Tattoos and body piercing
GP Dr Stefan Cembrowicz in conversation with plastic surgeon Mr Nigel Mercer about the medical aspects of body art
What's in this article
· Bacterial infection after ear piercing can lead to cartilage destruction
· Laser removal leaves a 'ghost' and works best on blue-black tattoos
· Silicone gel sheets are effective for treating hypertrophic scars
· Electrocautery can cause problems for people with nipple or genital piercings
Has the law kept up with social change?
What are the origins of tattooing and piercing?
Tattooing dates back several centuries. Though Native American tribes and Scythians have tattooed as well, it was thought to come back to Europe from the Polynesian islands with the first naval voyages there around the 17th century. From there it spread mostly through seamen and since then has become an international art form.
Ear piercings and nose piercings have been around for centuries. Culturally, throughout the whole world ear and nose piercings have been accepted from time immemorial: there are earrings dating back to pre-history. The origins of other, more extravagant body piercings are more difficult to trace. They probably relate mostly to the last century and have become much more common over the last 10 years.
Can we establish their prevalence?
Certainly tattooing and piercing are a cultural phenomenon of the young. One study recently showed maybe 50 per cent of students have piercings and tattoos. If you look at the media, lots of pop stars and young icons have multiple piercings and tattoos.
Are there regulations controlling the industry?
Local health authorities control tattoo parlours very carefully they are well-regulated and well-inspected. All the materials used, particularly the sharps, have to be disposable, gloves must be used, the whole place has to be disinfected regularly and all the surfaces washable and wipeable.
The law, I understand, is still the same in that you have to be 18 to have a tattoo or a piercing performed, though proving this is obviously difficult. There have been only one or two successful prosecutions for underage tattooing; I think it would be very difficult to follow that through if people took exception.
The biggest potential risk is from the amateur tattooist or piercer who isn't aware of the risk of cross-infection and doesn't take appropriate precautions, using the same needle on several people. The amateur market is where a lot cross-infections may come from.
What are the adverse effects of tattooing, medical and social?
To start with the social first, I think the effects are less than they used to be. Certainly you used not to be able to join the police, the navy or the services generally with a visible tattoo. I think most of us would have seen policemen and servicemen nowadays with tattoos. They are becoming much more acceptable, as are piercings.
The medical side-effects are more important, and we see a regular stream of people, especially young children, who have had piercings, particularly of the upper pole of the ear, where they get a bacterial infection. As we all know any operation can be complicated by bacterial infection, but in the upper pole of the ear it can destroy the cartilage and they end up with a very severe deformity and probably a very, very angry family because they hadn't been warned of this prospect by the people who performed the piercing.
What is the position with minors?
In theory they should not be pierced as it is against the law, but obviously if the parent agrees it becomes a difficult issue.
We've all seen young babies who've
had ears pierced. But I think ears are probably not such a problem because ear piercing is now a cultural norm. It's the other body piercings that should be more of concern.
Excision and reconstructive surgery
When a patient runs into trouble after a piercing or tattoo and requests removal, what can the NHS offer them?
If someone has a piercing that causes problems, the reconstructive surgery would probably be funded, although that may be a question for the PCT to sort out with the GP. A deserving example would be an upper pole of the ear damaged by infection, which may be reconstructable but would never be a normal ear.
It's much more difficult to get tattoos removed on the NHS. Some health authorities will not fund it at all, while others will fund removal on exposed areas like the hands and the face, but only if it is interfering with job prospects. Again, local PCTs have their own individual guidelines.
What techniques are available in the private medical sector?
Tattoo removal has not really progressed in the past 10-15 years; we're still using laser treatment. Unfortunately any successful removal of the tattoo by laser leaves a 'ghost', so patients need to be warned they will get some lightening of the tattoo but may not get complete removal.
Complete removal I'm afraid is still surgical with the attendant scarring and the possibility of a need for skin grafts.
What surgical excision techniques are commonly used?
