Surgical foreskin restoration
|Foreskin restoration surgery|
Written by Aulus Cornelius Celsus some time between 14 and 37 CE, On Medicine contains the first written description of surgical circumcision reversal. Celsus was not himself a doctor, so it is possible that On Medicine (which was once part of a much larger encyclopedia) is a translation of an earlier Greek text.
Surgical foreskin reconstruction has remained largely unchanged since Celsus first described the procedure 2000 years ago. An incision is made around the base of the penis and the penile shaft is denuded (in other words, the skin is peeled off), leaving the shaft skin attached only beneath the glans penis. This skin is then pulled forward to replicate a foreskin. To tighten the new foreskin and improve its contour, a wedge-shaped section may be removed and the opening sutured shut. Skin is then harvested from the scrotum and grafted onto the penis to patch the missing shaft skin. This is performed as a series of three operations, followed by several sessions of electrolysis to kill the hair follicles in the grafted scrotal skin.
Celsus described two methods, the above method mostly for children with naturally short foreskin, and a different method for patients circumcised after the customs of certain races.
Both methods suggest a significant risk or complications and postoperative failure given the technological possibilities of the time.
Johann Friedrich Dieffenbach
The founder of modern plastic surgery, Johann Friedrich Dieffenbach (1795-1847, Berlin), dedicated a whole chapter in both of his surgical textbooks, from 1829 and 1845, on the problem of how to restore the prepuce. He entitled this operation "posthioplastice". After recapitulating Celsus methods, he offered technical improvements to prevent postoperative failure.
The Nazi era
The persecution of Jews under the Nazi regime made the state of being circumcised a life-threatening fact, making no difference whether the person had lost his foreskin for religious reasons or because of a congenital or acquired phimosis. So every circumcised man at that time was in danger of being denounced and, therefore, had to hide his genital state or have it uncircumcised. There exist several personal reports of patients undergoing and doctors performing uncircumcision during this time. One example is the work of Tenenbaum who knew several of these doctors and also examined some of the patients treated.
According to the literature, there were Polish doctors who devised hasty, crude surgical techniques to help Jews in occupied areas of Europe avoid detection. Some of these procedures were surprisingly reminiscent of those described by Celsus nearly 2000 years earlier. There is no evidence that any of these methods was continued after the collapse of the Nazi regime.
Feriz performed several operations on circumcised patients in occupied Holland. After a circumferential incision at the base of the penis the penile skin was pulled over the glans, forming the new prepuce. The proximal skin defect was then covered by burying the penis under a tunnel of ventral scrotal skin. In a second stage operation about 10 days later he mobilized the penis and closed the new skin layer at the underside of the penis. The scrotal defect was easily closed in all cases. In his publication from 1962, Feriz reported no complications, and all of his patients were satisfied with the postoperative result; none of them requested a reversal of the surgery after the war.
In 1965, Tushnet reported three different procedures to restore the prepuce depending on the age of the patient, the remaining preputial skin, and the skill of the surgeon.
Modern foreskin restoration
Since the 1970s a new movement of foreskin restoration has emerged mainly in the United States not originating from social, religious, or political demands. With routine male infant circumcision being established in America, more and more adult circumcised males are disturbed by the fact that the shape of their body had been altered after birth. Their main complaint is the loss of function; the prepuce is not just seen as a part of the human skin but referred to as a sensory organ of the body. Circumcision results in a lack of this organ and furthermore in a decrease of lubrication and sensibility of the glans because of increasing keratinization of the epithelium. Others are disturbed by the outer appearance of their circumcised penis and want to regain the natural status of a covered glans for physical and emotional wholeness and aesthetic body imaging. Some are additionally irritated by the feeling of being mutilated as an infant without the chance to have a free choice of their genital status. A high percentage of these patients even resent their parents, doctors, or culture for their circumcision.
The first report of uncircumcision for psychological reasons was reported by Penn in 1963. His article and the ones of the following years failed to give detailed information on the patient's motivation, and the authors were to a certain extent criticized for performing such a procedure at all.
In 1981, Mohl presented the first detailed analysis of psychiatric aspects in a group of eight patients seeking prepuce restoration. He described several psychological disorders in these patients as narcissistic and exhibitionistic body image, depressions, major defects in early mothering, and ego pathology.
Nowadays the understanding of the psychological motivations for uncircumcision is increasing, and the problem is dealt with more seriously.
In 1963 Penn from Johannesburg, after performing a proximal circular incision and pulling forward the penile skin to form a new prepuce, covered the denuded shaft with a "free graft", not indicating from where he took this graft.
Goodwin covered the same defect in 1990 by implantation of the penis into the scrotum first and then liberating it in a second stage. This procedure is almost identical to the method of Feriz mentioned earlier and had been slightly modified before by Greer in 1982. A pedicled island scrotal flap was used for the same purpose by Lynch and Pryor in a one-stage procedure in 1993.
One of the simplest methods involved the implantation of a small platinum ring within the tip of the "foreskin." The ring held the skin in place over the glans, resulting in a "created phimosis" (meaning that the skin could not be retracted while the ring was in place). The hope was to generate enough new skin to permanently re-cover the glans after the ring was removed. As it turned out the skin was left was a fibrous, raised band where the platinum ring had been lodged and there was not enough skin to cover the glans.
The jump to non-surgical methods
While reviewing the results of the implanted-ring procedure, an engineer living the Pacific Northwest hit upon the idea of using tape to hold the skin in place over the glans. His intent was to avoid both the surgery needed to have the platinum ring implanted and the unsightly fibrous band it left. This simple idea was circulated among a small network of men who had been sharing whatever information they could find on foreskin restoration as well as their ideas and experimentation. As a result, in 1982, BUFF (Brothers United for Future Foreskins) was born.
Despite the possible complications of surgery and the inevitable presence of scars, the main disadvantage seems to be the different color and texture of the original penile skin and the graft. This outcome may not be what the patient had expected; therefore, most foreskin restoration seekers nowadays prefer skin expansion systems, which avoid these problems.