.
2. cause dental trauma, such as fractures and fissures.
3. cause gum and soft tissue injury.
4. cause bleeding and edema during intubation.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
AORN Journal j 339
LEARNER EVALUATION
Continuing Education: Body Art
and the Perioperative Process
2.3
www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
Learner Evaluation at http://www.aornjournal.org/content/cme.
Rate the items as described below.
7. Will you change your practice as a result of reading this
article? (If yes, answer question #7A. If no, answer
question #7B.)
7A. How will you change your practice? (Select all that apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
OBJECTIVES
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss societal acceptance and prevalence of body art.
Low
1.
2.
3.
4.
5.
High
2.
Identify different types of body art.
Low
1.
2.
3.
4.
5.
High
3.
Describe cultural and perioperative considerations for
patients with body art.
Low
1.
2.
3.
4.
5.
High
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
7B. If you will not change your practice as a result of reading
this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
CONTENT
4.
2. I do not have enough time to teach others about the
purpose of the needed change.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
5.
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
6.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
340 j AORN Journal
3. I do not have management support to make a
change.
4. Other: __________________________________
8.
Our accrediting body requires that we verify the time
you needed to complete the 2.3 continuing education
contact hour (138-minute) program: ______________
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October 2016, Vol. 104, No. 4
Body Art and Perioperative Care
Supplementary Table 1. Sites of Body Piercings
Site
Ear
Face
Torso, limbs, hands
1-6
Type of Piercing
Tissue
Estimated Healing
Time
Earlobe
Soft tissue of earlobe
6-8 wk
Tragus
Cartilage in front of the opening to the ear canal
6-12 wk
Helix
High pinna outer cartilage; across 2 helices is an
industrial helix piercing
4-6 wk
Inner conch
Inner conch cartilage surrounding the lower outer helix
4-6 wk
Antitragus
Ridge of cartilage immediately above the earlobe
4-6 wk
Daith
Cartilage that protrudes from the inner cartilage
of the ear
4-6 wk
Rook
Upper cartilage fold of the ear
4-6 wk
Eyebrow
Anywhere on eyebrow
6-8 wk
Antibrow
Below the eyebrow or along the lower orbital ridge
6-8 wk
Bridge/Earl
Nasal bridge between the eyes
8-12 wk
Nose
Lateral nares (cartilage), distal part of nose, nasal
septum (soft tissue)
6-8 wk, base of
nostril; 4-6 wk,
nasal septum
Madonna/Monroe
Above the upper lip or outer corner of mouth; location
varies
6-8 wk
Tongue and lingual
frenulum
Anywhere on the tongue, usually centered, can be
horizontal or vertical; in frenulum under the tongue
4-6 wk
Lip
Anywhere on the upper or lower lips
6-8 wk
Medusa
Philtrum (the area between the nasal septum and the
upper lip)
6-8 wk
Labret
Below the bottom lip and above the chin
6-8 wk
Navel
Upper or lower lip of the umbilicus
6-12 mo
Nipple, female
Base of the nipple, where it meets the areola
6-8 wk
Nipple, male
Base of the nipple, may extend into the areola
6-8 wk
Hand
Web between any two fingers
6-12 mo
Surface piercings
Anywhere on a flat surface of the torso or limbs
6-8 wk
Neck
Madison
Anterior neck at sternal notch
4-6 wk
Genitalia, male
Prince Albert
Transurethral: extends from the penile urethra opening
downward to where the glans meets the shaft of
the penis on the inferior surface at the frenulum
4-10 wk
Reverse Prince
Albert
Transurethral: enters the male urethral orifice and exits
from the superior surface of the penile glans
4-10 wk
Apadravya
Glans: passes vertically through the glans and is a
combination of Prince Albert and reverse Prince
Albert
1-12 mo
Ampallang
Glans: passes horizontally through the glans, either
through the urethra or just above it
1-12 mo
Dydoe
Glans: passes through the flared edges of the glans in
circumcised men
