Above-the-Neck (Oro-Facial) Anatomy for Piercers

Course Focus • Overview of the anatomy we commonly pierce • Areas safe to pierce • Risky anatomy to avoid • Practical and useful hints and tips Elayne Angel: What Are My Qualifications? • I’ve been piercing professionally since the 1980s • I wrote The Piercing Bible • I’m credited with the popularity of tongue and other piercings • I’ve co-taught this course numerous times Disclaimer • I am a piercer, not a medical or dental professional Taking this course does not mean: • That I have taught you to pierce • That you have apprenticed under me • That you know all there is to know about oro-facial anatomy Betsy Reynolds • I am an oral biologist who has taught graduate and post-graduate classes in the dental sciences for over twenty years • I am not a piercer but I am an advocate for the piercing industry Overview of Topics Basic anatomy of head and mouth with piercings of: • Ear lobe • Ear Cartilage (including variations) • Eyebrow (and nearby facial placements) • Nostril • Septum • Tongue and other intra-oral placements • Lip/ • Cheek

Anatomical Considerations • There is a network of nerves, blood vessels and lymphatic vessels throughout the head & neck • The larger of these tend to be located close together • They are also commonly situated in protected locations (behind bone, tendon, muscle, etc.) Piercing consideration: NEVER pierce behind such structures!!! • Fortunately, blood vessels and nerves tend to slide or roll when grabbed or poked at (which makes drawing blood a challenge at times) • Piercers routinely puncture the smallest and most peripheral of the vessels and nerves with no ill effect whatsoever Blood Supply to the Head and Neck Area Arteries carry blood from the heart to the tissues of the body; the blood is freshly oxygenated and bright red • The principal arteries that supply the head and neck are the Common Carotid Arteries • They run on both the right and left sides of the neck Veins carry the blood from the tissues TO the heart following the same general pathway of the arteries • They carry DE-OXYGENATED blood back to the heart Piercing consideration: Avoid the pterygoid plexus—a concentrated group of veins located behind the last upper molar

Head and Face Anatomy CAVERNOUS SINUS • MANY veins of the face, particularly from the lip and nose, drain right into the brain • Because of its connections with the facial vein it is possible to get infections in the cavernous sinus from an external facial injury within the danger area of the face Piercing consideration: An infection of the cavernous sinus can go right to the brain

Lymphatic System • Disease-fighting cells move about the body in the blood and in a clear, yellowish fluid called lymph • The lymphatic system is the “garbage collector” • Sucks up metabolic waste and toxins from the extracellular fluid of every organ • Lymph flows through vein-like tubes that enlarge in places to form LYMPH NODES • Lymph vessels follow the vascular system (veins and arteries) • There are more lymph glands in the head and neck that any other part of the Considerations: • Feel (‘palpate’) for any swelling or hardness in the area of the piercing prior to the procedure • When swelling appears suddenly and is painful, it is most likely a result of injury, inflammation or infection • Some lymph node swelling post-piercing is normal (indicates the body is ‘healing’) • Inflamed but not painful lymph nodes can mean trouble (potential malignancy)— especially if the node is ‘fixed’ (non-moveable)

Nerves of the Head and Neck

Facial Nerve • Like lymphatic vessels, nerves ‘run’ with blood vessels throughout the body • Where there is a nerve, there will be a corresponding vein and artery • VAN = Vein, Artery, Nerve • Facial nerve allows for facial expression • The Facial nerve plays a role in taste, hearing, balance and tear production Piercing consideration: If damaged, Bell’s Palsy can result Trigeminal Nerve • The Trigeminal nerve provides sensation to all of the teeth • Carries taste fibers to the tongue • Innervates the muscles responsible for chewing and swallowing Piercing Considerations: • If a nerve is severed, loss of sensation and/or function occurs • Sometimes sensation/function returns; sometimes it does not • If a nerve is traumatized or irritated by piercing, pain, tingling, and/or numbness can occur

