From Ancient Traditions to Modern Medicine: A Review of the Evolution, Procedural Complications, and Surgical Challenges of Piercings

Abstract

Piercings have evolved from ancient cultural traditions to a mainstream form of body modification, interweaving personal expression and modern medicine. This review traces the historical origins of piercings, highlighting cultural significances and transformation into contemporary trends. As piercings have become increasingly commonplace, the incidence of medical complications has risen, necessitating medical and surgical intervention. Moreover, the growing popularity of body modifications, including gauges and dermal implants, presents unique surgical challenges in reconstructive procedures following piercing removal. By exploring the intersection of historic cultural practices and medical science, this review aims to provide a broad understanding of the evolution of piercings and considerations for physicians managing piercing-related concerns.

Historical Overview of Piercings

Body piercings have played an integral role in human culture for thousands of years, symbolizing status, beauty, and spirituality. The earliest physical evidence of piercing comes from Ötzi the Iceman, a 5,000-year-old mummy with gauge-style ear.^1,2 In Ancient Egypt, piercings symbolized wealth and status, and ear and nose piercings were common among the elite, including King Tutankhamun.^3,4 In ancient African cultures, tribes like the Maasai and Mursi used large earlobe discs and lip plates, respectively, as markers of beauty, maturity, and social status (Figure 1).⁵ Meanwhile, in ancient Rome, soldiers pierced their nipples as a show of strength and solidarity, while the Aztecs and Mayans used lip and tongue piercings as part of religious rituals.^6,7

Figure 1.

African cultures, tribes like the Maasai and Mursi used large earlobe discs and lip plates, respectively, as markers of beauty, maturity, and social status.

From the Middle Ages through the Renaissance, the popularity and meaning of piercings in Europe varied significantly, often reflecting shifting societal and religious attitudes. During the Middle Ages, the Christian Church opposed body modifications, viewing the body as sacred and unalterable.^8,9 However, the Renaissance saw a renewed interest in self-expression, influenced by increasing global trade and cultural exchange. In Victorian England, piercings, particularly among women, were viewed with moral disapproval but persisted as symbols of fashion and status.¹⁰ European colonial expansion in the 19th century also brought awareness of non-Western body modification practices, occasionally influencing Western styles.

In the early 20th century, industrialization and mass production made jewelry more widely available, leading to broader acceptance of ear piercings across social classes. Following the world wars, jewelry trends became simpler, but ear piercings remained common among women. Social changes after World War II, including the women’s liberation movement, brought a shift in attitudes toward personal adornment, paving the way for expanded forms of self-expression and body modification.

The counterculture movements of the 1960s and 1970s transformed piercing practices in Western societies. Hippie and punk movements embraced piercings as symbols of rebellion, and celebrities like David Bowie and Madonna popularized the trend in the 1980s. The 1990s saw the establishment of professional piercing studios, which offered safer environments and increased awareness about aftercare. By by the early 21st century, various types of piercings—such as septum, lip, eyebrow, navel, and dermal piercings—gained traction alongside more extreme modifications like stretched earlobes and dermal implants. Social media platforms played a significant role in normalizing these practices by creating a global community where individuals could share their unique styles and experiences.

Today, body piercings are popular across cultures and are seen as extensions of personal identity, belief, and style. Advances in biocompatible materials, personalized jewelry, and healing techniques have increased safety, reduced complications, and broadened the appeal of piercings.^11,12 These innovations ensure that body piercings will continue to evolve as an essential medium of self-expression and cultural tradition.

Complications from Piercings

Short-term Medical Complications

The most common site of piercings is the ear, with increasing popularity involving the mouth, nose, eyebrows, nipples, navel, and genitals.^11,12 While piercings are generally safe when performed by trained professionals, they can lead to immediate complications, although the absence of regulation and incident reporting, particularly for sensitive or high-risk piercings, results in inconsistent and unreliable estimates of the frequency of complications associated with body piercings.¹³

Immediate complications of body piercings include bleeding, pain, and nausea. The use of firm pinpoint pressure as a form of hemostasis may address most instances of superficial bleeding. In some cases, excessive bleeding can indicate more serious underlying medical issues that require focused medical attention. Materials known to cause allergic reactions—including sanitary products used in the procedure (e.g. nickel-plated items, latex surgical gloves)—should be avoided in sensitive individuals undergoing body piercings.^13,14

