Dear Dr. Beth:

My lover has done the same cutting on my upper arm four times, and it has repeatedly faded to near-invisibility. What can we do to increase visible scarring without causing an infection?

--Frustrated

Dear Frustrated:

Cutting is an SM technique which is not for the squeamish or the inexperienced. A basic understanding of skin structure in the area of a cutting is essential for a scene to be safe and aesthetic. Otherwise the bottom may end up looking like the main attraction in a third-rate sushi bar. A well-done cutting can be uniquely satisfying for aficionados of this type of play.

Human skin has two main layers, the dermis and the epidermis. The epidermis has five layers which get pushed out from the stratum basale, where new epidermal cells come are formed, to the stratum corneum, which contains keratin and which dries up and falls off. There is no blood supply in the epidermis. Underneath the epidermis is the dermis, a tough layer made of elastic fibers; it contains blood vessels, lymph vessels and nerves. These layers are not laid flat one on top of another like sheets of paper. Instead, the dermis has lots of folds, ridges and valleys. The epidermis lies on top of these folds and follows them. This elastic layer is much thicker in some places than in others. The skin of the outer arms and legs, the back, and the palms and soles is relatively thick. The skin of the inner arms and thighs, the chest, the genitals, and the face is much thinner and unsuitable for cuttings.

SM cuttings are intended to involve the epidermis. Because of the irregular nature of the dermis, superficial ridges in this layer will inevitably be cut as well. This is why cuttings bleed. However, cuttings should never go all the way through the dermis. A cutting that goes all the way through the dermis for more than an inch isn't a cutting, it's a laceration and may need stitches. This type of accident is likely to happen if the bottom moves suddenly against the blade. Apply direct pressure to stop the bleeding and have the wound checked by a health care professional.

Basic care of a cutting is the same as for any other cut or scrape. The skin should be cleaned well with an antiseptic solution such as betadine or rubbing alcohol before starting the cutting, and a sterile blade should be used to do the cutting, so infection is less likely than with an accidental injury. After the cutting is completed, many people like to clean the fresh cutting with rubbing alcohol. This has both health and aesthetic benefits, and may produce interesting sound effects as well.

A cutting should be kept covered with sterile gauze until a scab forms. In order to minimize scarring, the scab should then be left alone. Antiseptic ointments are popular, but I'm not a big fan of them, since they can interfere with wound healing and sometimes harbor bacteria themselves. It is also not necessary to repeatedly cleanse a cutting with alcohol, hydrogen peroxide, Hibiclens, etc. These can actually slow healing by killing delicate new cells.

The amount and type of scarring will depend on a number of factors. Some people are genetically prone to forming keloids, which are thick raised scars; if the person receiving the cutting or their family members tend to form keloids, this may happen after a cutting, even if no previous wounds have keloided. Cuttings which are affected by traction or movement of underlying muscle, such as horizontal cuts in skin of the breasts, are likely to have thicker scars than cuts in other places or vertical aspects of the same cutting. Cuttings which become infected are also more likely to scar permanently. While some people have deliberately used keloids as a method of scarification, these can sometimes be chronically painful.

The reasons for doing cuttings are as varied as the SM community itself. Some people do it primarily for the sensation, some because they have eroticized bloodletting, and some desire permanent scarification for artistic and/or spiritual purposes. There are methods for increasing the permanence of a cutting. Ash from either wood or cigar tobacco may be rubbed into cuttings to produce a grey coloration; freshly burned ash is probably sterile. Sterile tattoo ink can be rubbed across the cutting and then covered with Tegaderm. Another technique involves repeatedly pouring red wine vinegar over the cutting to give a pinkish tint to light skin. One person has had good results by repeatedly rubbing the scab off in the shower, daily from day one.

Whenever a foreign substance is introduced into the skin, it causes more inflammation and more chance for infection. It is essential to use clean, sterile substances and to take extra care to keep the cutting clean after introducing a coloring or scarring agent. People with immune system disorders or those taking cortisone-type medications or cancer chemotherapy should be even more careful. And everybody who gets a cutting should be up-to-date on their tetanus and hepatitis immunizations.