Example #1: 1/1 – 1/3
Patient had circumcision 10 years ago and never really happy about laxity of skin. Requests revision. Circ done very close to glans (don’t know why). Options is to make another incision/scar higher and have 2 circles of fairly uniform circumference, or make incision again low and place dart on underside to avoid puckers. Patient opted for the latter.
Example #2: 2/1 – 2/2
Patient requests moderately high circumcision with release of frenulum.
Example #3: 3/1 – 3/4
Our patient, status post cosmetic circumcision.
Example #4: 4/1 – 4/3
A mature result with fairly smooth suture line: 5/1 – 5/6
Example #6: 6/1 – 6/11
Patient has had 2 circumcision procedures done by others and still not happy. Photos 6/1- 6/9 all pre-op to Dr. Reed’s intervention. Photos 6/10 and 6/11 are immediately following Dr. Reed’s surgery. Redundant tissue, fin remnant under glans, suture tracts, hypertrophic scar, and peno-scrotal web….gone.
Example #7: 7/1 – 7/11
“Attached are two images of the end result from the circumcision Dr. Reed and you performed on me a year ago. I am extremely pleased with the outcome. Thank you both for getting me back to a road of happiness. M.”
Example #8: 8/1 – 8/3
Sam, you made the pants too long.
Unhappy camper had circumcision 2 weeks ago (elsewhere).
Q. Will the skin ever heal shorter?
A. Doubtful. Please wait 3 to 4 months and we’ll revise to suit. Most probably we will have to remove 3/4 to 1 inch of skin or more, to have a smooth confluency of skin all the way to the coronal sulcus. A hand held mirror will allow you to see work in progress and verbally sign off, “this looks good or needs to be tighter.”
High Japanese styled cut(s): 9/1 – 9/2
Potential problems: A. Skin septa (connective tissue strands) even if released may still may cause the inner skin to wrinkle slightly as the tension applied that seems to completely stretch the foreskin is often applied at the mid shaft by the patient to get some idea of what to expect. Applying the traction further away at the base requires
more force and if so greater potential for incisional breakdown. B. Lymphedema or persistent swelling of the entire penile skin.
Phimosis Example: 10/1 – 10/3
10/1 – 10/2 Two pre-op views of extreme adult phimosis. Handsome school athlete, avid golfer, with otherwise large penis. Would a small tube of steroids make this (phimosis) go away? How about a large tube? How about a kilo of steroidal cream, how about a ton?
10/3 Remedy: cosmetic adult circumcision with removal of all scarified foreskin. For this reason the circumcision is of necessity low, but moderately tight. Patient given hand held mirror to watch work in progress, and his Dad, a physician, was present in OR for support. Two gentlemen of the highest caliber.
Phimosis Example: 11/1 – 11/2
Before and after photo of a gentleman from the UK, showing another tight phimotic ring that has not responded to conservative therapy. Circs on phimotic patients are lower than for most, because the scarified foreskin has to be removed lest the problem will be re-created surgically.
Phimosis Example: 12/1 – 12/2
Phimosis with micro-tears and shiny atrophic skin, with loss of elasticity. Repeated tearing during retraction or erections simply compounds situation. Presenting for circumcision.
Phimosis Example: 13/1 – 13/3
37 year old man claims never known his penis to be any other way. White avascular fibrous tissue of tight phimotic ring is clearly evident.
After phimosis is opened under anesthesia, a melanotic (pigmented) lesion is note and a “kissing lesion” is seen on the inner prepuce directly overlying it. Sent off to pathology. One in 400 to 900 uncircumcised men will get cancer of the penis, which occurs more than 20 times more commonly in uncircumcised men. A quarter of these will die from it and the rest will require complete or partial penile amputation as a result. (In contrast, invasive penile cancer never occurs or is extraordinarily rare in men circumcised at birth.)
Paraphimosis Example: 14/1 – 14/3
Note ring like contracture of prepuce (foreskin) on the shaft proximal to the head with redness (congestion of entrapped blood), swelling, and unusual shininess to the head and prepuce.
Paraphimosis is a not uncommon medical condition where the foreskin becomes trapped behind the glans penis, and cannot be reduced (that is, pulled back to its normal flaccid position covering the glans penis). If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as a tourniquet like constriction can result in gangrene or other serious complications.
This patient did not respond to a course of high potency steroid (Clobetasol-17-propionate) and came to me for circumcision. Addtionally I separated adhesions of the corona to the shaft exposing more of the coronal sulcus. A skin graft taken from “healthy” prepuce that was removed was needed to resurface the underside of the penis.
Phimosis Example: 15/1 – 15/4
Penile Skin Tunnels or Penile Skin Bridges: Example: 16/1 – 16/3
Penile skin bridges or tunnels are seen occasionally after neonatal circumcision because of a re-attachment of raw skin, especially if the circumcision is loose. In this slide note also to the left of the probe an area of corona (rim of the glans) which is attacked to the penile shaft skin. Both areas were opened and allow to re-epithelialize. To prevent adhesions, an antibiotic ointment will be applied daily until skin coverage is complete. The wrinkled effect is an artifact associated with Betadine prepping before surgery. Patient complained of recurrent build up of discharge from the tunnel.
Penile Skin Bridge: Example: 17/1 – 17/3
A young adult with unwanted preputial skin bridge. Resected using 2.5 Keeler loupes. Gone.
Circumcision Revision, before and after (left vs. right)
Fordyce spots on penis: Example: 19/1
Commonly seen, not communicable, usually treated gratis during adult circumcision