Skin • Largest organ in body • Weighs 6-9 lbs. (3-4 kg.) • Makes up approx.16% of body weight • Comprised of layers: Dermis and Epidermis Keratinized Epithelium (Skin) Functions • Barrier to outside environment • Maintains water balance and temperature • Protects body from injury and infection • Excretes various waste substances • Sensation Strata: Skin Layers • Epidermis--epithelial outer layer • Dermis--dense fibrous connective inner layer • Subcutaneous Layer--hypodermis Piercing Considerations • Always thoroughly inspect the local anatomy before piercing • Look! Bright light (transillumination) can help • Palpate! Feel for veins, vessels, any structures you can/should avoid with

Techniques and Tips for Common Above-the-Neck Piercings

EAR LOBE PIERCINGS • Serious consequences (such as keloid formation) can result from ear piercings Ear Anatomy The external ear consists of the flared portion (‘auricula’ or ‘pinna’) and the external acoustic meatus (‘ear opening’) It is composed of a single thin plate of cartilage (with minimal blood supply) which is covered by skin—the ear is connected to the skull by ligaments and muscles On the surface of the ear, the skin is covered by fine hairs, sebaceous (‘oil’) glands and sweat glands The lobule (‘earlobe’) is the one part of the human auricle that normally contains NO cartilage • The lobule is a wedge of fibrous and adipose tissue (‘fat’) covered by skin • There are many normal variations to the size and shape of the earlobe There are two sets of muscles for the ear: • The extrinsic muscles (connect the ear to the skull and scalp and move the auricular as a whole) • The intrinsic muscles (extend from one part of the auricle to another) Blood vessels in the ear are usually small, though there are arteries • The anterior auricular from the superficial temporal artery on the front of the ear • The posterior auricular from the external carotid, on the back of the ear • Auricular branch from the occipital artery • There are also corresponding veins Earlobe Piercing Placement Earlobe piercings are prone to problems only when the placement is extreme • The bottom of the lobe (too little tissue) • The juncture of the earlobe and face (area of large blood vessels) Piercing considerations: • Ask your client during marking if (s)he has a particular vision for the piercing (including future stretching) • ‘Cheating’ the placement a bit higher may be helpful if future stretching is a consideration

Ear Cartilage Anatomy The entire cartilage framework is fed by a thin covering membrane (‘perichondrium’)—an infection of this dense, irregular connective tissue is called ‘perichondritis’ VERY IMPORTANT: Cartilage lacks vascularity (‘blood supply’)—majorly affects healing as an adequate blood supply in an area of trauma (such as piercing sites) is extremely critical!!!!! Ear Cartilage Placement • Acceptable to pierce at the base of the helix where it joins the scapha (the flatter portion of the cartilage from which the helix curves); often, these piercings are referred to as ‘helix’ piercings but are technically scapha piercings • Piercing can pass through the helix (curled outer rim of the ear) IF it is pronounced enough • Do NOT try to sidestep the cartilage by piercing a pinch of skin close to the edge—the piercing will tent to migrate or reject; additionally, the pressure from hard cartilage from behind them pushes the jewelry out • NOTE: If a piercing is so superficial that a 6 mm (1/4 inch) diameter ring fits, the placement of the piercing is too shallow Ear Cartilage Risks • Piercings of the ear cartilage are prone to disfigurement if a serious infection develops • The cartilage can collapse, causing a “cauliflower ear” appearance • Perichondritis can cause severe damage to the ear structure if it becomes chondritis -- infection of the cartilage itself • Keloid scarring can form as late as a year after injury Ear Anatomy/Function • The pinna projects from the side of the head to collect the vibrations of air created by sound • The external acoustic meatus leads inward from the bottom of the auricular and conducts the vibrations to the inner ear Piercing consideration: Large punches or stretches of the cartilage can result in diminished function (hearing loss) unless plugs (versus eyelets) are worn Ear Procedure • Piercing needle: up-gauge (vs. same-gauge) • Intended to promote the comfort and healing of the piercing by allowing your body to form a small cushion of scar tissue • The jewelry does not press directly against the dense cartilage • The piercing may bleed a little more when it is performed with a larger needle Cartilage Tips (For Ear and Nostril Cartilage) Compression Technique • To avoid hypertrophic scarring during healing • As soon as the piercing is done and the jewelry in place, use sterile gauze or cotton swabs to apply firm pressure on both sides of the piercing • For fifteen seconds to a minute, as if attempting to stop bleeding (even if no blood is present) • Reattaching the surface tissue to the cartilage underneath helps reduce the likelihood of localized ear cartilage and nostril bumps

