In Reply:-Dr. Rosenberg and his colleagues cite their concerns about elective surgery in patients who wear jewelry in the operating room. We agree with them in this regard. It is our practice to remove jewelry from patients, if possible, before proceeding with surgery (elective and emergent). Body jewelry worn during the perioperative period poses a number of potential hazards. Pressure necrosis or nerve injury can result from ineffective padding. Lacerations can result from entanglement with drapes, gowns, and various monitor cables (electrocardiograph leads, pulse oximeter cables, blood pressure cuff tubing). In addition, electrocautery can potentially result in burns to the patient. This can occur if electrocautery is used near the site of the metal jewelry, because the current would flow preferentially, following the path of least resistance, to the metal jewelry instead of the dispersive plate of the electrosurgical unit. When current flows through an alternative return site, rather than through the dispersive plate, current density is high and serious burns may result. [1,2]Burns have been known to occur when needle localization breast biopsies are performed using electrocautery, as high-density current flows through the needle used to localize the lesion. To avoid problems with electrical burns, a number of precautions are taken. First, jewelry is removed if possible. Second, the dispersive plate is placed at a site distant from the surgical field. Third, electrocautery is not used if the jewelry is close to the site of surgery. Another option is the use of a bipolar electrosurgical unit, which uses less power because current passes only between the tips of the unit (and not from the tip of the monopolar unit, through the body, to the dispersive pad). [1,2]It is also important to remember that newer electrosurgical units have isolated electrosurgical generators that limit the risk of alternate site burns. The current is isolated from the ground-it will not usually function unless the current returning to the unit by means of the dispersive unit equals the amount leaving the source. 
This leaves us with the more important question. Is elective surgery cancelled in a patient who wears oral jewelry? Other than issues related to electrical safety, we share similar concerns as cited by Dr. Rosenberg and his colleagues regarding risks of oral/dental trauma, aspiration, failure to secure the airway, and others. In the patient reported by Dr. Rosenberg's group, the patient has a tongue ring that is quite long, allowing greater movement in the mouth. There is probably even greater danger of oral and dental trauma with this type of jewelry. If the tongue ring has been placed recently, it may not be acceptable to the patient to remove it for the perioperative period. If the patient's jewelry has been in place for a while, it might be possible to remove the piece and replace it with a nontraumatic sterile stent (such as a loop of suture) before the induction of anesthesia. Anesthesia may or may not impose additional risks for the patient who has chosen to wear oral jewelry if the patient has been functioning with the jewelry in place for a considerable time, going about his or her activities of daily living. We will continue to evaluate these issues on a case-by-case basis and would not necessarily cancel an elective case simply because oral jewelry is present. Finally, as we mentioned in our previous letter, we anticipate additional reports of problems and issues with body art and anesthesia in the future.
Mark G. Mandabach, M.D.
University of Alabama at Birmingham; Department of Anesthesiology; Birmingham, Alabama;firstname.lastname@example.org
Diedre A. McCann, M.D.
Gale E. Thompson, M.D.
Department of Anesthesiology; Virginia Mason Medical Center; Seattle, Washington
(Accepted for publication May 19, 1998.)