A couple of years ago, I first started to see microdermal implants in my jail patients. This is, of course, jewelry that is implanted in the skin. These have become so popular as to be almost universal. If you work in a jail or prison (or even if you have looked around at your local grocery store), you certainly have seen these. Microdermal implants can be problematic in correctional settings, because they cannot be easily removed like the older bolts and rings. Microdermal implants are imbedded in the skin, and removal requires making an incision to extract them.
But in corrections, even though it is difficult, microdermal implants often must be removed, either as a security issue or because the patient requests that they be removed. Nowadays, these implants are so common that all correctional practitioners really should know how to deal with microdermal jewelry. But most of us were never taught how to do this in our training! I certainly never learned about these in my residency training. Such a thing would have been inconceivable back then. Cutting edge fashion in those days was long hair and grungy jeans!
So I was grateful when an opportunity for education presented itself recently. A friend of mine asked me if I would remove two of her micro dermal implants and kindly consented to have the procedure photographed. Todays JailMedicine post is a photographic tutorial on how to remove microdermal implants.
In order to remove a microdermal implant, you need to know what they look like. Here is a picture of a typical microdermal implant. It has two arms that extend beneath the skin and hold it in place. Notice that one of the arms is shorter that the other. Notice also that the decorative jewel above the skin unscrews from the base. In fact, if the patient will only be incarcerated for a short time, instead of removing the implant, you could just unscrew the jewel and place it in the patient’s property.
Removing a dermal implant requires a skin incision. Though this incision will be small, it still carries a risk of bleeding, infection and scarring. Because of this, correctional patients should consent to the procedure before you begin. Can you get by with just unscrewing the jewel and leaving the implant base? How you get this consent and how you document it, I will leave to your facility’s policy.
You begin the procedure by removing unscrewing the decorative jewel and removing it (Note that the base alone without the jewel is seen as a little black dot on the skin, not very obtrusive). The next task is to palpate the base of the implant to identify the orientation of the dermal arms and especially try to identify which side the shorter arm is on. If you can, you should make your incision over the shorter arm so it can be a little smaller. Depending on how thick the skin is, this may be difficult. Like in this case! Back skin is thick, and I really couldn’t tell which side had the shorter arm. But that’s OK. It still will work out, as it did in this case.
Step Three—Prep the area.
In this case, I cleaned the skin with betadine followed by alcohol. I also then used a fenestrated drape to keep the area clean–and also to keep betadine and blood off of my patient’s clothes..
I prefer to use 0.25% bupivicaine (Marcaine) with epinephrine. Why Marcaine? Well, they are comparable in price and Marcaine has the advantage of lasting 3-4 times longer, so the area stays numb for 12-16 hours instead of 4 hours. Why use epinephrine? The main reason to use epinephrine is that it constricts skin blood vessels so there is much less bleeding. This makes the procedure that much easier to perform. Epi also makes the anesthesia last longer—another bonus for the patient!
Step Five—Make the Incision.
The best scalpel for this procedure–by far– is a #11 blade. The #11 blade is pointed at the tip and becomes broad at the base, like a spear point which allows you to make a much smaller incision than does a #15 or even worse, a #12 blade. Place the tip of the blade at the base of the implant and stab down along the edge of the subdermal arm that you identified before. The deeper you stab, the bigger the incision. In this way, you can easily control the incision length. The cut does not have to be very big! A couple of millimeters is all you need. Note that you must hold the implant steady with forceps.
Once you have made a small incision with your #11 blade, it is easy to pull the implant out with the forceps.
Notice that the incisions on my patient’s back are tiny. No suture was needed in this case or in most cases. I imagine that you could consider one small (6.0) suture if the site was on the patient’s face.
And you’re done! These tend to bleed a minimal amount and can be dress with a bandaid. Easy Peasy! This procedure is much easier, for example, than I&D of an abscess or removing a toenail. Correctional Practitioners should not feel intimidated by a little microdermal implant!
Mandatory disclaimer! The technique I used here is a result of my training, experience and preferences. Others may use different techniques that are just as effective. Also, my patient was young, healthy and cooperative and her implants were in an easy-to-access area. You may consider sending patients to an expert if the implant is in a potentially complicated area, like a scrotum or near the eye or if the patient has complicating health issues!
