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Identifying and minimizing risks for surgical patients with dermal implants

Publish Date: 10/17/2012

Linda J. Wanzer, DNP, RN, CNOR
Rodney W. Hicks, PhD, RN, FNP-BC, FAANP, FAAN

New forms of body decoration have recently emerged that pose additional challenges to patient safety within the perioperative environment. This nontraditional approach to body decoration has blended traditional piercing with implantation in the form of sub-dermal, trans-dermal, and micro-dermal implants.

Sub-dermal implants consist of burrowing (referred to as pocketing) and embedding decorative shapes (made of silicone, Teflon, or metal) under the skin, which results in a silhouette of the molded shape on the surface of the skin. Trans-dermal and micro-dermal implants consist of a footplate (or anchor) inserted into the epidermis with a thin piece of metal protruding from the skin, to which jewelry is attached.1 In all forms, the common denominator is the permanency of the body modification.

Moving and positioning for safety 

With traditional piercings, patients can remove body jewelry to avoid risks of injury from pressure or electrosurgical burns. When the perioperative team encounters a patient with a sub-dermal implant where the skin completely covers the implant, the patient safety priority is the maintenance of skin integrity.

However, with trans-dermal and micro-dermal implants, a thin metal post protrudes from the skin with jewelry attached to it. The metal post poses additional risks related to positioning, patient transfer, and electrocautery concerns.2,3 Regardless of which type of body modification is present on the patient, proper positioning ensures skin integrity.

One of the first concerns for skin integrity occurs when moving or transferring a patient, because of the risk of the piercing becoming caught on items such as equipment, drapes, or bedding material. AORN’s “Recommended practices for positioning the patient in the perioperative practice setting” recommends that jewelry be removed before positioning and transfer activities if the piercing or piercing accessories will cause “injury or interfere with the surgical site.”2 (p 428) Safe movement also avoids potential for sheering injury.

Another concern is pressure at the site of the implant, which could have a negative effect not only on the integrity of the skin,2 but also on interior tissue. The results from pressure at the implant site may not be immediately visible because pressure on the site will initially manifest in the deeper tissue. Thus, the direct pressure on interior tissue becomes the real threat to patient safety. When determining a patient’s level of risk for skin breakdown, health care providers should assess the length of time the area will be under direct, sustained pressure and the patient’s pre-existing conditions such as body mass index, nutritional status, and whether the pierced site is completely healed.4 

Potential burns 

Trans-dermal and micro-dermal implants also pose burn risks if patients are not properly grounded when electrocautery is used during surgery. The risks associated with alternate site burns are minimized when using newer isolated generator technology (i.e., return electrode monitoring), which removes the ground as a reference and disables the active electrode if a disturbance in flow of current is detected.3,5 However, this technology will not prevent a burn if direct contact is made with the active electrode (e.g., during tonsillectomies where lip, cheek, or uvula jewelry may be present).

Whether using ground referenced or isolated generator technology, a small amount of radio frequency current is emitted from the electrode cord when activated. This leakage of current can be concentrated to one area when the cord is looped or wrapped around an object to secure the cord to the drapes. If this area of concentration is near the pierced jewelry or trans-dermal or microdermal implant under the drape, that current could pass directly over the jewelry and increase the patient’s burn risk.3 


The question of how to best protect patients with dermal implants who present for an operative or other invasive procedure is not specifically addressed in literature. Perioperative professionals can reference AORN Perioperative Standards and Recommended Practices6 for how to provide overarching support in the management of patients with piercings. When caring for patients with dermal implants, special attention should be paid to risks posed during positioning, patient transfer, and electrocautery use.


  1. Dermal implants. The Sharp Practice. 2008. http://www.sharp-practice.com/bodypiercing/dermal-implants.html. Accessed August 30, 2012.
  2. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:421-444.
  3. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:99-118.
  4. Halliday KA. Body piercing: issues and challenges for nurses. J Forensic Nurs.2005;1(2):47-56.
  5. Pyrek KM. Education in electrosurgery technology is key for patient safety. July 1, 2002. http://www.infectioncontroltoday.com/articles/2002/07/education-in-electrosurgerytechnology-is-key-for.aspx. Accessed August 30, 2012.
  6. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012.

Read this article in the October Connections issue.


Guidelines for Perioperative Practice


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