Infections Associated with Body Modification

Journal of the Formosan Medical Association (2012) 111, 667e681

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REVIEW ARTICLE Infections associated with body modiﬁcation

Samson Sai-Yin Wong a, Sally Cheuk-Ying Wong b, Kwok-Yung Yuen a,* a Department of Microbiology, Research Centre for Infection and Immunology, Faculty of Medicine, The University of Hong Kong, Hong Kong b Department of Microbiology, Queen Mary Hospital, Hong Kong

Received 30 August 2012; received in revised form 10 October 2012; accepted 25 October 2012

KEYWORDS Although exact statistics are lacking, body modifications for cosmetic purposes are performed body modification; in many countries. The commonest forms include tattooing, body piercing, and breast and body piercing; facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, breast implants; mesotherapy are also practiced in many countries. Infective complications of these procedures mesotherapy; include local infections, transmission of bloodborne pathogens (viral hepatitis and human tattooing immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures. Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Introduction subdermal and transdermal implantation, and breast augmentation, to more drastic procedures such as tongue Body modification or body art for nontherapeutic purposes splitting, genital modification, and gender reassignment encompasses a vast variety of procedures, ranging from surgery. There are few formal statistics on the prevalence common procedures such as tattooing, body piercing, of body modification in most parts of the world. In a study of undergraduates in the United States, the prevalence of body piercing and tattooing was found to be 51% and 23%, respectively.1 In Europe, the prevalence of tattooing has * Corresponding author. Department of Microbiology, Research e Centre for Infection and Immunology, Faculty of Medicine, The been reported to be 6 12% in different studies, and that of 2,3 University of Hong Kong, Hong Kong. body piercing about 20% in some studies. Similarly, the E-mail address: [email protected] (K.-Y. Yuen). incidence or risk of infective complications following these

0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2012.10.016 668 S.S.-Y. Wong et al. procedures is unknown. This is due to the fact that there is metallo-beta-lactamase-producing Enterobacteriaceae had no information on the denominator of persons who have received prior medical care in the Indian subcontinent.45 received these procedures, and that cases reported in the literature tend to be isolated case reports or well- Tattooing documented outbreaks. The vast majority of individuals who went for tattooing or body piercing had not considered In the process of tattooing, colored inks are introduced the potential health risks prior to the procedures.4 In most mechanically into the skin dermis by electrically driven countries, practitioners of body modification and body art needles. Local and systemic health problems are common parlors are not strictly regulated by law, and therefore after tattooing, which persist even for weeks after the stringent adherence to the recommended infection control procedure.2 Infective complications may result from the practice is sometimes doubtful. Persons embracing body cross-contamination of inadequately sterilized equipment modifications sometimes also engage in other risky behav- and contaminated tattoo inks. Reported infections, which iors such as illicit drug use and alcoholism, which may e were sometimes associated with outbreaks in the tattoo predispose them to other infective complications.5 7 recipients, include tuberculosis (lupus vulgaris), leprosy, Body modification procedures can be complicated by verruca vulgaris and verruca plana due to human papillo- local pain, inflammation, infection. Circumstances predis- maviruses, zygomycosis, community-associated methicillin- posing individuals to infections after body modification are resistant Staphylococcus aureus, and atypical mycobac- manifold. Various microbial and environmental factors e e teria, especially the rapid growers.10 13,46 53 Noninfective contribute to the transmission of microbial pathogens causes of local skin reactions to tattoos, including allergic, during body modification procedures. Since these proce- granulomatous, and lichenoid reactions or coincidental dures inevitably involve breaches in the skin or mucosae, lesions such as malignancies, should also be considered as pathogens can be introduced from the normal flora colo- differential diagnoses.54 nizing the surfaces or from exogenous microbes such as Exposure to bloodborne pathogens poses a major infec- contaminated instruments, jewelry, and disinfectants. tious risk to persons receiving tattoos. Although syphilis These infecting organisms can sometimes cause infections used to be a common infection transmitted during tattoo- in distant organs. Organisms such as Pseudomonas aerugi- ing, it is relatively uncommon nowadays. One of the largest nosa and atypical mycobacteria are ubiquitous in the outbreaks of HBV infection affected 34 persons of whom 31 environment. Their resistance to and ability to contaminate were tattooed by one artist and three were secondary low-level disinfectants and antiseptics have been well cases.55 Epidemiological studies have shown tattooing to be documented.8 Other major concerns are bloodborne a risk factor for HCV infection, and a dose-related response infections such as viral hepatitis and human immunodefi- was noted.56,57 In contrast to HCV infection acquired from ciency virus (HIV) infection. High-level viremia can be blood product transfusion, that acquired from tattooing is encountered in patients with hepatitis B virus (HBV) and HIV often subclinical, probably reflecting the smaller inoculum infections, and even minute contaminations with their of viruses transferred in such settings.58 Tattooing has been blood and body fluids can result in infections if disinfection shown to be a risk factor for HIV infection in some studies, of the environment and instruments is inadequate. The but not in others, possibly due to the confounding effects of prolonged survival of hepatitis C virus (HCV) in the envi- e various at-risk behaviors in this group of individuals.59 61 ronment may also contribute to its transmission under such However, a recent case of HIV infection in an Australian circumstances.9 tourist after receiving tattoos in Bali again raised the In many countries, body modification procedures per- possibility of HIV transmission in such settings.62 formed in parlors are not subjected to strict hygienic regulations. The majority of these “minor” procedures are performed in commercial premises or by unlicensed Body piercing personnel, sometimes without strict adherence to infection control guidelines. Sterilization and disinfection of instru- Body piercing involves puncturing of the skin or mucosae ments between clients, choice and maintenance of chem- with subsequent insertion of foreign bodies, such as rings, ical disinfectants and antiseptics, and adoption of bars, or other jewelries. In some procedures, the cartilage a particular infection control practice (such as mainte- is also pierced, as in case of “high piercing” of the ear nance of a sterile field, prevention of cross-contamination, involving the cartilage of the pinna. Common sites of and disposal of biohazardous wastes) often depend on the piercing include ears, eyebrows, lips, navel, nipples, geni- conscientiousness of the premise owners and operators. A talia, nose, tongue, and other parts of the oral mucosa. As number of outbreaks related to such procedures have been in the case of tattooing, body piercing can be associated reported in recent years (Table 1).2,10e44 As a form of with transmission of bloodborne pathogens.63e65 Local “medical tourism”, consumers are often receiving body inoculation of pathogens has likewise resulted in the