Circumcision Procedure Frequently Asked Questions (FAQs)

Yes, it is important to have a consultation visit. The consultation is included and the time required is approximately 30 minutes. Both the consultation and procedure may be performed during the same office visit, requiring an overall time of one and a half hours.

I regularly use glue to close the skin in scrotal, groin, and abdominal incisions but I think it is a poor choice for circumcisions. When the glue is applied to a surgical wound, some of the glue makes its way into the tissue below the skin and bonds these tissues to the skin. In the wounds I utilize glue, penetration into the deeper tissues is not problematic. In the penis, the layer beneath the skin is a thin muscle layer called Dartos fascia. This layer of fascia lies between the penile skin and the functional structures of the penis, the two corpora cavernosa (erectile bodies), and the corpus spongiosum (structure on the underside that contains the urethra). The fascia is a vital tissue layer because it is the structure that allows the penile skin to slide over the functional components of the penis. When skin glue gets into this layer it will penetrate the fascia and bond the skin to the functional components of the penis so that it will no longer slide. Studies using glue for circumcision were done in children who were too young to be bothered by this factor.

The other problem with using glue for circumcision wounds is that it does not bring the skin edges as close together as sutures do. This means the scar will be wider and more visible. The key for an ideal circumcision wound is to carefully place sutures close to the skin edges, the use of very fine suture material, and carefully tying of the sutures to prevent cutting off the blood flow to the skin edges as the wound heals.

Producing an outcome of a circumcision procedure which suits the aesthetic preferences of a patient when the penis is flaccid and allows for a comfortable erection is my goal with each procedure I perform. Removing the proper amount of skin is an important aspect of achieving this. I mark the skin incision lines on both the outer surface of the foreskin as well as on the mucosal (inner) surface and then stretch the penis while using a forceps to move these incision points together. This provides an accurate assessment that incisions made along these two lines will result in a final outcome which will accommodate a full erection. I have tried using erection induced by injection of medication into the penis to compare to the method of stretching. The method of stretching I use is superior for three reasons in my experience. First, there is much more bleeding during circumcision performed n an erect penis because the veins are dilated. Second, once the erection is induced it is not possible to go back and forth comparing the incision points between erect and flaccid states the way I am able to compare stretched and unstretched locations of the incision points. Third, the outcome of circumcision performed on an erect penis tends to remove an inadequate amount of skin because it is technically more difficult to close the wound when it is under tension as it will be with erection.

I do not use this device because it does not allow the precision I think is necessary to create an outcome that is crafted to the patient’s unique anatomy. These clamps do not allow careful visualization of both the outer and inner skin surfaces of the foreskin. It is difficult, if not impossible, to ascertain that the proper amount of skin is being pulled through the clamp before crushing the skin. I have dealt with some men who have attempted self-circumcision using this device and have removed inadequate or excessive amounts of skin. An adult circumcision has to be very carefully crafted to result in a nice cosmetic as well as a functional result. It is a big mistake for a man to attempt self-circumcision using one of these devices.

Lasers are great for use in some types of surgical procedures. For circumcision, a laser offers no benefit and potential problems. A laser cuts, nothing else. The surgeon can not control the depth of the cut with a laser. As circumcision is concerned, it is important that the surgeon be able to control the depth of a cut to a very fine degree. Too much depth of cut and injury to the urethra or erectile bodies could result. I use a stainless steel scalpel for circumcision.

Neonatal circumcision is performed utilizing one of a number of clamp devices which remove the redundant foreskin, stop bleeding arteries and veins by crushing them, and bond the skin edges without the need for sutures. The most common devices used are the GOMCO (acronym for Goldstein Manufacturing Company) introduced in 1934, The Mogen clamp introduced in 1954, and the Hollister PlastiBell clamp introduced in 1950. Each one of these creates a pressure bond to hold together the skin edges so that their is no need for sutures. These devices provide an adequate wound closure for infants because they do not have powerful enough erections to pull apart the skin edges. The bond created by these clamps at the skin edges consists of the clamp crushing the two opposing skin edges together. The force of a powerful erection would pull apart the wound edges resulting in wound 'dehiscence' or opening up of the wound thus making it an inadequate wound closure for a circumcision in an older child or adult. Adults require a suture closure (stitches) to provide a secure enough closure to allow the wound to remain intact despite the force of erections. Also, it should be mentioned that careful suture closure leads to a much finer scar once the healing is complete. Sutures guide the healing edges of the wound close together so that the end result is a very fine line. I have performed some circumcisions in which I did not suture (stitch) the wound. The results were scars that were wider than ones I create with suture closure.

Neonatal circumcisions are done with minimal local anesthesia or no anesthesia. Using a clamp device, a neonatal circumcision is a quick, five minute procedure. An adult circumcision is a more lengthy procedure and requires a more elaborate anesthetic. 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. I use the sleeve resection technique in which I remove the redundant foreskin with a scalpel. 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 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.

Yes, we gladly treat patients from any country. There are many low fares into Hartsfield-Jackson Atlanta International Airport and our location is a convenient 30-minute train ride by MARTA. Please reference our website for travel information.

If I had my wish, all my patients would remain in Atlanta for several weeks to allow complete wound healing. This is not practical for most men. The majority of my patients travel out of Atlanta within 48 hours of the procedure and have no problems.

I suggest a week of moderate activity following circumcision. Sedentary activity and travel is possible the same day.

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

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 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, place them 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.

As mentioned in the initial paragraph, the outcome may be customized to patient preference. Since the incision on the outer surface of the foreskin is made separately from the incision on the inner, or mucosal, surface of the foreskin, these incisions can be made at different distances from the tip of the foreskin. The effect of this is that the incision line may be moved closer to the edge of the glans or further down the shaft. This is a separate issue from the overall tightness of the skin on the penis. The tightness has to do with the overall length of foreskin removed.

Absolutely not. The structures of the penis that give it length and girth are deeper in the anatomy than the skin. The skin is the only component that is altered with a circumcision, therefore there is no possibility of altering penile size with a circumcision.

Yes, this is a frequently performed procedure in the office.

You can see photographic examples of some outcomes of revision in the Outcome Images section on the website. However, I cannot guarantee the outcome of any cosmetic procedure as there are wound healing differences from one patient to another. I have found with experience that revisions tend to heal with somewhat more scarring than initial procedures. This would seem to be the result of the blood supply to the wound edges having been altered (reduced) by the prior circumcision. That being said, it is still worth making an effort at revision, but, with realistic expectations.

No, in fact, I have performed circumcision for men over eighty years of age. The more important factor is the state of their general health to allow for minor surgery. However, minimum age is 18.

The injection is done at the base of the penis utilizing a short acting product called Lidocaine. The patient usually only feels several needle sticks and after that, no discomfort.

If you are afraid of needles and/or tend to become faint at the sight of needles, it would be best to have your procedure performed under general anesthesia. Please contact my office to speak with a member of my staff about scheduling the procedure to be performed under general anesthesia.

Yes, I do this if the patient desires it, either at the time of circumcision or as a separate procedure.

The frenulum is a structure which is not identical in configuration from man to man. I suggest removing it only if it detracts from the overall aesthetic appearance.

I respect the aesthetic wishes of my patients and will gladly perform adult circumcisions for purely cosmetic reasons.