Eyebrow Anatomy • Eyebrow piercings are sometimes rumored to cause facial paralysis (HIGHLY unlikely) • The main nerve in this region is the Trigeminal nerve • Smaller nerve fibers provide sensation (not motor) function • To impact one of these nerves, a piercing would need to be placed far deeper than normal, or unusually close to the nose or temple • Even then, numbness would be more likely, not paralysis Placement • Placing enough tissue is important-very close to 10 mm (3/8”) minimum • Complications often occur if the brow is not well padded, which causes excessive pressure of jewelry against the bone • Piercings all along the brow may be possible • If the tissue is tight and difficult to pinch, it is less likely to heal successfully • If the skin cannot be pinched up and rolled, it is harder to avoid piercing other structures such as blood vessels Eyebrow Piercing • A horizontal alternative is less common but gaining in popularity • Piercing is placed slightly above or below the eyebrow hairs or directly within the brow and is angled to suit the anatomy • When the tissue is pliable, this piercing can be successful Eyebrow Piercing Tips • Eyebrows can be vascular; they may swell, bruise or bleed (tell clients before you pierce) • Following the procedure, a small percentage of eyebrow piercings swell considerably • If this occurs, supply ice packs post-piercing • Place in a glove or wrap in dental bib or paper towel • Piercings that bleed under the surface can leave a colorful bruise • Arnica montana may help to diminish the discoloration—this natural herb is available in cream or gel and should be applied to the bruised area but NOT directly into the wound

Other Facial Piercings • Other piercings are done in the region surrounding the eyes • Not as easy to heal • Fewer people are anatomically suited for them WARNING: If there is not enough padding between the jewelry and the structures beneath, direct pressure can cause diminished blood supply to the bone—leading to loss or bone density and possible bone death (‘necrosis’); DO NOT PIERCE IF THERE IS NOT ENOUGH PLIABLE TISSUE!

Myohyoid Muscle (the floor of the mouth): • The myohyoid muscle is a thin muscle that makes up the floor of the mouth • Like all muscle tissue, the myohyoid cannot ‘regenerate’ (grow back) if it is damaged— piercing this area should be discouraged

Nose Anatomy • The nostrils are comprised of plates of cartilage • The interior surface of the nostril is mucous membrane • Cilia (tiny hairs) and mucus line the inside wall of the nasal cavity • They trap and remove dust and pathogens from the air as it flows through the nasal cavity (the nose functions as a filter) • The cartilage of the nose is covered by 10 small muscles and is contained within skin which houses hair, sebaceous glands and sweat glands Vascularity of the Nose: • Dorsal nasal artery • Lateral nasal artery • Angular vessels • Columellar artery Nerve Supply to the Nose • The olfactory bulb and associated fibers originate in the brain and perforate the skull directly into the nasal passage to deliver the sense of smell • This is the ONLY one of the five senses that DIRECTLY connects to the brain (because of this, infections within the nasal passages can potentially be transferred directly to the cranial cavity fairly easily) Nostril Piercing Placement • Traditional nostril placement is in the crease at the side where the nose naturally flares (the supra alar crease)--jewelry rests well in the natural niche • A big smile accentuates the supra alar crease and helps to locate the piercing site • This area is often thinner than the rest of the nose so it may be less tender and heal faster than other placement sites Nostril Piercing Procedure • Compression technique for nostril piercing • One swab on the inside and one on the outside • PRESS firmly for 15-60 seconds to reattach the surface tissue to the cartilage underneath High Nostril Piercing Placement • Safe so long as the placement is not against the bone (which is easy to locate) • Can be harder to care for and keep clean—requires a dedicated client Septum Anatomy A traditionally placed septum piercing is NOT in the cartilage—it rests in a ‘sweet spot’ in the thin, soft membranous tissue just below the septum cartilage (but not above the skin) On most individuals, the piercing will be well up into the nose (toward the lip) When viewed from underneath, the visible tissue is cartilage and should be avoided The piercing should be above this cartilage and below the septum cartilage Evaluate the Septal Anatomy: • Are the nostrils of equal length? • How is the overall symmetry? • Is there any septum deviation? If so, how severe? • Has there been a previous piercing in the area? Some deviation of the septum is not unusual There is often a raised ridge on one side and a concave crease on the other where the piercing should be placed Report any findings to the client In the case of a deviated septum, there is a tendency for the piercing to be askew—show the client the anatomical irregularities (for severe deviation, avoid piercing; if the deviation is mild, a septal piercing may be possible but challenging Septum Piercing Placement • Visually inspect the area • Palpate it to check for the gap between the cartilage and nose surface tissue • The septum’s ‘sweet spot’ does not necessarily correlate with the overall dimensions of the nose (a large nose does not necessarily have a large sweet spot!) Septum Piercing Marking • A well placed dot, lined up with the guideline on the nose surface, and just in front of the crease Septum Piercing Procedure • Tissue manipulation is probably the most important technique to improving septum piercings! • Place the receiving tube on the exit side over the dot • With a clear Pyrex NRT, you can see when the dot is centered in the lumen of the tube • Use the padded end of a cotton swab on the entrance dot Septum Piercing Tips: • Adjustability: Whether the septum is deviated or the piercing simply turns out crooked, using clean or gloved hands, the client can twist the jewelry in the desired direction • If done frequently (10-20 times daily) during the first few weeks of healing, the piercing can be coaxed into the desired position IF the piercing was placed in the sweet spot