modifications in overseas countries where the costs are transmission of tuberculosis (lupus vulgaris) and lower. Some of these medical tourism destinations and tetanus.66,67 Bacterial infections of the skin and soft tissues institutions may have less stringent levels of infection tend to be commoner in body piercing than in tattooing control, which might have explained the occurrence of because of the greater degree of tissue damage, presence infection outbreaks among some of the recipients.44 A more of deeper wounds, and placement of foreign bodies recent concern over medical tourism is related to the (jewelry) in the wounds in the former case. One important country-to-country transfer of multiresistant bacteria. For contributing factor is the long healing time of the wound example, many early cases of infections due to New Delhi after piercing, which may take up to 6e9 months in some netosascae ihbd modification body with associated Infections Table 1 Clusters, outbreaks, or case series of infections associated with body modification procedures. Procedure Year Location Number of patients Type(s) of infection Organism(s) Important Reference with infective involved epidemiological complications characteristics Tattooing NA Germany 7 Skin infection, Mycobacterium spp., Eyebrow tattoos by the 10 granulomatous and possibly related to same tattooist using purulent Mycobacterium Chinese tattoo ink; haemophilum onset days to weeks after tattooing; all had local lymphadenopathy Tattooing 2004e2005 Ohio, Kentucky, 44 Skin abscesses Community-associated 44 recipients in six 11 Vermont, USA methicillin-resistant unlinked clusters from Staphylococcus aureus 13 unlicensed tattooists in three states; onset within 4 e22 d; skin lesions were present in some tattooists Tattooing 2007e2008 Germany, Austria, 0.4% Pustular skin lesions NA 5997 individuals, as 2 Switzerland 1.0e1.2% Fever found from the Internet survey Tattooing 2007e2008 Minnesota, USA 6 Skin infection Mycobacterium All received tattoos by 12 chelonae the same tattooist; onset within 1e2 wk; environmental cultures negative; original ink not available for culture Tattooing 2011 USA 14 confirmed cases, 4 Skin infection M. chelonae, M. chelonae also 13 probable cases, 1 Mycobacterium isolated from suspected case abscessus unopened bottles of tattoo ink, with identical PFGE patterns as patients’ isolates Nipple piercing Literature Literature 12 Breast abscess Streptococcus Incubation period 2 wk 14 review review pyogenes, to 12 mo Streptococcus agalactiae, coagulase- negative staphylococci, anaerobes, M. abscessus, Mycobacterium fortuitum 669 (continued on next page) Table 1 (continued) 670 Procedure Year Location Number of patients Type(s) of infection Organism(s) Important Reference with infective involved epidemiological complications characteristics Ear piercing 2000 Oregon, USA 7 confirmed, 18 Auricular chondritis P. aeruginosa, S. 118 customers of a 15 suspected cases and ear lobe infection aureus from one case jewelry kiosk with ear lobe infection interviewed; improper practices noted; P. aeruginosa isolated from some of the staff and from an atomizer solution containing a mixture of quaternary ammonium and phenolic disinfectant, which had been refilled repeatedly; cartilage piercing associated with a higher risk of infection Oral piercing 1966e2009 Literature review 18 Infective endocarditis Endocarditis cases: No fatal cases reported 16 (8), Ludwig’s angina Neisseria mucosa (1), (2), tongue abscess (1), Haemophilus glossitis (1), cephalic aphrophilus (1), tetanus (1), cerebellar S. aureus (2), oral abscess (1), streptococci (3), lymphadenitis (2), Gemella (1); other sialadenitis (1), dental infections: oral abscess with neck streptococci, Eikenella extension (1), corrodens, chorioamnionitis (1) Lactobacillus, anaerobes, Actinomyces Oral piercing 2002e2003 Ghent, Belgium 13 History of symptoms NA 50 persons attending a 17 suggestive of infection dental clinic surveyed; average duration of

oral piercing 12.6 mo al. et Wong S.S.-Y. Oral piercing 2002e2008 Emergency 9926 Infection at piercing NA 24,459 with oral 18 departments, USA site piercing-related injuries Ear piercing 2003 New York, USA 15 Auricular chondritis P. aeruginosa Outbreak associated 19 with the same piercing facility; incubation netosascae ihbd modiﬁcation body with associated Infections period 1e13 d; risk factors for infection: helix piercing and use of aftercare solution; P. aeruginosa isolated from aftercare solution containing benzalkonium chloride Oral piercing 2005 Strasbourg, France 6 Any infective NA Questionnaire survey of 20 complication 201 individuals with current oral and perioral piercings only Oral piercing 2009 Bele´m, Brazil 16 Purulent discharge NA 39 university students 21 with oral piercing Breast implants, 1964e1991 Minnesota, USA 19 patients, 21 breasts Wound infection NA 749 cases recruited 22 cosmetic and from one institute: reconstructive cosmetic 532, reconstructive 125, prophylaxis 92; overall complication rate: reconstructive > prophylactic > cosmetic surgery Breast 1985 USA 8 Surgical wound Culture positive for Contaminated gentian 23 augmentation infection M. abscessus in ﬁve violet solution used for and face lift cases skin marking by the same surgeon; also culture positive for M. abscessus Breast implants, 2003 Israel 15 Surgical site infection Mycobacterium Associated with one 24 cosmetic jacuzzii single medical center and surgeon; incubation period 9e52 d. Same organism isolated from his whirlpool and hair- bearing regions of the skin Breast implants, 1999e2007 Denmark 63/80, 67/81, 35/38 Wound infection and NA Primary cosmetic 25 cosmetic women/implants periprosthetic implantation, 5130/ within 30 d, 3 y, and infection 10,252 women/ 5 y, respectively. implants; primary implantation for breast

anomalies, 243/388 671 women/implants (continued on next page) 672 Table 1 (continued) Procedure Year Location Number of patients Type(s) of infection Organism(s) Important Reference with infective involved epidemiological complications characteristics Breast implants, 1999e2002 Denmark 6/6 patients/implants Wound infection NA Cohort with 1946 26 cosmetic (initial); 4/5 patients/ persons, 3390 primary implants (subsequent) implantations, 454 2/2 patients/ implants Periprosthetic subsequent (initial); 0/0 patients/ infection implantations implants (subsequent) Breast implants, 1999e2004 Birmingham, UK 33 Surgical site infection NA 3002 women; onset of 27 cosmetic infection 22 Æ 12.8 d; Reduced risks associated with Mentor prostheses, and use of antiseptics and antibiotics; increased risk associated with use of drains Breast implants, 2005e2007 Genoa, Italy 16 Implant-associated S. aureus (4), 240 breast cancer 28 reconstructive infections coagulase-negative patients reviewed; staphylococci (2), onset 2e239 d; higher S. agalactiae (1), risk in patients Serratia marcescens receiving radiotherapy (2), Enterobacter after surgery cloacae (1), P. aeruginosa (3), Acinetobacter baumannii (1), culture negative (4) Breast implants, 1994e1998 Michigan, 28/21/12 patients in Surgical site infections NA 325 patients: 29 reconstructive Pennsylvania, implants/pedicle expander/implants, 79 Louisiana, USA; TRAM/free TRAM flap patients; pedicle TRAM Ontario, Canada groups, respectively flaps, 179 patients; free TRAM flaps, 67 patients Breast implants, 1999e2003 Denmark 29/30 patients/ Wound infection NA Cohort with 574/901 30 reconstructive implants (initial); 13/ patients/implants; al. et Wong S.S.