Dear Dr. Reed,

A bit of an upset within the pro-circumcision community. Your name was mentioned as the exponent of a particular opinion concerning circumcision style. I’d like to check whether you have been correctly quoted.   It’s the old high/low debate again. The opposing factions are lined up thus:   One group is saying, in effect, that all circumcisions should be in the ‘high’ style (ample retention of inner foreskin) because (a) that is more sensitive and (b) subsequent conversion to a ‘low’ style is a possibility whereas the converse (conversion low-to-high) is not.   The opposing opinion is that the ‘low’ style (minimum retention of inner foreskin) should be contemplated on a “where appropriate to the objective” basis. This second group do not express disagreement with the tenets (a) and (b) of the first group, but go on from that point to reason thus: If retention of inner foreskin enhances sensitivity, then it follows that removal of inner foreskin should reduce it. Such reduction may be beneficial especially in instances where the objective is to increase what is sometimes termed ‘latency time’. An instance would be a problem of premature ejaculation.   So:   [A] Do you ALWAYS rule out ‘low’ styles, and if so… why?

Gary

Good morning Gary,

Thank you for your interesting questions.

My position is:

1.  For most man who practice good hygiene and are monogamous, a circumcision is not a medically necessary operation.  Can 350,000 years of human evolution be all that wrong?

2.  Pre-mature ejaculation is as commonly seen in circumcised as in uncircumcised men.  This is confirmed in our practice and my training is that no studies have shown otherwise.

3.  Large studies involving perhaps 20,000 cohorts of men (Kaiser Permanente Clinic in California), circumcised versus non, show no difference in penile sensitivity as a rule.  True if a doctor cuts inappropriately deep, there can be nerve injury.  In our practice we believe “a circumcsion is about removing skin.”

4.  The problem with very low circumcsion is that the circumference near the coronal sulcus or neck” is narrower versus the main portion of the shaft and marrying 2 circle or ellipses of unequal circumference can result in puckers in the larger circle, unless a V-cut or some other remedy is employed to reduce the larger circle.

5.  Moderation is always a good idea, although we try if possible to accede to patient request.

6.  For the present, I think we can agree circumcsion will continue for some to remain an emotionally  charged subject, contexted and laden with misrepresentation and exaggeration.

7.  Yesterday did an 11 week old boy with a  huge tubular umbilical hernia (its size, the  diameter of a garden hose and stuck out about 2 inches, 5 cm.).  The mother has been told to follow this expectantly as it might recede.  He also had a pin point phimosis that barely admitted the tip of a fine malleable rounded edge probe.  Surprised that he could urinate at all.

I didn’t believe for one second the umbilical hernia will go away, nor would the phimosis.  Did an uneventful circumcsion using a Mogen clamp.

Sincerely,

Harold M. Reed, M.D.

305-865-2000

Dear Dr. Reed,

 I had a circumcision about 5 months ago and it was not done neatly at all there are suture tracks, raised and sensitive spots and this 3 cm scar which looks like a incision that didn’t heal let when they put in the stitch I agreed to, I agreed to a straightening bendable stitch to be put inside of my penis to make it straight because of my downward curvature but they put it too close to the surface on top of my penis right below my head and the whole area keeps getting irritated and you can see one prong of the stitch through the skin and it looks terrible would i be able to get a revision and have the stitch inside of my shaft taken out or moved to the middle bottom of my shaft without leaving extra incision marks?
contact:     Nathan

Good morning Nathan,

Thank you for your excellent case presentation. Really sorry to hear that so many things have not worked out as you
anticipated. We would never close a penile curvature case without producing an erection in the operating room to be sure
it is straight. or meets with patient approval. Look at photographic examples of our circumcision results and see if this is more to your expectations.

The following is a letter we send to prospective concussion patients.   Might be of interest.

Thank you for your interest in what we do. Your penis is one of the most important cosmetic and functional features of your body.

We have performed over 6500 cosmetic circumcisions and revisions in the past 35 years and usually do several cases every week.

We have done sons of physicians, brothers, religious circumcisions, men who have not seen the heads of their penis for 20 years!  This is your circumcision and we do it the way you want with respect to 4 parameters.
 
Please don’t be like the patient done elsewhere who writes: “Dr. Reed I just got circumcised two days ago and my result was not what i expected. I was wondering when i recover can i get a consultation with you.” Photos sent and received (unspoken comment “disaster zone”)
 
Be assured we will show you every courtesy,
 
All the best,
 

Harold M. Reed, M.D.
305-865-2000

Had a circ last year in Baltimore. How do you explain some wrinkles I have in
my distal mucosal, or inner skin after circumcision. I thought they would go
away.

