Adult circumcision styles involve the amount of excision of the inner and outer foreskin with or without frenuloplasty. The style also varies depending on
- Reasons for circumcision
- Anatomy of the external genitalia
- The extent of the disease of the foreskin
- Mobile penoscrotal junction
- Body mass
The high/low styles of circumcision are how much inner skin ( musua) is removed. The loose/tight style is a way of expressing how much total outer 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 of circumcision vary due to:
- Circumcision with or without frenuloplasty
- Reconstruction of the foreskin around the penis shaft in case of short penile skin
- Circumcision with the buried penis or mobile penoscrotal junction
- Circumcision with the penoscrotal web
- Circumcision with Balanitis Xerotica Obliterans (BXO) leaves almost no scarred skin.
A urologist can discuss the characteristics of high and low circumcision cuts, as well as tight and loose circumcision styles.
High and Low “Cut” Styles of Circumcision
This concept arises from the scar line extending away from the groove (sulcus) of the head of the penis (corona of the glans) and also depends on the amount of inner skin (mucosal skin) removed.
Some believe that a high “cut” results in less outer skin and the shaft of the penile skin being cut more, leaving a considerable length of inner skin. Leaving the inner skin longer may make it more or less sensitive and cause it to become loose again.
However, some people have the opposite concept.
Low “cut” means to cut more of the 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 for all men.
Putting a scar line in the middle of the shaft or close to the base of the penis is not recommended as it leaves too much 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.
It’s important to note that keeping too much inner foreskin can lead to problems. The thin, stretchable inner skin may permanently stretch if significant postoperative swelling results in a loose, puffy appearance. While this won’t affect penile function, it can be unsightly.
This also involves excessive cutting of the penile shaft.
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 the attachment of the skin at the base of the penis toward the abdomen (penoscrotal junction). The tightness of skin around the penis is sometimes impossible, 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, ageing, or being 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 similar to partial circumcision. The position of the remaining shaft of the penis skin should be assessed according to the flaccid and erect states of the penis.
Tight circumcision is impossible for those with a considerable size difference between a fully flaccid and fully erect penis and a 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.
Tight skin after circumcision may become loose over time.
Conclusion
In conclusion, it is essential to discuss the styles of circumcision with patients before the operation to give the best care and realistic expectations. Penis anatomy, diabetes, healthy inner foreskin and balanitis xerotica obliterans are also essential factors for the outcome of the circumcision.
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