-Y. 13 patients/implants 407/484 patients/ (subsequent) implants enrolled at 14/16 patients/ Periprosthetic initial implantation, implants (initial); 3/3 infection 302/417 patients/ patients/ implants implants enrolled at netosascae ihbd modification body with associated Infections (subsequent) subsequent implantation Injected PAAG 1997e? China 2 Infection NA 12 persons presenting 31 augmentation with complications mammoplasty after injection Injected PAAG 1999e2003 China 8 Infection NA 30 persons presenting 32 augmentation with complications mammoplasty after injection Injected PAAG 2000e2003 China 6 Infection NA 42 persons presenting 33 augmentation with complications mammoplasty after injection Injected PAAG 2005e2008 China 6 Infection NA 235 persons presenting 34 augmentation with complications mammoplasty after injection Injected PAAG 1997e2008 Iran 11 Infection and abscesses NA 98 persons presenting 35 soft tissue with complications augmentation after injection to face (73), breasts (16), and buttocks and legs (9) Injected PAAG 2001e2005 15 sites in Europe 4 Infection NA 251 persons enrolled 36 for facial augmentation Mesotherapy 2004e2005 Colombia 15 Skin infection M. chelonae (5), Incubation period 1e12 37 nontuberculous wk mycobacteria (6), culture negative (4) Mesotherapy 2004e2005 Colombia 70 Skin infection Culture positive in 29 Incubation period 8e60 38 cases: M. chelonae d; 66% of the cases (26), M. abscessus (2), received mesotherapy M. fortuitum (1) from one practitioner Mesotherapy 2004e2005 Peru 35 Skin infection Culture positive for Median incubation 39 M. chelonae in four period 16 d; cases epidemiologically linked to two mesotherapy training courses; M. chelonae isolated from a procaine vial Mesotherapy 2005 District of 14 Skin inflammation, Culture positive for All received injections 40 Columbia, USA ulceration, and M. chelonae in one case from the same person drainage at sites of at a private home; injection multiple breaches in safe injection practices

reported 673 (continued on next page) 674 Table 1 (continued) Procedure Year Location Number of patients Type(s) of infection Organism(s) Important Reference with infective involved epidemiological complications characteristics Mesotherapy 2006e2007 France 16 Skin infection M. chelonae and/or 105 patients exposed, 41 Mycobacterium 48 responded and frederiksbergense examined; incubation period 7e152 d; inappropriate cleansing of equipment with tap water; 100% similarity between patient isolates and tap water isolates of M. chelonae by PFGE Mesotherapy 2006e2007 France 16 Skin infection Culture positive in 12 All received 42 cases: M. chelonae (11) mesotherapy from the and/or same practitioner; M. frederiksbergense incubation period 7 (2) e152 d; M. chelonae identified from tap water Mesotherapy 2007 La Rioja, Spain 39 Skin infection Culture positive for 138 persons received 43 M. fortuitum in 12 mesotherapy by a cases single practitioner in the same salon; incubation period 1e254 d Liposuction and 2003e2004 Eastern USA, ex 20 Abdominal wall wound M. abscessus Received breast 44 other cosmetic Dominican Republic infections, breast augmentation and surgeries implant infections liposuction at a clinic in Dominican Republic; 45% of cases had procedures in the same clinic; incubation period 2e18 wk Z Z Z Z NA not available; PAAG polyacrylamide hydrogel; PFGE pulsed-field gel electrophoresis; TRAM transverse rectus abdominis musculocutaneous. al. et Wong S.S.-Y. Infections associated with body modification 675 locations.68,69 Ear piercing, for example, may lead to streptococci, S. pyogenes, Neisseria mucosa, Haemophilus infection and purulent discharge in 11e24% of the individ- aphrophilus, H. parainfluenzae, and Gemella, all of which uals (Fig. 1).70,71 The commonest pathogens involved are are part of the normal flora of the skin and S. aureus, Streptococcus pyogenes, and P. aeruginosa. oropharynx.16,81e86 Although current guidelines on antibi- Local abscess formation, toxic shock syndrome, and Four- otic prophylaxis against infective endocarditis do not nier’s gangrene (after genital piercing) have been reported specifically address body piercing, this prophylaxis has been to occur after piercing.14,72,73 Auricular chondritis caused suggested to be beneficial for intraoral piercing.87 Never- by P. aeruginosa is particularly difficult to manage, and high theless, the actual benefit of single doses of antibiotics can piercing of the ear pinna is a definite risk factor for the be nullified by the prolonged presence of mucosal wounds development of infection.15,19,74e77 Failure to disinfect the and foreign bodies in such settings. equipment properly and use of contaminated disinfectants have been found to be associated with P. aeruginosa chondritis after high piercing.15,19 The cartilage is an Breast augmentation procedures avascular structure; its infection is extremely problematic because systemically administered antibiotics may not Breast implants are used for either reconstructive surgery penetrate sufficiently well into the site of infection. or cosmetic purposes. The practice of injecting paraffin or Substantial necrosis and destruction of the cartilage can be silicone for this purpose is now obsolete because of the followed by deformities that require extensive recon- severe adverse reactions associated with it, such as mas- structive surgery to correct.78 Infections caused by rapidly titits, chronic inflammation (paraffinoma and siliconoma), growing mycobacteria following body piercing have also and discharging sinuses (Fig. 2). Nowadays, either fixed- been reported.79,80 volume silicone gel-filled implants or adjustable-volume Intraoral piercing poses some unique infective problems. saline-filled implants are most commonly used.88 In some The oral mucosa is heavily colonized by normal flora, and countries, soft tissue fillers such as polyacrylamide hydro- therefore invasive infections such as intraoral abscesses gel have also been used in breast augmentation procedures. and severe head and neck infections such as Lemierre’s Infective complications of breast augmentation may be syndrome can occur readily following oral piercing. Infec- classified into early and late infections. An overall inci- tive endocarditis is a major complication following piercing dence of 2.5% is often quoted, with acute postoperative of the mouth and skin. Reported pathogens include infection accounting for 1.7% and late infection for 0.8%.88 S. aureus, coagulase-negative staphylococci, viridans Infections that occurred after 1 month postoperatively are usually considered to be “late” infections. The risk of infection is much higher (up to 10 times) in patients undergoing reconstructive surgery as compared to in those undergoing aesthetic surgery because the former group of patients have a higher incidence of underlying (systemic and local) comorbidities, prior chemotherapy and radiotherapy, and a greater degree of local tissue trauma.22,89 The use of human acellular dermal matrix for cosmetic breast augmentation is associated with a higher risk of infection (relative risk 2.47) and other complications as compared to conventional submuscular reconstructions.28 The routes of infection for breast implants are similar to those for other implants such as joint prostheses and heart valves. Infection can result from the use of contaminated prostheses or saline (in the case of saline-filled implants), microbial contamination of the surgical site during surgery, or seeding from distant infective foci. On rare occasions, contaminated gentian violet skin-marking solution led to an outbreak of Mycobacterium abscessus surgical wound infection after cosmetic surgery.23 The breast glandular tissues are not sterile, as the ducts are colonized by normal flora of the skin. Such microbes are the commonest cause of acute postoperative infections. S. aureus is the predominant pathogen, with beta-hemolytic streptococci and fast growing atypical mycobacteria being important causes as well.24,90,91 Late infections are often secondary to episodes of bacteremia and distant infections; cases due to S. aureus, coagulase-negative staphylococci, P. aeruginosa, Pasteurella multocida, Bacteroides fragilis, Enterococcus,andKlebsiella pneumoniae have been reported.88 The optimal pharmacological prophylaxis of breast Figure 1 Cellulitis around the earlobe after ear piercing. implant infections is not completely clear, and current 676 S.S.-Y. Wong et al.