Lex

Hi Lex,

A circumcision is more than just an approximation of 2 fresh incisions. If the doctor doesn’t like what he sees or knowing how it’s going to look before he’s finished, it would not be very cosmetic to ignore that.

Underneath the loose skin of the penis are tissue septa or strands that limit the amount of stretching penile skin will undergo. On the soles of the feet, the septa are very short, somewhat looser on the palm, still looser on the back of the hand and much looser on the penis.

However, because of chronic inflammation the septa may yield just a little and so when the penile skin is on the stretch, they still are seen, creating little wrinkles.

The way we handle this is to undermine the septa and allow them skin to heal over the dartos fascia without wrinkles. If we see there is a potential for a penile scrotal web, we also free up the skin at the base of the penis on the underside, so it settles better. Please understand that this is our intention and no urologist can guarantee a perfect result, but we try to get as close as we can. We might be a little fussier, and that is why it is important to leave your dressing on for a good week, to immobilize the skin so it will heal with minimal scarring. 

For excesive wrinkled skin we may often removed a strip on the underside and close in the midline to provide a smoother look.

For this reason we prefer to have our patients watch work in progress with a hand held mirror to be sure, they are happy before the dressing is applied.

Harold M. Reed, M.D.
305-865-2000

December 18, 2010

Good morning Paul,

You had a circumcision on December the 8th, and the best time to have
these sutures removed would be on December the 20th, a Monday 12 days later.

Our experience has been the longer sutures stay in, the greater the  potential for cross hatch marks which are of course permanent.

As most doctors do not remove absorbable sutures, you can think that way, but we are a little fussy.  We’ll be in the office on December 23rd.

Your call,

Harold M. Reed, M.D.
305-865-2000

October 25, 2010

Good afternoon Lemuel,

Thank you for your continued interest in what we do.

If the tissues are well healed enough we probably could do BellaDerm at the same time.  Your will need to stay here for a good week after surgery so I can follow you on a daily basis.

We will use your photos after we do the revision.  Thank you for that.

Sincerely,

Harold M. Reed, M.D.
305-865-2000

Lionel

September 9, 2010

Good morning Lionel,

Please read the letter we send to prospective patients and a personal comment will follow…

Thank you for your interest in what we do. Yes, we do men in your age group every week.

We have performed over 6000 cosmetic circumcisions in the past 35 years and usually do several cases every week.

We do ask that you stay for one, ideally 2 days at the Baltic Hotel (advanced tourist class) or Daddy’s O’s (more posh) and I will see you there daily.

You could return to an office environment in about 4 days after circumcision. Our 2 layered wrap of soft conforming gauze and Coban will provide comfort and reduce swelling.

We have done sons of physicians, medical students and residents, brothers, religious circumcisions, men who have not seen the heads of their penis for 20 years! This is your circumcision and we do it the way you want with respect to
4 parameters.

Please don’t be like the patient who writes: “Dr. Reed I just got circumcised two days ago and my result was not what i expected. I was wondering when i recover can i get a consultation with you.” Photos sent and received (unspoken
comment “disaster zone”)

Be assured we will show you every courtesy,

Sincerely,

Harold M. Reed, M.D.
305-865-2000

OK Lionel, here’s my take and I have a professional responsibility not to be
castigating..

Could have been a lot better. Aside from every critique you mention, of which I would agree, widely placed sutures lead to a lot of puckering which is evident on some of your photos.

Circumcisions are traditionally not well paid for at least in the United States, because conventional wisdom (wrong) is a urologist could run through this procedure in 15 minutes.

When I was a resident, I saw a urologist ask a nurse in the operating room with a prominent clock on the wall…”What time is it.” and the nurse said with some askance “Why doctor it is 8:15.”. Fifteen minutes later he completed the circumcision and the urologist said again, “nurse, what time is it, and she dutifully looked at the clock and complied, “why doctor it is 8:30.” He then said, “Do you mean I just did a circumcision in 15 minutes?” When I look down at the poor patient I thought to myself, it looked like it had been done in 15 minutes.

Lionel, in our practice it takes about 55 minutes. Penile skin does not come cheap.

The unevenness may resolve only somewhat as the swelling subsides, but I would be hard pressed to say this will self-correct. Also there is an area where the penile skin is inverted.

Suggestion, wait a good 3 to 4 months after your circumcision for everything to heal as well as it is going to. If continued improvement is slowly noted, wait even longer, then most likely you will come to revision. We do not maintain a directory of a handful of urologists in Australia who are cosmetically minded (there must be some).  Or see me. In fact we see Australians here quite regularly,

Lastly, I would like permission to post some of your photos on our web-site without mention of your name.