I have recently started work in a prison.
An in-mate transferred to our prison disclosed to a nurse that he has inserted a ball baring under his skin along the shaft of his penis.
This happens fairly often here apparenltly, a type of body piercing.
Anyway nurse suggested he come and see me and ask for antiseptic etc.
So I saw him, he said everything was fine, no swelling or redness, and did not want or need to be examined.
The manager of the health centre has asked if I can examine next time.
I have two issues, one, is it a privacy matter and, two, if therevis no medical issuec, why would I examine.
The manager says its against prison rules for him to be doing this to himself.
I worked at a prison in west Texas where this was a common occurance. It is most definitely against the rules for inmates to do this, but it happens with regularity.
I agree that, unless there are complications (infection, etc), there’s really no need for you to examine the inmate unless there’s something in your policy stating otherwise. (And even then, the inmate would have to consent to be examined.)
We had a case where a gentleman experienced complications r/t a “marble” as they were called at my facility; he was sent to the hospital and received fairly extensive surgery to remove the SEVEN marbles that were close enough to extract. (Apparently there were several older ones that had been scarred over extensively and adhered to the corpus cavernosum, so they left those alone.)
Going forward, I would recommend a campaign of infection control/risks of, er, tampering with one’s anatomy. Many of the inmates at our facility didn’t understand the how high the risks of HCV, HIV, etc were for people who did this, and once we were able to communicate this, the incidence of “marbles” decreased significantly.
1. What is your state’s legal stance on a minor surgical intervention that is not medically indicated? Does Custody’s Policies & Procedures (vested in law) cover this procedure?
2. Has there been any civil lawsuits due to the removal of the item and subsequent scar (though minor)?
Jim Flowers, R.N.
Supervising RN II
Thanks for the questions, Jim. 1. This is irrelevant since I will not remove these without consent from the inmate-patient. For most inmates in jail, you don’t have to remove them. It is enough to simply unscrew the jewel and place it in the inmate’s property for the duration of the incarceration. I would like to hear how prison systems address this issue! 2. The potential of scarring should also be part of the consent. Like any other minor surgical procedure, the patient should be informed of the potential harms of the procedure, like scarring and bleeding (usually minor) and then consent.
The Wisconsin DOC has taken the position that the removal of these is not medically necessary and our providers will not remove them if the only indication is that Security wants them removed. At my institution we met with the Security Director and the Warden, and explained the risk of infections and scars that might result from a non-indicated procedure. The agreement [by both Medical and Security] was that if Security feels strongly a piece of jewelry must come out, they will arrange it with an outside provider. If a patient wants it out, we will remove it with the usual counseling and consent. We do other procedures, so it wasn’t the procedure itself but the fact that it wasn’t “medical.”
I agree. Often the right move is to just unscrew the jewel and leave the underlying subcutaneous post in place.
Dr. G and others , a SQ ball bearing seems benign. However, it will set off a metal detecting wand used routinely at prisons. And unless there’s a strip search EACH time the metal detector goes off over his penis, the inmate could use the ballbearing as cover for a shiv carried in his groin. More importantly, how do you know the inmate is telling you the truth? Why is there a request for antiseptic if the skin is covering the ball bearing and healed? You have no idea what he has down there and you’re wondering if you should look? How do you know that what your inmate has attached to his penis is not a handcuff key? Which they could use when transported to the local ER for a sprain ankle. At which time he escapes, shooting the hospital guard and later a deputy dead with their own gun.
Look closely at a microdermal implant and see how easily it could be modified into the working end of a cuff key. How can all this not be a security and safety issue?
BTW, before you dismiss the above preventable tragedy as improbable, consider that I’m writing you from Blacksburg Virginia. Then kindly look up the acts of one jailed inmate named William Charles Morva, a few years back.
Hi! Former piercing apprentice here! (I ended up moving on to a different lime of work)
That could be true with the ball bearing that DoctorG mentioned because if the inmate did it himself who knows what material it was made out of.
But a professionally done microdermal would be made out of titanium which is not magnetic and wouldn’t set off the metal detector. They would be unable to use it for that kind of escape plan.
Very informative. Thanks for the work of putting it the article together!
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