Oral Anatomy and Piercings Oral Piercing Risks: Infection is NOT the most common complication of oral piercings The human mouth is NOT prone to infection due to high blood flow, extensive lymphatics and the protective effects of saliva (NOTE: diminished salivary flow will hamper healing) The biggest danger (from common placements) is damage to teeth, gums, and oral structures from jewelry The delicate enamel on teeth can get cracked or chipped if jewelry is played with Biting or clicking jewelry often or hard—for fun or by accident—will result in wrecking ball fractures (small cracks in the teeth) Over time, continuous pressure from hard metal can damage teeth and/or diminish the density of the underlying bone Gum recession is caused by jewelry that is too big or improperly placed, or from excessive rubbing of hard metal against the delicate soft tissue of the palate or gums IMPORTANT: Enamel, bone and gum tissue do NOT regenerate!!!!! • Damage to these oral structures is irreversible and can be serious • ANY possible repairs can be costly and painful • Educate your clients about this—before you pierce them!

Proper oral hygiene is important to regaining and maintaining a well-functioning sense of taste According to study investigators, after only two weeks of tongue cleaning, taste sensation significantly improved--Quirymen M et al; J Clin Periodontol 2004; 31: 506-510 Cleaning the tongue is a vital component to comprehensive oral hygiene care—both professionally as well as in the home setting

Oral Anatomy: Mucosa The mouth, (as well as nose, sinuses, eyelids, throat, and digestive tract) are lined with mucous membrane This tissue that is similar in composition to external skin It is softer/not as tough Has ability to stretch and compress Has many mucous glands that keep its surface moist A healthy mouth: clean teeth, coral pink gums, then bright red line—gums calloused/ keratinzed The mucosa is more vascular and movable, but the gums stay put Lining Mucosa • Lines most of the oral cavity • Composed of stratified (“multi-layered”) epithelium overlying a connective tissue layer—the lamina propria, separated by a basement membrane • Generally, heals quickly Specialized Mucosa Lingual papillae make up the specialized mucosa of the tongue surface There are four types: • Fungiform papillae* • Foliate papillae* • Circumvalate papillae* • Filiform papillae * has taste function Fungiform Papillae • Found on the body of the tongue • 1mm in diameter raised red dots • Taste buds are located in the superficial portion of the papillae Foliate Papillae • Appear as 4-11 vertical ridges or folds on the lateral surface of the posterior tongue • Contain MANY taste buds Circumvalate Papillae • 7-15 “large” (3-5 mm diameter) papillae in an inverted V-shaped row facing the throat • Hundreds of taste buds surround the base of each papillae in a trough lined by the surrounding tongue surface