Figure 2 A 64-year-old lady had received bilateral breast augmentation surgery with silicone gel prosthesis in her early years. (A) She developed extensive inflammation, scarring, and cavity formation over bilateral chest wall with sternal and costal osteomyelitis. (B) Rupture of the prostheses was evident upon removal. (C) Histopathology of the surrounding tissues revealed multiple, large vacuolated areas (original magnification, 100Â). (D) Grocott stain of the tissues showed numerous septate branching hyphae (original magnification, 1000Â), culture of which yielded Aspergillus spp. practice varies greatly among different centers due to the augmentation were first observed in 1997.31 Since then lack of large randomized controlled trials. Local irrigation, a number of complications, such as multiple induration, using povidone-iodine, bacitracin, povidone-iodine/ palpable lumps, mastalgia, lactorrhea, disfigurement, cefazolin/gentamicin, or bacitracin/cefazolin/gentamicin, migration of implant, and infection, were reported.31e35,100 has been performed.92e94 Preoperative prophylactic anti- Infection has been quoted in most series as a complication biotics are useful for preventing surgical site infection in (incidence ranged from 4% to 27%), but its detailed course patients undergoing breast surgery.95 The most commonly and causative agents were not described. used antibiotics are penicillins with antistaphylococcal activities, first-generation cephalosporins, and beta- lactam/beta-lactamase inhibitor combinations; patients Mesotherapy, liposuction, tissue filler with beta-lactam allergy generally receive macrolides or injections, and other procedures clindamycin. The role of postoperative antibiotic prophylaxis in breast augmentation surgery is more contentious. In Subcutaneous injection therapy, also known as meso- some studies, no benefits have been found after giving therapy, using phosphatidylcholine or other agents (such as antibiotics for 3 postoperative days in primary or secondary isoproterenol), has become a popular method for body breast augmentation, whereas other studies have advo- contouring in some countries, although the efficacy of such cated the use of more prolonged postoperative prophylaxis procedures has not been confirmed scientifically.101,102 By in breast reconstruction patients who required implants, far, the commonest pathogens causing infections after especially in those who had received chemotherapy and/or mesotherapy are atypical mycobacteria, especially the radiotherapy after surgery.94,96,97 rapid growers such as M. chelonae and M. abscessus, and Injectable permanent soft tissue fillers, such as poly- outbreaks are being reported regularly.37e43,103,104 The use acrylamide hydrogel, for breast augmentation was first of contaminated injection materials and tap water for used in Ukraine, subsequently gaining popularity in China. cleaning instruments has been associated with outbreaks of The polymer is considered to be nontoxic, nonbiodegrad- infection.39,41,42 Similarly, the rapid growers are often able, and nonteratogenic.98 Some claimed that tissue involved in infections associated with liposuction.44,105e107 response to the polyacrylamide polymer is moderate to Indeed, a number of novel Mycobacterium species have minimal with little fibrosis, but others reported dense been described in recent years in cases of infections fibrous tissue formation with inflammation.98,99 In contrast acquired after body modification or cosmetic procedures, to the small amount being used in facial augmentation, such as M. cosmeticum, M. jacuzzii, M. massiliense, and large volumes (up to 200 mL or more) of polyacrylamide M. bolletii.24,108,109 In addition, other environmental hydrogel are used in breast augmentation. Adverse reac- pathogens such as Nocardia and Sporothrix schenckii are tions to polyacrylamide polymer following its use in breast associated with such procedures.110,111 It is therefore Infections associated with body modification 677 imperative that patients who have developed infection empirical antibiotics and/or drainage, often without after body modifications should be investigated for such microbial cultures. First-line empirical antibiotics with mycobacterial, nocardial, and fungal etiologies, in addition beta-lactam/beta-lactamase inhibitor combinations (such to routine bacteriological studies. as co-amoxiclav or ampicillinesulbactam) or first- and In recent years, the use of dermal filler injections for second-generation cephalosporins (such as cephalexin, soft tissue (especially facial) augmentation has gained cefazolin, or cefuroxime) should cover the common popularity in many parts of the world. Although the commensal flora, including staphylococci, beta-hemolytic procedure is generally safe, associated infective compli- streptococci, and some Enterobacteriaceae (especially in cations are not unheard of.112e114 Chronic mandibular the case of genital piercing). Infections in the oral cavity or osteomyelitis has been reported to complicate facial pelvic regions, or specific syndromes such as Lemierre’s augmentation using polyacrylamide hydrogel.115 Unlike in syndrome should be treated with antibiotics with anaerobic other conventional prosthesis-related infections, complete coverage (beta-lactam/beta-lactamase inhibitor combina- removal of the injected fillers may not be possible, and tions or adding metronidazole to the cephalosporin regi- hence a more prolonged course of antibiotics may be mens). Severe or systemic infections or those that do not necessary in some situations. respond to standard treatments should always be accom- More recently, new procedures have been used in some panied by appropriate microbiological investigations. This developed countries for their purported cosmetic or health is important not only for the diagnosis of fungal, nocardial, benefits. One example is the so-called “cell therapy”, and mycobacterial pathogens, but also for excluding which involves the injection of cells of animal or human antibiotic-resistant pathogens such as P. aeruginosa and origin or extracts of animal tissues. In addition to the lack community-associated methicillin-resistant S. aureus that of any scientific basis for their therapeutic claims, the is prevalent in many parts of the world. potential health risks of such “therapies” are unknown. Acid-fast staining, and mycobacterial and fungal Transmission of zoonotic pathogens is one theoretical cultures should be performed in nonresponding cases. Pus possibility, but a real threat is the transmission of bacterial specimens or skin biopsies should be performed in patients pathogens through contaminations during the procedure. In presenting with nodular or pustular lesions suggestive of a recent outbreak in Hong Kong, at least four customers atypical mycobacterial infections. Additionally, histological who had received “cytokine-induced killer cell therapy” examination of the biopsy samples is needed since some (intravenous infusion of the customers’ own leukocytes fungal or mycobacterial pathogens may require prolonged after a period of ex vivo incubation) at a beauty treatment incubation for growth or may not be readily cultivable in center developed severe septic shock caused by routine culture media. The presence of these microbes and M. abscessus.116 At least one patient died as a result of the the type of inflammatory response may help establish the infection. Although the exact mode of contamination preliminary diagnosis and guide empirical therapy. remains to be investigated at the time of writing, this Patients with suspected breast implant infections should incident highlights the importance of stricter public health undergo ultrasonographic or computed tomography exami- control on these potentially dangerous procedures. nation, and any collection should be aspirated for microbiological investigations, including Gram and acid-fast stain, and routine bacterial and mycobacterial cultures. General approach to diagnosis and therapy Surgical removal of the implant should ideally be