4-10 wk
Prince’s wand
Transurethral: looks like a Prince Albert, but the jewelry
is T-shaped with an extension that resides in the
4-10 wk
(continued)
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AORN Journal j 340.e1
Dunn
October 2016, Vol. 104, No. 4
Supplementary Table 1. (continued )
Site
Type of Piercing
Tissue
Estimated Healing
Time
urethra; the extension is a hollow tube that extends
into the urethra by 3-6 inches
Genitalia, female
Foreskin
Anywhere on foreskin
4-10 wk
Guiche
Surface between scrotum and anus (perineum)
4-10 wk
Hafada
Superficial, anywhere on scrotum
4-10 wk
Frenum
Underside of the penis near the glans where it meets
the shaft
4-10 wk
Lorum
Where the penis joins the scrotum
4-10 wk
Ladder
Underside of the penis: an even row of multiple
piercings
4-10 wk
Labia majora
Anywhere on labia majora
4-10 wk
Labia minora
Anywhere on labia minora
4-10 wk
Clitoral hood
Anywhere on clitoral hood
4-10 wk
Triangle
Deep clitoral
4-10 wk
Fourchette
Inner labial juncture or between vagina and anus
4-10 wk
Christina
Superior labial juncture
4-10 wk
Princess Albertina
Transurethral or transvaginal; a female variation of the
Prince Albert
4-10 wk
References
1. Boschert S. Tattoos, piercings can present problems. American College of Emergency Physicians. https://www.acep.org/content.aspx?
id¼82882. Published December 2011. Accessed June 29, 2016.
2. Currie-McGhee L. Tattoos, Body Piercings, and Teens. San Diego, CA: ReferencePoint Press; 2014.
3. Halliday KA. Body piercing: issues and challenges for nurses. J Forensic Nurs. 2005;1(2):47-56.
4. Larkin BG. The ins and outs of body piercing. AORN J. 2004;79(2):333-342.
5. Marenzi B. Body piercing: a patient safety issue. J Perianesth Nurs. 2004;19(1):4-10.
6. Young C, Armstrong ML. What nurses need to know when caring for women with genital piercings. Nurs Womens Health. 2008;12(2):128-138.
340.e2 j AORN Journal
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October 2016, Vol. 104, No. 4
Historical Highlights of Piercing1-7
Body piercing is an ancient practice dating back to 3000
BCE that is performed for ornamental, religious, and
cultural reasons. Today, the wide variety of body piercings
found on people of all ages is no longer considered taboo.
Some historical highlights of body piercing are given
below.
3500 BC: An Iranian figurine shows a female with four
piercings in her ears.
Circa 900e800 BC: An engraving from Iraq shows a
male with a pierced ear.
Circa 450 BC: Statues of the Siddhartha Gautama, an
ancient Indian philosopher and the founder of
Buddhism, portray him with long, stretched-out
earlobes, indicating he wore earrings or ear plugs.
Circa 400e200 BC: People living on the island of
Cyprus pierced their ears.
250 AD: The Kama Sutra, an ancient Hindu text on
human sexual behavior, discusses male genital piercings
(apadravya).
550e577 AD: A Chinese stone head of a Bodhisattva
has pierced ears and stretched earlobes.
700 AD: The Maya pierced body parts, including the
tongue, as a common religious or spiritual practice.
900e1500 AD: Mesoamericans, including the Maya,
stretched their earlobes and wore ear-spools made from
obsidian.
Circa 1400e1600: Inca nobles wore large, diskshaped earrings called ear flares; nose rings, bracelets,
and giant neck collars were also common Inca
jewelry and were usually made from copper, silver,
and other materials.
1564e1616: William Shakespeare allegedly wore an
earring, as depicted in a portrait of unknown
origin. Whether Shakespeare actually wore an earring
is not confirmed, but other notable Englishmen
from this period, such as Sir Francis Drake and
Sir Walter Raleigh, have also been depicted wearing
earrings.
19th century: A Tlingit Alaskan native artifact is
displayed with a large nose ring. Men and women of
the Eskimo people of Alaska also wore labrets, and
lip piercing was an indication of social status.
1837e1901: Victorian royalty had nipple and genital
piercings.
1960s: Many types of body piercings became popular
and more mainstream. Piercers were considered artists
and their creations art.