Filiform Papillae • Filiform are the most common papillae • Fine, pointed cones 2-3mm tall with the tips pointed toward the back of the throat (may aid in swallowing) • NO taste buds! “What if I Pierce a Taste Bud?” • Circumvalate: easy to avoid—large, and far back • Foliate: far back and on the sides • Fungiform: there are many—won’t prevent the ability to taste Tongue Anatomy • The tongue is a muscular organ, richly supplied with blood vessels and nerves • There are two parts to the tongue—the one we deal with: • Oral part (front two-thirds of the tongue) that lies mostly in the mouth • The tongue’s primary blood supply is from the lingual artery—a branch of the carotid artery • There is secondary vascular supply to the tongue from other arteries Tongue Functions • Manipulates food for chewing and swallowing • Primary organ of taste • Assists in speech Placement • Note whether the midlines (top and bottom) are in the CENTER of the tongue • This can affect placement if one is off-center, which is not unusual--tell your client what you see • Look at lingual frenulum for “cord” vs. “web” • It is GOOD to pierce along the center (median groove or sulcus), on top, and bottom to avoid damage to taste buds, muscle, nerves, and blood vessels, which are off to the sides • A central position in the mouth is popular because it minimizes visibility and keeps the jewelry away from the teeth, but still allows for fun and function • Do not to try to pierce through the lingual frenulum, the webbed portion underneath • Where it is merely a little cord-like, the body will push the piercing slightly off to one side • If concealment is important, it is not necessary to place the piercing at the very back of the tongue—the piercing will likely be more uncomfortable and will be prone to more swelling • If placement is vertical with the tongue sticking out, when in the mouth, the underside is often a little more forward than the top • The top of the will slant slightly back toward the highest part of the upper palate, where there is most space for it in the oral cavity • Prevents the jewelry from standing straight up in the mouth, which could jam the bottom ball against the lower palate • Don’t make angle too steep, or the bottom ball will rub behind the lower front teeth Tongue Jewelry • Acrylic barbell ends are softer than metal—they are cheaper and easier to replace than a tooth! • If the client is concerned about oral health and has extensive dental work, acrylic is suggested • A disc on the bottom is comfortable for many piercees • Add approximately 1/8” - 1/4” (3.2 - 6 mm ) extra post length to allow for swelling • Overly long bars are a liability and can cause damage • Once the swelling is gone, the jewelry must be changed for a shorter post (do you have a “downsize policy”?) • Internally threaded jewelry allows for easier insertion and removal Tongue Piercing Tip • Piercing with client seated (as opposed to reclining) reduces risk of choking hazard • Tilting the chin slightly toward chest may help extend the tongue Alternative Tongue Piercing Placements • Non-midline tongue piercings are tricky—avoidance of blood vessels and nerves is critical! • Transverse (horizontal) tongue piercings are DANGEROUS!!!

Salivary Glands Produce SALIVA • Lubricates • Digests (“amylase”) • Buffers • Antimicrobial (“lysozyme” & “lactoferrin”) • Aids in remineralization Major Salivary Glands • Submandibular (also known as “submaxillary”) gland • Sublingual gland • Parotid gland Submandibular Gland • Provides 60-65% of saliva volume • Wharton’s (or “submandibular”) duct on the floor of the mouth opens into the oral cavity via the sublingual caruncle Sublingual Salivary Gland • Smallest major salivary gland (almond sized) • Provides 10% of salivary volume • Short ducts combine to form the sublingual (or Bartholin’s) duct • Mainly opens via the sublingual caruncle but other openings may be present along the sublingual folds • MANY vital structures are right under the tongue—another reason to avoid piercing the floor of the mouth • Myohyoid muscle is just a little hammock of muscle under the chin • The floor of the mouth is made up of MUSCLE—no bone! Piercing Considerations • Thou shalt not pierce through or near the salivary ducts! • Saliva is the BEST healing aid • Clients with decreased salivary flow will have a very difficult time healing (MANY drugs cause dry mouth) • Saliva contains organic compounds that are mostly proteins or peptides that contribute significantly in protecting us • Nutrients needed for the synthesis of these compounds pass from the capillaries surrounding the glands into the acini cells • The lingual frenulum may not be sufficiently pronounced in all people wishing to have a frenulum piercing • If too little tissue is pierced, migration and rejection will likely occur • Avoid piercing into the deeper structures of the tongue or floor of the mouth! Parotid Gland & Duct 1. Largest encapsulated salivary gland 2. Provides 25% of saliva 3. Parotid duct opens opposite the 12-year molar Fordyce’s Spots • In the labial and buccal (cheek) lining mucosa, Fordyce’s spots or granules can be found • They are generally yellowish in color and represent misplaced sebaceous (oil) glands • Not a problem per se if you pierce through, but avoid if you can