performed, and a 2-week course of antibiotic has to be The presentation of body modification-related infections advocated.88 Antibiotics such as co-amoxiclav, ampi- falls into three major categories: infections caused by cillinesulbactam, or a first- or second-generation cephalo- bloodborne pathogens (mainly viruses such as HBV, HCV, sporin will cover most of the common pathogens, while and HIV); local infections at the sites of tattoo, piercing, antibiotics with antipseudomonal activities should be used surgery, or injections; and metastatic or disseminated for patients with documented P. aeruginosa infection. infections. Patients who had received body modifications Immediate reimplantation is not advisable. should alert the clinician to these associated infections. Conversely, in patients with aforementioned infections but with unexplained origins, body modification procedures Prevention and regulation should be enquired as possible predisposing factors. This is not only clinically important for the individual patients, but Preventive measures can reduce but not abrogate all the also significant from the public health perspective. Initial risks of infection associated with body modification. cases may represent the few most severe victims, and Infections by endogenous flora of the skin and mucosae further investigations and case findings may unravel a silent after body piercing cannot be prevented completely, given outbreak in the community. Prompt control measures by that the wounds take a long time to heal and that foreign the health authorities are crucial to prevent the occurrence bodies are present. Prevention of exogenous infections of new cases. requires proper skin antisepsis prior to the procedures, The clinical diagnosis of local or systemic infections is adequate disinfection of all instruments and the operating generally not difficult for most clinicians. The timing and field, hand hygiene, use of standard precautions, avoiding nature of specific microbiological investigations are crucial the presence of pet animals and plants in the premises, and for more serious cases. In otherwise uncomplicated infec- proper choice and maintenance of antiseptics, disinfec- tions, such as cellulitis or local abscesses, patients are tants, and sterilization techniques. Improper choices, frequently managed in the primary health-care setting with dilutions, and topping up of chemical disinfectants as well 678 S.S.-Y. Wong et al. as their use beyond the expiry dates constitute a recipe for with personal and family characteristics. Fam Med 2010;42: disaster. Contamination of disinfectants by environmental 273e9. bacteria is well documented, and such incidents can lead to 4. Huxley C, Grogan S. Tattooing, piercing, healthy behaviours e outbreaks of infections.8 P. aeruginosa is a frequent culprit, and health value. J Health Psychol 2005;10:831 41. although bacteria such as other Pseudomonas spp., Bur- 5. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behav- kholderia spp. (especially B. cepacia), Serratia marcescens, e 117 iors. Pediatrics 2002;109:1021 7. and atypical mycobacteria can also be involved. Atypical 6. Deschesnes M, Fine`s P, Demers S. Are tattooing and body mycobacteria can often be found in tap water, and the sole piercing indicators of risk-taking behaviours among high use of tap water for cleaning of mesotherapy instruments school students? J Adolesc 2006;29:379e93. has been reported to lead to the outbreaks of cutaneous 7. Braithwaite R, Robillard A, Woodring T, Stephens T, Arriola KJ. mycobacterial infections.41,42 Tattooing and body piercing among adolescent detainees: In many developed countries, guidelines or codes of relationship to alcohol and other drug use. J Subst Abuse practice are available for body art practitioners and parlors 2001;13:5e16. to reduce the risk of transmission of infection.118e121 8. Weber DJ, Rutala WA, Sickbert-Bennett EE. Outbreaks asso- However, these regulations are not always legally binding. ciated with contaminated antiseptics and disinfectants. Antimicrob Agents Chemother 2007;51:4217e24. Body modification practitioners and tattooists likewise have 9. Doerrbecker J, Friesland M, Ciesek S, Erichsen TJ, Mateu- been found to have inadequate training, insufficient Gelabert P, Steinmann J, et al. Inactivation and survival of knowledge of infection control, and poor compliance to hepatitis C virus on inanimate surfaces. J Infect Dis 2011;204: 121e124 proper safety precautions. Activities such as more 1830e8. stringent inspections, providing adequate educating, and 10. Hamsch C, Hartschuh W, Enk A, Flux K. A Chinese tattoo paint more feedback activities have to be carried out by the as a vector of atypical mycobacteria-outbreak in 7 patients in regulatory authorities in this often-overlooked field to Germany. Acta Derm Venereol 2011;91:63e4. minimize the risk of infection and other health 11. Centers for Disease Control and Prevention. Methicillin- problems.125,126 resistant Staphylococcus aureus skin infections among tattoo recipientsdOhio, Kentucky, and Vermont, 2004e2005. MMWR Morb Mortal Wkly Rep 2006;55:677e9. Conclusion 12. Drage LA, Ecker PM, Orenstein R, Phillips PK, Edson RS. An outbreak of Mycobacterium chelonae infections in tattoos. J Am Acad Dermatol 2010;62:501e6. Body modification is a popular form of body art in many 13. Kennedy BS, Bedard B, Younge M, Tuttle D, Ammerman E, parts of the world. Various patient- and procedure-related Ricci J, et al. Outbreak of Mycobacterium chelonae infec- factors may predispose individuals to the development of tion associated with tattoo ink. N Engl J Med 2012;367: local and systemic infections. Individuals must be made 1020e4. aware of the health risks prior to undergoing any such 14. Kapsimalakou S, Grande-Nagel I, Simon M, Fischer D, Thill M, procedure, and medical practitioners should be aware of Sto¨ckelhuber BM. Breast abscess following nipple piercing: the infective and noninfective complications associated a case report and review of the literature. Arch Gynecol Obstet 2010;282:623e6. with these procedures. Patients with infections not 15. Keene WE, Markum AC, Samadpour M. Outbreak of Pseudo- responding to conventional antibacterial coverage should monas aeruginosa infections caused by commercial piercing be investigated for pathogens such as atypical mycobac- of upper ear cartilage. JAMA 2004;291:981e5. teria, nocardiae, and fungi. More importantly, lapses in 16. Yu CH, Minnema BJ, Gold WL. Bacterial infections compli- infection control and disinfection procedures have cating tongue piercing. Can J Infect Dis Med Microbiol 2010; frequently been found to result in outbreaks of infections. 21:e70e4. Stricter regulations and inspections of operators by the 17. De Moor RJ, De Witte AM, Delme´ KI, De Bruyne MA, health authorities are necessary to reduce the risks, and Hommez GM, Goyvaerts D. Dental and oral complications of e the medical practitioners, who play an important role in lip and tongue piercings. Br Dent J 2005;199:506 9. the surveillance of disease activity, should have a high 18. Gill JB, Karp JM, Kopycka-Kedzierawski DT. Oral piercing injuries treated in United States emergency departments, index of suspicion for identifying such outbreaks, especially 2002e2008. Pediatr Dent 2012;34:56e60. when outbreak-associated pathogens such as atypical 19. Fisher CG, Kacica MA, Bennett NM. Risk factors for cartilage mycobacteria or pseudomonads are isolated. infections of the ear. Am J Prev Med 2005;29:204e9. 20. Hickey BM, Schoch EA, Bigeard L, Musset AM. Complications following oral piercing. A study among 201 young adults in References Strasbourg, France. Community Dent Health 2010;27:35e40. 21. Vieira EP, Ribeiro AL, Pinheiro Jde J, Alves Sde Jr M. Oral 1. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence piercings: immediate and late complications. J Oral Max- of body art (body piercing and tattooing) in university illofac Surg 2011;69:3032e7. undergraduates and incidence of medical complications. 22. Franchelli S, Vassallo F, Porzio C, Mannucci M, Priano V, Mayo Clin Proc 2002;77:29e34. Schenone E, et al. Breast implant infections after surgical 2. Klu¨gl I, Hiller KA, Landthaler M, Baümler W. Incidence of reconstruction in patients with breast cancer: assessment of health problems associated with tattooed skin: a nation-wide risk factors and pathogens over extended post-operative survey in German-speaking countries. Dermatology 2010;221: observation. Surg Infect (Larchmt) 2012;13:154e8. 43e50. 23. Safranek TJ, Jarvis WR, Carson LA, Cusick LB, Bland LA, 3. Cegolon L, Mastrangelo G, Mazzoleni F, Majori S, Baldovin T, Swenson JM, et al. Mycobacterium chelonae wound infections Xodo C. VAHP Working Group. Body art in 4,277 Italian after plastic surgery employing contaminated gentian violet secondary school adolescents: prevalence and associations skin-marking solution. N Engl J Med 1987;317:197e201. Infections associated with body modification 679

