Styles of circumcision in men
All styles involve the excision of the inner and outer foreskin with or without frenuloplasty. The style also varies upon
- Reasons for circumcision
- Anatomy of the external genitalia
- Extend of disease of the foreskin
- Mobile penoscrotal junction
- Body mass
The high/low circumcision is a way of stating how much inner skin is removed. The loose/tight style is a way of stating how much total foreskin is removed. These styles are almost independent, hence there are four circumcision styles and many mixed styles:
- Low and Loose
- Low and Tight
- High and Loose
- High and Tight
Other Styles vary due to:
- Circumcision with or without frenuloplasty
- Circumcision with the buried penis or mobile penoscrotal junction
- Circumcision with penoscrotal web
- Circumcision with Balanitis Xerotica Obliterans (BXO)
A urologist can discuss the characteristics of high and low cut, tight and loose cut types or styles of circumcision.
High and low “cut” circumcision
This concept is due to the scar line from the groove (sulcus) of the head of the penis (corona of the glans) and also depends upon how much inner skin called mucosal skin is removed. Some people believe that high “cut” means excess outer skin along with the shaft of the penile skin is cut, leaving long inner skin. However, some people have the opposite concept. Low “cut” means to cut more inner skin so that the scar line is very close to the groove of the head of the penis. The “cut” or scar line must be taken to the glans/groove of the penis. These high or low styles are not possible in all men. To put a scar line in the middle of the shaft or close to the base of the penis is not recommended as it leaves too long inner skin, which can swell up due to lymphatic drainage (lymphedema) and also over time, the inner skin stretches to become a loose fold of skin over the glans which gives unsatisfactory results in the long term. This also involves cutting too much shaft of the penile skin.
Tight versus loose circumcision
This might depend upon many factors such as how much total foreskin is removed, the mobility of penile shaft skin and attachment of the skin at the base of the penis toward the abdomen (penoscrotal junction). The tightness of skin around the penis is sometimes not possible, no matter how much foreskin is removed during the circumcision. This is due to the loose attachment of skin at the base of the penis to the body at the penoscrotal/penopubic junction. This may be affected by birth, the ageing process or overweight. Tight circumcision should not be confused with the quality of erection which depends upon other factors. The concept of loose circumcision may also be taken as similar to partial circumcision. The position of the remaining shaft of penis skin should be assessed according to the flaccid and erect state of the penis. Tight circumcision is not possible for those who have a considerable difference in size between a fully flaccid and fully erect penis and non-fixation of the penoscrotal junction. They may have a painful erection during sexual activity in the first 3-6 months if a tight circumcision is performed.
In conclusion, it is important to discuss the styles of circumcision before the operation with patients to give the best care and realistic expectations. Penis anatomy, diabetes and balanitis xerotica obliterans are also important factor for the outcome of the circumcision.
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