Cheek Piercing Considerations • A dangerous placement due to the location of the parotid ducts • Best to place the piercing close to the mouth, in front of the molars for safety

Lip/Labret Piercing Pronounced “la-bret” with a HARD “t” at the end-- NOT “la-bray” Discuss potential risks to oral structures FIRST! Informed consent release Lip Anatomy • Lips are multifunctional—they surround the entrance to the oral cavity; provide sensory information about food; support eating, drinking and speech; and provide changes of facial expression Different surfaces of the lip area: • Skin of the facial surface is covered with ‘keratinized’ epithelium (tougher) • A mucous membrane lines the inner lip • The vermillion border (pigmented portion) is thin and has many capillaries (blood vessels) close to the translucent surface • The skin of the lip is made up of 3-5 cellular levels (much thinner than skin located elsewhere on the face)—making this area somewhat fragile • No protective hair, sweat glands, or sebaceous glands are found on the lips • The principle lip muscle is the orbicularis oris—a concentric band of muscle that is suspended from other surrounding muscles; forms a ‘sphincter’ around the mouth • There are six other muscles associated with the lip • Sensation in the upper lip provided by the infraorbital nerve as well as the trigeminal nerve • The lower lip is innervated by the mental nerve • The perioral muscles are innervated by the facial nerve • Blood supply for the lips is provided by the lower branches of the facial artery—the facial artery is a branch of the carotid artery Piercing considerations: • It is safest to avoid the “vermillion border” (pigmented area) • Place so the front and back of jewelry will rest naturally and comfortably framing the mouth • If client plans to switch between ring- and stud-style jewelry after healing, the angle and depth of the piercing may be affected Labret Jewelry • A jewelry option is a circular barbell, as it has ability to change diameters (bigger and smaller) without changing jewelry • Helps to avoid jewelry contact with teeth or gums • Can be widened to “c-shape” to resemble a vertical Lip Alternate Placements • Upper Lip Side (‘Monroe’, ‘Madonna’, or ‘ChromeCrawford’) o May take longer to heal due lip movement • Philtrum piercing in the natural divot (‘infranasal depression’) between the mouth and the nose Lip/Labret Piercing Tip • A small percentage of lips (usually upper lip) swell excessively right away • Change out the jewelry using a taper before client leaves if jewelry is too tight or small • If you can see there will be a problem, don’t wait for them to come back with jewelry embedded •

Marking Tips • Explain to the client any anatomical irregularities you see that cause you to place the piercing in a non-standard or off-set position • Asymmetry, mole, scar, etc. • Sometimes it is appropriate to decline

Tissue Manipulation • Utilize the time to assist client with slow, deep breathing and relaxation • Can call it “massage” for eyebrow, navel, or ear • Best to term it “tissue manipulation” for nipple or • Pinch and roll the tissue in the direction the tissue will be held or clamped to prepare the area, and the client for the piercing • Increases circulation and pliability • Helps to form the tissue into the right shape for the piercing, and stabilizes it • Increases client comfort Tissue Manipulation for NRTs • Helps to seat the receiving tube on the exit side more securely • Use cotton swab on one side (where the PN will go) and place the tube at exit • Massage the tissue, pressing gently; use a tiny circular motion

General Piercing Tips IMPORTANT: Try to make one single motion for the piercing, and one single motion for the jewelry transfer • Don’t wiggle, scoot, or stop and start • The more smoothly you work, the more comfortable for the piercee

For body piercings, use of sterile saline wipe after piercing soothes and cools--helps to clean the area and is soothing

Size Matters! • Stocking only “every other” size will result in some piercees wearing ill-fitting jewelry! • It is important to have all sizes necessary to accommodate the range of human anatomy • Avoid “standard” sizes and use what fits each individual client • For some piercings such as labret, “approximate” lengths are highly unsuitable

Final Disclaimer I don’t know all there is to know about piercing When you think you do, it’s time to find a new field Keep learning

Where to Get More Information • APP Conference courses • Networking/sharing with other piercers • Read The Piercing Bible • APP Manual • Email me: [email protected]