Piercing site infection, including localized cellulitis, is the most common non-immediate complication of piercings.^11,12 The most commonly identified organisms from piercing-related infections are staphylococcus and streptococcus species, although there is a higher rate of incidence of pseudomonas infections when cartilaginous ear and nasal structures are involved in body piercings (Figure 2).¹¹ Individuals with genital piercings are at increased risk for sexually transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis.¹² Culture and gram stain of purulent drainage of piercing-related skin infections can help aid in the diagnosis and treatment of skin and soft tissue infections. If localized infections are not properly identified and treated, they can cause more serious systemic complications such as Ludwig angina, endocarditis, toxic shock syndrome, and Fournier gangrene, although instances are rare.^11,12

Figure 2.

Various ear piercings through cartilage and ear lobe.

Symptoms of piercing site infection include redness, swelling, pain, and discharge. Preventative measures include proper sterilization of equipment, the use of autoclaves at piercing studios, and appropriate aftercare. Conservative treatment of minor local infections includes warm compress application and over the counter or prescription topical antibiotics, such as mupirocin. Oral antibiotics such as cephalexin or clindamycin provide adequate coverage for streptococcus and staphylococcus. If concerns for methicillin-resistant Staphylococcus aureus exist, oral trimethoprim/sulfamethoxazole confers adequate coverage. As discussed, infected piercings involving the cartilaginous structures of the ear are more likely to be caused by Pseudomonas and are treatable with a fluoroquinolone like ciprofloxacin.¹¹

Allergic contact dermatitis is the most frequent non-infectious cutaneous complication of piercings. Importantly, nickel is the most common allergen associated with body piercings, and ear piercing is believed to be the most common source of nickel sensitization.^13,14 A 2001 study by Ehrlich et. al demonstrated a 4.0% nickel sensitization rate in males with no piercings compared with 11.1% and 14.% in males with one or multiple piercings, respectively.¹⁴ To minimize the risk of sensitization, the use of hypoallergenic metalware in piercings (e.g. surgical stainless steel, niobium, titanium, or gold) is recommended in lieu of nickel, particularly in the period from piercing administration to resolution of healing.¹⁵ Triple antibiotic ointments like Neosporin should be avoided due to increased risk of allergic contact dermatitis.¹⁶ Irritant contact dermatitis can occur from the cleaning solutions used to clean piercings as well. Symptoms of allergic reactions include itching, redness, and swelling at the piercing site. Treatment involves the removal of the piercing or jewelry piece or cleaning solution and future avoidance of allergic triggers.

Removal of infected piercing jewelry is requisite for most forms of treatment, and the placement of a loose loop suture through the piercing can be used to maintain piercing patency throughout infection treatment. Oral piercings tend to have a lower infection rate but, when present, are treatable with amoxicillin/clavulanate (Figure 3). The recommended duration of treatment for local cellulitis is five days, but extension of therapy should be considered if there is no improvement in symptom burden.¹¹ The addition of oral alcohol rinses or topical cleaners containing hydrogen peroxide or vinegar can aid in infection healing. Treatment for genital piercing infections should include coverage for Neisseria gonorrhea and Chlamydia trachomatis with intramuscular ceftriaxone and oral azithromycin in appropriate settings.^11,12 If the patient has not received a tetanus vaccination or booster within the last five years, then this should be updated if a patient presents with an infection after a recent body piercing.¹¹

Figure 3.

Oral piercings.

Long-term Medical Complications

Potential complications of piercing-related infections are relatively minor when identified early and treated with appropriate antimicrobials. However, the risk of infectious complications is greater in deep piercings and those that pierce through mucosal surfaces. A delay in clinical presentation can lead to increasingly severe local skin and soft tissue infections such as abscess formation, cellulitis, chondritis, sepsis, nasal septal perforation, airway compromise as in cases of Ludwig angina, or possible dissemination to distant sites such as infective endocarditis, from oral piercings, or toxic shock syndrome, from genital piercings.^11,12 Long-term complications can arise months or even years after an initial piercing.