24. Rahav G, Pitlik S, Amitai Z, Lavy A, Blech M, Keller N, et al. An mycobacterial subcutaneous infections related to multiple outbreak of Mycobacterium jacuzzii infection following mesotherapy injections. J Clin Microbiol 2009;47:1961e4. insertion of breast implants. Clin Infect Dis 2006;43:823e30. 42. Regnier S, Cambau E, Meningaud JP, Guihot A, Deforges L, 25. Hvilsom GB, Ho¨lmich LR, Henriksen TF, Lipworth L, Carbonne A, et al. Clinical management of rapidly growing McLaughlin JK, Friis S. Local complications after cosmetic mycobacterial cutaneous infections in patients after meso- breast augmentation: results from the Danish Registry for therapy. Clin Infect Dis 2009;49:1358e64. Plastic Surgery of the Breast. Plast Surg Nurs 2010;30:172e9. 43. Quinõnes C, Ramalle-Go´mara E, Perucha M, Lezaun ME, Fer- 26. Henriksen TF, Ho¨lmich LR, Fryzek JP, Friis S, McLaughlin JK, nańdez-Vilarinõ E, Garcıá-Morra´s P, et al. An outbreak of Høyer AP, et al. Incidence and severity of short-term Mycobacterium fortuitum cutaneous infection associated complications after breast augmentation: results from with mesotherapy. J Eur Acad Dermatol Venereol 2010;24: a nationwide breast implant registry. Ann Plast Surg 2003;51: 604e6. 531e9. 44. Furuya EY, Paez A, Srinivasan A, Cooksey R, Augenbraun M, 27. Araco A, Gravante G, Araco F, Delogu D, Cervelli V, Baron M, et al. Outbreak of Mycobacterium abscessus wound Walgenbach K. Infections of breast implants in aesthetic infections among “lipotourists” from the United States who breast augmentations: a single-center review of 3,002 underwent abdominoplasty in the Dominican Republic. Clin patients. Aesthetic Plast Surg 2007;31:325e9. Infect Dis 2008;46:1181e8. 28. Kim JY, Davila AA, Persing S, Connor CM, Jovanovic B, 45. Chan HL, Poon LM, Chan SG, Teo JW. The perils of medical Khan SA, et al. A meta-analysis of human acellular dermis and tourism: NDM-1-positive Escherichia coli causing febrile neu- submuscular tissue expander breast reconstruction. Plast tropenia in a medical tourist. Singapore Med J 2011;52: Reconstr Surg 2012;129:28e41. 299e302. 29. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications 46. Ghorpade A. Tattoo inoculation lupus vulgaris in two Indian in postmastectomy breast reconstruction: two-year results of ladies. J Eur Acad Dermatol Venereol 2006;20:476e7. the Michigan Breast Reconstruction Outcome Study. Plast 47. Ghorpade A. Lupus vulgaris over a tattoo markdinoculation Reconstr Surg 2002;109:2265e74. tuberculosis. J Eur Acad Dermatol Venereol 2003;17:569e71. 30. Henriksen TF, Fryzek JP, Ho¨lmich LR, McLaughlin JK, Krag C, 48. Singh G, Tutakne MA, Tiwari VD, Dutta RK. Inoculation leprosy Karlsen R, et al. Reconstructive breast implantation after developing after tattooingda case report. Indian J Lepr 1985; mastectomy for breast cancer: clinical outcomes in a nation- 57:887e8. wide prospective cohort study. Arch Surg 2005;140:1152e9. 49. Trefzer U, Schmollack KP, Stockfleth E, Sterry W, Kolde G. 31. Cheng NX, Wang YL, Wang JH, Zhang XM, Zhong H. Compli- Verrucae in a multicolored decorative tattoo. J Am Acad cations of breast augmentation with injected hydrophilic Dermatol 2004;50:478e9. polyacrylamide gel. Aesthetic Plast Surg 2002;26:375e82. 50. Miller DM, Brodell RT. Verruca restricted to the areas of black 32. Qiao Q, Wang X, Sun J, Zhao R, Liu Z, Wang Y, et al. dye within a tattoo. Arch Dermatol 1994;130:1453e4. Management for postoperative complications of breast 51. Ragland HP, Hubbell C, Stewart KR, Nesbitt Jr LT. Verruca augmentation by injected polyacrylamide hydrogel. Aesthetic vulgaris inoculated during tattoo placement. Int J Dermatol Plast Surg 2005;29:156e61. 1994;33:796e7. 33. Feng XL, Yi C, Zhang Y, Wang Y, Li W, Yang M, et al. Analysis of 52. Baxter SY, Deck DH. Tattoo-acquired verruca plana. Am Fam the complications induced by polyacrylamide hydrogel Physician 1993;47:732. injection. Plast Reconstr Surg 2004;114:261e2. 53. Parker C, Kaminski G, Hill D. Zygomycosis in a tattoo, caused 34. Luo SK, Chen GP, Sun ZS, Cheng NX. Our strategy in compli- by Saksenaea vasiformis. Australas J Dermatol 1986;27: cation management of augmentation mammaplasty with 107e11. polyacrylamide hydrogel injection in 235 patients. J Plast 54. Jacob CI. Tattoo-associated dermatoses: a case report and Reconstr Aesthet Surg 2011;64:731e7. review of the literature. Dermatol Surg 2002;28:962e5. 35. Manafi A, Emami AH, Pooli AH, Habibi M, Saidian L. Unac- 55. Limentani AE, Elliott LM, Noah ND, Lamborn JK. An outbreak ceptable results with an accepted soft tissue filler: poly- of hepatitis B from tattooing. Lancet 1979;2:86e8. acrylamide hydrogel. Aesthetic Plast Surg 2010;34:413e22. 56. Samuel MC, Doherty PM, Bulterys M, Jenison SA. Association 36. Pallua N, Wolter TP. A 5-year assessment of safety and between heroin use, needle sharing and tattoos received in aesthetic results after facial soft-tissue augmentation with prison with hepatitis B and C positivity among street-recruited polyacrylamide hydrogel (Aquamid): a prospective multi- injecting drug users in New Mexico, USA. Epidemiol Infect center study of 251 patients. Plast Reconstr Surg 2010;125: 2001;127:475e84. 1797e804. 57. Haley RW, Fischer RP. Commercial tattooing as a potentially 37. San˜udo A, Vallejo F, Sierra M, Hoyos JG, Yepes S, Wolff JC, important source of hepatitis C infection. Clinical epidemi- et al. Nontuberculous mycobacteria infection after meso- ology of 626 consecutive patients unaware of their hepatitis C therapy: preliminary report of 15 cases. Int J Dermatol 2007; serologic status. Medicine (Baltimore) 2001;80:134e51. 46:649e53. 58. Haley RW, Fischer RP. The tattooing paradox: are studies of 38. Correa NE, Catanõ JC, Mejıá GI, Realpe T, Orozco B, Estrada S, acute hepatitis adequate to identify routes of transmission of et al. Outbreak of mesotherapy-associated cutaneous infec- subclinical hepatitis C infection? Arch Intern Med 2003;163: tions caused by Mycobacterium chelonae in Colombia. Jpn 1095e8. J Infect Dis 2010;63:143e5. 59. Estebanez Estebanez P, Colomo Gomez C, Zunzunegui 39. Munayco CV, Grijalva CG, Culqui DR, Bolarte JL, Sua´rez- Pastor MV, Rua Figueroa M, Perez M, Ortiz C, et al. Jails and Ognio LA, Quispe N, et al. Outbreak of persistent cutaneous AIDS. Risk factors for HIV infection in the prisons of Madrid. abscesses due to Mycobacterium chelonae after mesotherapy Gac Sanit 1990;4:100e5. sessions, Lima, Peru. Rev Saude Publica 2008;42:146e9. 60. De A Nishioka S, Gyorkos TW, Joseph L, Collet JP, MacLean JD. 40. Centers for Disease Control and Prevention. Outbreak of Tattooing and transfusion-transmitted diseases in Brazil: mesotherapy-associated skin reactionsdDistrict of Columbia a hospital-based cross-sectional matched study. Eur J Epi- area, JanuaryeFebruary 2005. MMWR Morb Mortal Wkly Rep demiol 2003;18:441e9. 2005;54:1127e30. 61. De A Nishioka S, Gyorkos TW, Joseph L, Collet JP, Maclean JD. 41. Carbonne A, Brossier F, Arnaud I, Bougmiza I, Caumes E, Tattooing and risk for transfusion-transmitted diseases: the Meningaud JP, et al. Outbreak of nontuberculous role of the type, number and design of the tattoos, and the 680 S.S.-Y. Wong et al.

