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Are there differences in circumcision procedure and outcome based on patient ethnic background?

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Are there differences in circumcision procedure and outcome based on patient ethnic background?

April 2018

I treat any circumcision procedure with an equal concern for the attention to detail with surgical technique. The principal features of technique that impact the quality of cosmetic outcome are 

  1. length of foreskin removed,
  2. symmetry of the incision lines, 
  3. gentleness of handling of the skin and the Dartos fascia layer which lies beneath the skin
  4. careful attention to control of bleeding arteries and veins,
  5. careful attention to aligning the skin edges for wound closure,
  6. delicate handling of the suturing (stitching) process so that suture scarring ("railroad track" scarring) does not result,
  7. suture technique which is performed to prevent suture tunnels (These are NOT the result of stitches remaining in too long but are entirely the result to the surgeon's technique.)
  8. proper postoperative dressing (bandage) application to minimize swelling and stretching of the healing tissues.

For adult circumcision, I use the sleeve resection technique in which the foreskin is removed as a single ring of tissue utilizing a scalpel. In my opinion, this gives a symmetrical, fine incision line. In addition to a refined scar line, this technique allows the final result to be customized to the patient's specifications if he has a particular outcome in mind. 

Many urologists perform adult circumcisions with general anesthesia. This is a more complicated and expensive procedure than local anesthesia. I perform almost all of the procedures for my patients utilizing local anesthetics. This involves a series of injections around the base of the penis to encircle the penile circumference with the anesthetic agent. The injections are not particularly painful since the injections are just beneath the skin surface. After the anesthetic is injected, I allow five to ten minutes for the effect to occur and then check the patient’s sensation to ascertain that he is not able to feel pain. Only after the patient is comfortable, do I begin the procedure. 

For adult circumcision, I use the sleeve resection technique in which the foreskin is removed as a ring of tissue with a scalpel. In my opinion, this gives a symmetrical, fine incision line. In addition to a refined scar line, this technique allows the outcome to be customized to the patient's specifications if he has a particular outcome concept he wishes me to produce. This involves making an incision on the outer surface of the foreskin at the level where the edge of the glans (corona) is visible making an impression through the foreskin. I then retract the foreskin and make an incision in the inner (mucosal) surface of the foreskin following the contour of the glans. I mark the incision lines before making any incision and make measurements to be certain that the incisions will result in removing enough foreskin to meet the patient’s cosmetic preferences and allow for comfortable erections. An adult circumcision should be crafted to accommodate the dimensions of the erect penis. I simulate erect length by stretching the penis. I mark incision lines with an ink marker and then stretch the penis, to simulate erect length, and move the two incision lines into proximity. I want these two points to come together without excessive tension. This will avoid uncomfortable erections. Once I have determined the correct location of the incision lines, I make the outer incision, retract the foreskin and make the inner incision and remove the foreskin as one piece of tissue. Bleeding points are identified and cauterized with electrocautery. The frenulum is then removed if the patient desires this to be done. I then close the wound with fine sutures, placed in a very precise manner so that suture marks and tunnels will not occur, and finally apply a compression bandage to the surgical site. Typical outcome images can be viewed on the circumcisioncenter.com Website.

The technique for performing circumcision does not change with the patient's ethnicity, however in men with more darkly pigmented skin tones technical flaws with circumcision become much more obvious. Suboptimal surgical technique may lead to visible suture scars across the wound edges. Some people refer to this as "railroad track" scars. These are due almost entirely to the surgical technique involved in the wound closure, not to the fact that sutures were left in place for too long. Men who desire to have this type of unsightly suture marks are some of the patients who most commonly seek revision circumcision procedures. 

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