Over time, piercings can lead to scarring or the development of keloids or hypertrophic scars, which are raised, overgrown areas of scar tissue. Keloids generally occur four to eight weeks after piercings, increase in size for up to six months, then flatten over a period of a few years.^17,18 Keloids are more common in individuals with a genetic predisposition and can be difficult to treat. There is an increased likelihood of keloid formation in cases of post-procedure complications, such as hematoma, infection, excess skin tension, and/or delayed wound healing. Treatment options include steroid injections, silicone sheets, and in some cases, surgical removal.^17,18 Scar tissue can also cause discomfort and impact the appearance of body piercings.

Some piercings, particularly surface piercings, may migrate or be rejected by the body. This occurs when the body perceives the jewelry as a foreign object and slowly pushes it out. Factors that contribute to piercing migration and rejection include improper placement, excessive movement, and the body’s immune response. Migration can result in an unsightly appearance and may require the piercing to be re-pierced or removed. Jewelry can also sometimes become embedded in the skin if the piercing hole closes over it, requiring surgical removal. This complication is more common in piercings subjected to pressure or trauma. Embedded jewelry can cause pain and infection, necessitating prompt medical and/or surgical intervention.

Psychological and Social Complications

While it may be medically necessary to remove piercings, it may also be psychologically traumatic, particularly when piercings were obtained for reasons based on factors of identity, culture, spirituality, or remembrance. Suture material, non-stick posts or non-metal catheters can be used to maintain the body piercing opening if the removal is intended to be temporary to provide the patient or individual with reassurance of patency.¹⁷ The deformity that can occur from piercings can unintentionally reduce patient self-esteem and body confidence. For example, disinterest leads to the intentional removal of 13–18% of body piercings at body sites other than the earlobes in Western culture.^18,19 Individuals who undergo body piercing procedures may face discrimination and stigma arising from incorrect assumptions about the piercing, differing personal opinions, or non-conformance to staff dress codes and expectations around workplace appearances.²⁰ Counseling and social support can help individuals navigate these feelings.

Visible piercings can lead to discrimination and ostracization in certain professional environments. Despite growing acceptance, some work environments or industries impose strict appearance and dress code standards. Individuals with visible piercings may face challenges in job interviews or workplace settings where traditional norms prevail. Advocacy for body modification acceptance in the workplace continues to grow.

Challenges with Surgery and Reconstruction Following Piercing Removal

General Considerations

Along with the growing popularity of body art, there has been a parallel increase in individuals seeking removal and subsequent reconstruction of piercing sites, often due to aesthetic or professional reasons, infection, or other complications. Surgical reconstruction of these piercing sites, especially in cases of expanded piercings such as large-gauge earlobes, presents a unique set of challenges for reconstructive surgeons. These challenges span from managing scar tissue and skin integrity to achieving satisfactory cosmetic outcomes, restoring function, and addressing the patient’s expectations.

Reconstructive surgeons must carefully assess the extent of scarring and plan operative procedures to minimize further tissue damage. Techniques to reduce scarring include silicone gel sheets and fractional resurfacing and pulsed dye laser treatments. Managing patient expectations is crucial. Some patients may expect complete restoration of pre-piercing appearance, which may not always be aesthetically possible. Reconstructive surgeons should provide patients with realistic expectations and discuss potential limitations and risks of surgical intervention.

Scar Tissue and Healing Considerations

One of the primary challenges in repairing a site where a piercing has been removed is managing scar tissue that has developed over time. Piercings, particularly those that are in place for long periods of time, create a permanent tract lined with epithelial tissue. When the piercing is removed, this epithelial-lined tract can close but residual scar tissue remains, which can lead to various complications. Scar tissue can result in altered skin elasticity, because scar tissue lacks the same elasticity and tensile strength as normal skin. This makes reconstruction of the natural contour of the surgical site more challenging. Moreover, areas with significant scarring may have compromised blood supply, leading to slower healing and a higher risk of wound breakdown or post-operative infection. Patients who are prone to hypertrophic scarring or keloid formation may also develop unsightly or painful scars after reconstructive surgery, complicating the aesthetic outcome.

Challenges with Large-Gauge Piercings

Large-gauge piercings, or stretched piercings, particularly in the earlobes or other stretched tissues, pose unique reconstructive challenges These piercings can create large, stretched-out holes or even tears, leaving behind significant tissue distortion when jewelry is removed.¹⁷ The larger the gauge, the more complex the reconstruction. Tissue may be thin, fragile, and difficult to work with. Specific challenges include tissue deficiency, loss of natural contour, and asymmetry and cosmetic concerns.