conditions in which they were performed. Epidemiol Infect 86. Friedel JM, Stehlik J, Desai M, Granato JE. Infective endo- 2002;128:63e71. carditis after oral body piercing. Cardiol Rev 2003;11:252e5. 62. Department of Health, Government of Western Australia. HIV 87. Millar BC, Moore JE. Antibiotic prophylaxis, body piercing and link to Bali tattoo. Available at: http://www.health.wa.gov. infective endocarditis. J Antimicrob Chemother 2004;53: au/press/view_press.cfm?idZ1104; 23 December 2011 123e6. [accessed 20.08.12]. 88. Pittet B, Montandon D, Pittet D. Infection in breast implants. 63. Pugatch D, Mileno M, Rich JD. Possible transmission of human Lancet Infect Dis 2005;5:94e106. immunodeficiency virus type 1 from body piercing. Clin Infect 89. Gabriel SE, Woods JE, O’Fallon WM, Beard CM, Kurland LT, Dis 1998;26:767e8. Melton 3rd LJ. Complications leading to surgery after breast 64. Daniel AR, Shehab T. Transmission of hepatitis C through implantation. N Engl J Med 1997;336:677e82. swapping body jewelry. Pediatrics 2005;116:1264e5. 90. Brickman M, Parsa AA, Parsa FD. Mycobacterium cheloneae 65. Hayes MO, Harkness GA. Body piercing as a risk factor for viral infection after breast augmentation. Aesthetic Plast Surg hepatitis: an integrative research review. Am J Infect Control 2005;29:116e8. 2001;29:271e4. 91. Vinh DC, Rendina A, Turner R, Embil JM. Breast implant 66. Kaur C, Sarkar R, Kanwar AJ. How safe is nose-piercing? infection with Mycobacterium fortuitum group: report of case Inoculation cutaneous tuberculosis revisited. Int J Dermatol and review. J Infect 2006;52:e63e7. 2003;42:645e6. 92. Adams Jr WP, Rios JL, Smith SJ. Enhancing patient outcomes 67. O’Malley CD, Smith N, Braun R, Prevots DR. Tetanus associ- in aesthetic and reconstructive breast surgery using triple ated with body piercing. Clin Infect Dis 1998;27:1343e4. antibiotic breast irrigation: six-year prospective clinical 68. Meltzer DI. Complications of body piercing. Am Fam Physician study. Plast Reconstr Surg 2006;117:30e6. 2005;72:2029e34. 93. Burkhardt BR, Dempsey PD, Schnur PL, Tofield JJ. Capsular 69. Marenzi B. Body piercing: a patient safety issue. J Perianesth contracture: a prospective study of the effect of local anti- Nurs 2004;19:4e10. bacterial agents. Plast Reconstr Surg 1986;77:919e32. 70. Biggar RJ, Haughie GE. Medical problems of ear piercing. NY 94. Mirzabeigi MN, Mericli AF, Ortlip T, Tuma GA, Copit SE, State J Med 1975;75:1460e2. Fox 4th JW, et al. Evaluating the role of postoperative 71. Cortese TA, Dickey RA. Complications of ear piercing. Am Fam prophylactic antibiotics in primary and secondary breast Physician 1971;4:66e72. augmentation: a retrospective review. Aesthet Surg J 2012; 72. McCarthy VP, Peoples WM. Toxic shock syndrome after ear 32:61e8. piercing. Pediatr Infect Dis J 1988;7:741e2. 95. Sajid MS, Hutson K, Akhter N, Kalra L, Rapisarda IF, Bonomi R. 73. Ekelius L, Bjorkman H, Kalin M, Fohlman J. Fournier’s gangrene An updated meta-analysis on the effectiveness of preopera- after genital piercing. Scand J Infect Dis 2004;36:610e2. tive prophylactic antibiotics in patients undergoing breast 74. Sandhu A, Gross M, Wylie J, Van Caeseele P, Plourde P. surgical procedures. Breast J 2012;18:312e7. Pseudomonas aeruginosa necrotizing chondritis complicating 96. Mirzabeigi MN, Lee M, Smartt Jr JM, Jandali S, Sonnad SS, high helical ear piercing case report: clinical and public Serletti JM. Extended trimethoprim/sulfamethoxazole health perspectives. Can J Public Health 2007;98:74e7. prophylaxis for implant reconstruction in the previously irra- 75. Campiglio G. Ear reconstruction after auricular chondritis diated chest wall. Plast Reconstr Surg 2012;129:37ee45e. secondary to ear piercing. Plast Reconstr Surg 2004;113: 97. Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson EG. 768e9. Once is not enough: withholding postoperative prophylactic 76. Rowshan HH, Keith K, Baur D, Skidmore P. Pseudomonas antibiotics in prosthetic breast reconstruction is associated aeruginosa infection of the auricular cartilage caused by with an increased risk of infection. Plast Reconstr Surg 2012; “high ear piercing”: a case report and review of the litera- 130:495e502. ture. J Oral Maxillofac Surg 2008;66:543e6. 98. Christensen LH, Breiting VB, Aasted A, Jorgensen A, 77. Lee TC, Gold WL. Necrotizing Pseudomonas chondritis after Kebuladze I. Long-term effects of polyacrylamide hydrogel piercing of the upper ear. CMAJ 2011;183:819e21. on human breast tissue. Plast Reconstr Surg 2003;111: 78. Cicchetti S, Skillman J, Gault DT. Piercing the upper ear: 1883e90. a simple infection, a difficult reconstruction. Br J Plast Surg 99. Lee CJ, Kim SG, Kim L, Choi MS, Lee SI. Unfavorable findings 2002;55:194e7. following breast augmentation using injected polyacrylamide 79. Lewis CG, Wells MK, Jennings WC. Mycobacterium fortuitum hydrogel. Plast Reconstr Surg 2004;114:1967e8. breast infection following nipple-piercing, mimicking carci- 100. Zhao Y, Qiao Q, Yue Y, Kou X, Liu Z. Clinical and histologic noma. Breast J 2004;10:363e5. evaluation of a new injectable implant: hydrophilic poly- 80. Trupiano JK, Sebek BA, Goldfarb J, Levy LR, Hall GS, acrylamide gel. Ann Plast Surg 2004;53:267e72. Procop GW. Mastitis due to Mycobacterium abscessus after 101. Matarasso A, Pfeifer TM. Plastic Surgery Educational Foun- body piercing. Clin Infect Dis 2001;33:131e4. dation DATA Committee. Mesotherapy for body contouring. 