Every best wish,

Harold M. Reed, M.D.
305-865-2000

July 25, 2010

Good morning Robert,

Thank you for your interest in what we do.  What you described is quite common but did not have to be.  A circumcision should be the highest cosmetic calling of a urologist.

We have performed over 6000 cosmetic circumcisions in the past 35 years and quite a few revisions as well, usually doing several cases every week.

Harold M. Reed, M.D.
305-865-2000

July 24, 2010

Good morning Rudolfo,

Thank you for your interest in what we do.

We have performed over 6000 cosmetic circumcisions and revisions in the past 35 years and usually do several cases every week.

If when your penis is erect the penile shaft skin could still be tighter without lifting of pubic skin, then there is room for “tightening.”

We do ask that you stay for one, ideally 2 days at the Baltic Hotel (advanced tourist class) and I will see you there daily.

With kindest regards,

Harold M. Reed, M.D.
305-865-2000

Hi Arnaud,

Thank you for your interest in what we do.

We have performed over 6000 cosmetic circumcisions in the past 35 years and usually do several cases every week.  Many of our patients have phimosis so we well understand the principles of getting the best result.

Our sutrures while fast absorbing still should be removed 12 days after surgery to prevent permanent cross hatch marks (ghost lines and pin holes).  Please do not let anyone talk you out of having them removed, by saying “they are absorbable, they’ll melt out.”

This should be done by a health care practitioner who has a bright over head light, loupes (eyeglass with little telescopes on  the end) and delicate plastic surgery instruments  like for removing eyelid sutures)  EMLA cream could be applied for 20 minutes beforehand if you are very sensitive.  Some urologists have this equipment in their office if they do delicate surgery, or consider an urgent care center, or an emergency room of a quiet community hospital (not a county “zoo”). 

Next to the nose on your face, your penis is a very important cosmetic structure and standards for care should be no different.

We do ask that you stay for one, ideally 2 days at the Baltic Hotel (advanced tourist class) and I will see you there daily.

You could return to an office environment 3 days after circumcision.  Our 2 layered wrap of soft conforming gauze and Coban will provide comfort and reduce swelling.

We have done sons of physicians, medical students and residents, brothers, religious circumcisions, men who have not seen the heads of their penis for 20 years, and next week a father and 3 sons! 

This is your circumcision and we do it the way you want with respect to 4 parameters.

Please don’t be like the patient who writes: “Dr. Reed I just got circumcised two days ago and my result was not what i expected.   I was wondering when i recover can i get a consultation with you.”   Photos sent and received (unspoken comment “disaster zone”)

Our office hours are from 9 to 5, Monday through Friday.     Be assured  we will show you every courtesy.

          
                                                                                                                                                      
With kindest regards,
Harold M. Reed, M.D.
305-865-2000

Hi Dr. Reed,

I am interested in circumcision revision. I was circumcised at age 11, I’m now 32. Since I was old enough to know the difference, I’ve been very unhappy with how my penis looks. Based on my research, the procedure was done freehand using sutures. The incision line is uneven and I have a couple dozen suture scars around the top of the shaft just under the glans. (Kind of like railroad tracks.) Most of the suture scars are quite thick and pronounced. Many of them touch and even enter the corona. My question is: could a revision help clean up the look of my penis? I know it will never be “perfect” but I would love to lose the ragged, scarred look if possible.   Matthew

Good morning Matthew,

Thank you for your interest in what we do.   This is a letter we send to “virginal” patients.  Your situation is one we see frequently and I am confident with proper revision you’ll look a whole lot better.

We have performed over 6000 cosmetic circumcisions in the past 35 years and usually do several cases every week.

We do ask that you stay for one, ideally 2 days at the Baltic Hotel (advanced tourist class) and I will see you there daily.

You could return to an office environment 3 days after circumcision.  Our 2 layered wrap of soft conforming gauze and Coban will provide comfort and reduce swelling.

We have done sons of physicians, medical students and residents, brothers, religious circumcisions, men  who have not seen the heads of their penis for 20 years, and next week a father and 3 sons! 

This is your circumcision and we do it the way you want with respect to 4 parameters.

Please don’t be like the patient who writes: “Dr. Reed I just got circumcised two days ago and my result was not what i expected.   I was wondering when i recover can i get a consultation with you.”   Photos sent and received (unspoken comment “disaster zone”)

Be assured we will show you every courtesy,

With kindest regards,
Harold M. Reed, M.D.
305-865-2000