In some cases, there may not be enough adjacent tissue to properly close the defect without tension, increasing the risk of wound dehiscence or poor cosmetic results. The natural contours of body parts such as the earlobe can be significantly altered by large-gauge piercings. Restoring the natural, rounded shape of the earlobe can be technically challenging and may require flaps, grafts, or multi-step procedures to recreate.

Achieving perfect symmetry between the repaired side and the contralateral, non-operative side is difficult. In bilateral reconstructions, such as reconstructive procedures involving both ears or earlobes, slight differences in tissue thickness, skin texture, or shape may become noticeable. These differences are particularly apparent in operative areas like the face and ears, where symmetry is paramount for aesthetic satisfaction.

Smaller gauge holes can often be closed with less invasive techniques such as simple suturing. This involves removing the jewelry, allowing the remaining hole to shrink, removing the epithelialized tract, and subsequently stitching the edges together. This method is effective for minor stretching associated with smaller gauges but may not be suitable for larger gauges. Larger gauge piercings may require tissue grafting to fill in gaps and restore normal appearance and contours. This technique involves taking tissue from another area of the body and grafting it onto the piercing site. The graft must be carefully matched to surrounding skin to ensure a natural appearance. Advanced flap techniques can be used to reconstruct severely distorted areas, providing better cosmetic results. This involves creating flaps of skin and tissue to cover the defect and restore a more natural appearance. Flap techniques require careful surgical planning and expertise to avoid complications such as necrosis or infection.

Techniques and Surgical Challenges

In summary, several surgical techniques are used to repair tissue after piercing removal, but each comes with its own set of challenges. In some cases, more than one surgical stage may be necessary to achieve the desired cosmetic and functional outcome. However, this can be time-consuming, costly, and inconvenient for the patient.

Infection and Complications Post-Removal

Another major challenge faced by reconstructive surgeons during piercing repair is the risk of infection, both before and after the removal of the piercing. Infected piercings, particularly those involving cartilage, can lead to chondritis and, in severe cases, cartilage necrosis. For instance, in piercings through cartilage (such as the helix of the ear), infection can lead to permanent cartilage destruction, complicating the reconstruction process. Rebuilding cartilage requires specialized techniques, such as cartilage grafts, to restore structural integrity. If the surgical area was infected prior to removal, the infection can persist or recur post-surgery. This necessitates careful infection control and antibiotic management during reconstruction. Piercings that have been in place for an extended period can sometimes form a persistent sinus tract, leading to chronic drainage or infection even after removal. This can complicate healing and require additional surgical intervention.

Functional Considerations

For some piercings, particularly those in sensitive or functional areas such as the nasal septum, tongue, or lip, reconstruction should not only focus on achieving a cosmetic result but also restoring function. Challenges include maintaining airway patency and speech and swallow restoration. Nasal piercings, especially septum piercings, can cause scar tissue formation that may lead to nasal obstruction if not properly repaired. Restoring the nasal airway without causing further scarring or collapse of the nasal septum can be challenging. In cases of oral piercings (tongue, lip, or cheek piercings), improper healing after removal can lead to difficulty with speech, eating, or swallowing. Reconstructive surgeons must carefully repair these areas to avoid functional impairment.

Patient Expectations and Psychological Considerations

Patients seeking the removal and reconstruction of piercing sites often have high aesthetic expectations. They may wish for the piercing site to disappear or revert to its original appearance prior to its piercing, particularly in visible areas. Despite the best surgical techniques, it is often impossible to completely erase all clinical evidence of a piercing, particularly for large-gauge piercings or those that have been in place for many years. For some patients, removing a piercing may have deeper psychological or emotional implications. Some may feel a sense of loss or regret about removing a body modification that was once an important part of their identity. Balancing the physical outcome with the emotional aspects of piercing removal is an important part of the reconstructive surgeon’s role.

Conclusion

Body piercings have evolved from ancient cultural practices to contemporary fashion statements, reflecting broader societal changes in attitudes toward body modification and personal expression. While piercings offer a unique form of self-expression, they also come with medical risks and potential complications. With a growing number of individuals seeking piercing removal and repair, particularly for larger piercings, the demand for advanced surgical techniques and expertise in this area will continue to rise. As society continues to evolve, so too will the practices and perceptions surrounding body piercings.

Figures 3, 4, 5.

Removal and managing scar tissue can be challenging for reconstructive surgeons.