It depends on the size and site of the tattoo. Take tissue expansion, for example. Inflatable balloons are placed under the skin, the skin is stretched and the resultant tattoos or scars later removed: that is an involved procedure and takes many months to complete.
Procedures such as tangential excision, over-grafting or derma-brasion really aren't particularly successful; they would give you some lightening but they do also give scarring. The tattoo pigment, particularly in amateur tattoos, sometimes goes down into subcutaneous fat; in a professional tattoo it's in the deeper dermis. So whatever technique we use is to cause scarring.
When are techniques such as dye tuneable lasers and ruby lasers used?
These are the main treatments for blue-black tattoos. They work by destroying the pigment itself and making it into debris small enough to be taken up by local macrophages, so complete resolution of the pigment takes several weeks after the procedure.
Dye tuneable lasers are being used for other colour pigments but with variable success. The lighter blue tattoos sometimes don't respond terribly well. The patient has to have multiple treatments, the lasers can leave scars, and unfortunately the treatment doesn't get rid of all the pigment.
What is the availability and likely cost of this sort of treatment?
Most regions have a laser centre associated with the plastic surgery department, and in the private sector there are independent practitioners. Costs vary from area to area, but I think you could assume that it would be several hundred pounds to have a tattoo removed by laser, whereas it may cost £20 or £30 to have it applied.
What is available non-medically, such as from tattoo parlours themselves, to get rid of an unwelcome tattoo?
Some tattoo parlours will use over-tattooing, for example if someone has an unwelcome name that they need removed. There are other ways of bleaching and lightening the skin which have been used by tattooists, but these can cause significant scarring and would not be recommended medically. The uncontrolled use of some of the bleaching agents can lead to very significant problems. I'm afraid the spectrum of what's available is very limited.
Healing of scars and fistulas
Sometimes I've seen patients in my surgery who've had attempts at tattoo removal leading to considerable scarring, often as unsightly as the tattoo itself. Are any techniques available to help prevent these scars forming?
Hypertrophic scarring can be dealt with by silicone gel, available over the counter from most pharmacists. Silicone gel sheets are very, very good for hypertrophic scars, and there are a variety of different ones available. They have to be worn all the time to have their best effect for several months, and on a limb they are probably best put under a tubigrip to give some pressure to the area as well. Unfortunately they don't stop the scar from forming, they just help to modulate how quickly it settles.
I'm afraid there's been no progress with treating keloids. Steroid injections, silicone gel and excision with immediate post-operative radiotherapy are still the only methods of treatment we have.
Coming to specific areas such as the tongue and genitals, what problems can arise with a piercing?
Immediately after the piercing you can have infection; massive swelling of the tongue can occasionally occur. Bleeding from the tongue is very significant if the lingual artery is penetrated, and it's not something to be undertaken lightly. Removal of piercings in the tongue almost inevitably lead to healing very quickly because of the tongue being such a muscular organ. But also one must bear in mind that having a metal object permanently inside the mouth or in the upper lip may lead to dental problems with wearing down of the enamel.
As for genital piercings, if they're removed the area will usually heal uneventfully. I don't think I've ever seen a fistula remaining after removal of a Prince Albert, for example.
Can electrocautery cause any problems for somebody with a metal insert of this type?
It can. Something we see relatively frequently in patients who are having diathermy in the operating theatre is that they often forget to tell us beforehand about piercings of nipples or the genitalia. If the nursing staff and the surgeon don't remember to ask, the patient can get local diathermy burns associated with metal being in contact with the skin.
Henna is sometimes used as a temporary tattooing agent. Are there any hazards associated with its use?
Some patients have a local allergic reaction and end up being scarred. There can be deep pigmentation where the henna has been applied, so occasionally you get patients who have a permanent mark as a result of henna tattooing. Unfortunately, once the henna's on, it's on.
Stefan Cembrowicz is a GP in Bristol
Nigel Mercer is consultant plastic surgeon at Frenchay Hospital, Bristol