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Body Art and Perioperative Care
1980s: Body piercing was associated with counterculture
and fringe groups, such as punk rockers and bikers.
References
1. Bryson B. Shakespeare: The World as Stage. New York, NY:
HarperCollins; 2007.
2. Currie-McGhee L. Tattoos, Body Piercings, and Teens. San
Diego, CA: ReferencePoint Press; 2014.
3. Diccini S, Nogueira A, Sousa VD. Body piercing among Brazilian
surgical patients. AORN J. 2009;89(1):161-165.
4. Gordon SG. Expressing the Inner Wild: Tattoos, Piercings,
Jewelry, and Other Body Art. Minneapolis, MN: Lerner
Publishing Group, Inc; 2014.
5. Halliday KA. Body piercing: issues and challenges for nurses.
J Forensic Nurs. 2005;1(2):47-56.
6. Piercing: a world tour of body modification. University of
Pennsylvania Museum of Archaeology and Anthropology. http://
penn.museum/sites/body_modification%20/bodmodpierce.shtml.
Accessed June 29, 2016.
7. Siddhartha Gautama. Ancient History Encyclopedia. http://www
.ancient.eu/Siddhartha_Gautama/. Published December 9,
2013. Accessed June 29, 2016.
AORN Journal j 340.e3
Dunn
Historical Highlights of Tattooing1
Circa 3000 BC
o The oldest tattooed mummy on record is the
“Iceman”da European who lived >5,000 years
ago. He died in the mountains between Italy and
Austria and was covered by a glacier that preserved
him until he was discovered in 1991 by hikers.
o Clay figurines from tombs in Japan show the Japanese
were tattooing as early as 5,000 years ago.
Archaeologists have found tattooed mummies in Europe
(3000 BC), central Asia (400 BC), Peru (1000 AD),
Egypt (1550 BC-1080 BC2), and elsewhere.
400 BC: Pazyryk mummies of central Asia (between
Russia and China) were found to have ornately tattooed
images of animals and monsters.
Circa 700 AD: In Japan, tattoos were used to identify a
person punished for committing a crime. The
Japanese tattooed criminals with crosses, lines, circles,
and other marks on their faces or arms as a sign
of shame.
o By the 1700s, criminals began embellishing their
tattoos. It became a source of pride for the
Japanese outlawsda banner displaying membership
in the rebellious world of organized crime.
o Tattooing spread from Japanese criminals to “tough
guys” such as firefighters and manual laborers;
designs became more ornate.
o By the 20th century, tattoos had become highly
regarded in Japan.
Maori culture: The people of New Zealand traditionally
wore spiral tattoos on their bodies and faces that
signified their rank in society, the family to whom they
belonged, and their ancestry. Tattoos were created
with a sharpened chisel made from animal bone and
teeth dipped into dye that was then hammered to
insert the dye into the skin. The word used to describe
tattooing is moko.
Samoan culture: Samoans tattooed their bodies with
thick stripes of black dye from the waist to the knees as a
rite of passage and a sign of becoming an adult.
o Men of higher rank received different marks than
those of lower rank, and women wore marks
different from men.
o Samoans inserted dye into their skins like the M
aori;
their word for this process is tatatau, which
means “to tap.”
1700s: European sailors visiting the Samoan islands
altered tatatau to tattoo and started getting tattoos
340.e4 j AORN Journal
October 2016, Vol. 104, No. 4
themselves. It became common for sailors to have
tattoos in the 1800s in the port cities of Europe and the
United States.
1900s: Mostly sailors, soldiers, criminals, and other
“tough guys” got tattoos in the United States.
o 1960s: The hippie movement, with a strong focus on
individual expression, influenced mainstream tattooing.
References
1. Gordon SG. Expressing the Inner Wild: Tattoos, Piercings,
Jewelry, and Other Body Art. Minneapolis, MN: Lerner
Publishing Group, Inc; 2014.
2. Weisberger M. Egyptian mummy’s symbolic tattoos are 1st of
their kind. LiveScience. http://www.livescience.com/54687
-egyptian-mummy-tattoos.html. Published May 9, 2016.
Accessed August 25, 2016.
www.aornjournal.org