81. Lee SH, Chung MH, Lee JS, Kim ES, Suh JG. A case of Staph- Plast Reconstr Surg 2005;115:1420e4. ylococcus aureus endocarditis after ear piercing in a patient 102. Rotunda AM, Kolodney MS. Mesotherapy and phosphatidyl- with normal cardiac valve and a questionnaire survey on choline injections: historical clarification and review. Der- adverse events of body piercing in college students of Korea. matol Surg 2006;32:465e80. Scand J Infect Dis 2006;38:130e2. 103. Garcia-Navarro X, Barnadas MA, Dalmau J, Coll P, Gurguı´ M, 82. Lick SD, Edozie SN, Woodside KJ, Conti VR. Streptococcus Alomar A. Mycobacterium abscessus infection secondary to viridans endocarditis from tongue piercing. J Emerg Med mesotherapy. Clin Exp Dermatol 2008;33:658e9. 2005;29:57e9. 104. Nagore E, Ramos P, Botella-Estrada R, Ramos-Nı´guez JA, 83. Dubose J, Pratt JW. Victim of fashion: endocarditis after oral Sanmartıń O, Castejoń P. Cutaneous infection with Mycobac- piercing. Curr Surg 2004;61:474e7. terium fortuitum after localized microinjections (meso- 84. Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis therapy) treated successfully with a triple drug regimen. Acta after tongue piercing. Emerg Infect Dis 2002;8:850e1. Derm Venereol 2001;81:291e3. 85. Tronel H, Chaudemanche H, Pechier N, Doutrelant L, Hoen B. 105. Newman MI, Camberos AE, Ascherman J. Mycobacterium Endocarditis due to Neisseria mucosa after tongue piercing. abscessus outbreak in US patients linked to offshore surgi- Clin Microbiol Infect 2001;7:275e6. center. Ann Plast Surg 2005;55:107e10. Infections associated with body modification 681

106. Giannella M, Pistella E, Perciaccante A, Venditti M. Soft tissue content/116/26658.html; 7 October 2012 [accessed infection caused by Mycobacterium chelonae following a lip- 10.10.12]. osculpture and lipofilling procedure. Ann Ital Med Int 2005; 117. Wallace Jr RJ, Brown BA, Griffith DE. Nosocomial 20:245e7. outbreaks/pseudo-outbreaks caused by nontuberculous 107. Dessy LA, Mazzocchi M, Fioramonti P, Scuderi N. Conservative mycobacteria. Annu Rev Microbiol 1998;52:453e90. management of local Mycobacterium chelonae infection after 118. Worp J, Boonstra A, Coutinho RA, van den Hoek JA. Tattooing, combined liposuction and lipofilling. Aesthetic Plast Surg permanent makeup and piercing in Amsterdam; guidelines, 2006;30:717e22. legislation and monitoring. Euro Surveill 2006;11:34e6. 108. Cooksey RC, de Waard JH, Yakrus MA, Rivera I, Chopite M, 119. NSW Ministry of Health, Australia. Skin penetration code of Toney SR, et al. Mycobacterium cosmeticum sp nov., a novel best practice. Available at: http://www.health.nsw.gov.au/ rapidly growing species isolated from a cosmetic infection and resources/publichealth/environment/pdf/cobp_skin_pen. from a nail salon. Int J Syst Evol Microbiol 2004;54:2385e91. pdf; Published in March 2001 [accessed 20.08.12]. 109. Viana-Niero C, Lima KV, Lopes ML, Rabello MC, Marsola LR, 120. Essex Health Protection Unit. Infection control guidelines for Brilhante VC, et al. Molecular characterization of Mycobac- tattooists, body piercers and acupuncturists. Available at: www. terium massiliense and Mycobacterium bolletii in isolates hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947330313; collected from outbreaks of infections after laparoscopic Published in February 2010 [accessed 20.08.12]. surgeries and cosmetic procedures. J Clin Microbiol 2008;46: 121. Centre for Health Protection, Hong Kong. Recommended 850e5. guidelines on infection control for skin penetration practice. 110. Apostolou A, Bolcen SJ, Dave V, Jani N, Lasker BA, Tan CG, Available at: http://chp.gov.hk/files/pdf/Skin_Penetration_ et al. Nocardia cyriacigeorgica infections attributable to Practice_20080221.pdf; 2005 [accessed 20.08.12]. unlicensed cosmetic proceduresdan emerging public health 122. Oberdorfer A, Wiggers JH, Bowman J, Lecathelinais C. problem? Clin Infect Dis 2012;55:251e3. Infection control practices among tattooists and body pierc- 111. Gamo R, Aguilar A, Cue´tara M, Gonzalez-Valle O, Houmani M, ers in Sydney, Australia. Am J Infect Control 2003;31:447e56. Martıń L, et al. Sporotrichosis following mesotherapy for 123. Oberdorfer A, Wiggers JH, Considine RJ, Bowman J, Cockburn J. arthrosis. Acta Derm Venereol 2007;87:430e1. Skin penetration operators’ knowledge and attitudes towards 112. Sturm LP, Cooter RD, Mutimer KL, Graham JC, Maddern GJ. A infection control. Am J Health Behav 2003;27:125e34. systematic review of dermal fillers for age-related lines and 124. Hellard M, Aitken C, Mackintosh A, Ridge A, Bowden S. wrinkles. ANZ J Surg 2011;81:9e17. Investigation of infection control practices and knowledge of 113. Cohen JL. Understanding, avoiding, and managing dermal hepatitis C among body-piercing practitioners. Am J Infect filler complications. Dermatol Surg 2008;34(Suppl. 1):S92e9. Control 2003;31:215e20. 114. Rousso JJ, Pitman MJ. Enterococcus faecalis complicating 125. Oberdorfer A, Wiggers JH, Bowman J, Burrows S, Cockburn J, dermal filler injection: a case of virulent facial abscesses. Considine RJ. Monitoring and educational feedback to Dermatol Surg 2010;36:1638e41. improve the compliance of tattooists and body piercers with 115. Liu HL, Cheung WY. Complications of polyacrylamide hydrogel infection control standards: a randomized controlled trial. (PAAG) injection in facial augmentation. J Plast Reconstr Am J Infect Control 2004;32:147e54. Aesthet Surg 2010;63:e9e12. 126. Lehman EJ, Huy J, Levy E, Viet SM, Mobley A, McCleery TZ. 116. Centre for Health Protection, Department of Health, Hong Bloodborne pathogen risk reduction activities in the body Kong. Latest update on investigation of septic shock and piercing and tattooing industry. Am J Infect Control 2010;38: sepsis cases. Available at: http://www.chp.gov.hk/en/ 130e8.