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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 11  |  Page : 1792-1798

Penile skin length can be predicted before frenuloplasty during routine circumcision


Department of Pediatric Surgery, Faculty of Medicine, Nisa Hospital, Medipol University, Yenibosna, İstanbul, Turkey

Date of Submission27-Dec-2021
Date of Acceptance30-May-2022
Date of Web Publication18-Nov-2022

Correspondence Address:
Prof. M Akman
Department of Pediatric Surgery, Faculty of Medicine, Nisa Hospital, Medipol University, Fatih Caddesi, Yenibosna 34197 İstanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_2038_21

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   Abstract 


Background: One of the restricting factors for surgical treatment of congenital anatomical pathologies of the penis is the skin structure. Thanks to its structure, the penis is a flexible organ structure, and the treatment can be completed without the need for a free tissue graft. Length changes are obtained on the ventral side of the penis by frenuloplasty. Aims: Our study aims to attain an objective formula that could noninvasively predict these changes on the ventral side before the procedure. Patients and Methods: In our study, 52 patients who were admitted for routine religious circumcision were included, and penile ventral and dorsal skin and inner mucosa lengths were measured before and after frenuloplasty, which is a part of the normal routine circumcision procedure and performed via the “pull and burn” method. Stitches were done to prevent scar formation in the frenuloplasty area. The results were used to estimate the length changes to be obtained on the ventral side by performing a regression analysis of the patient's weight, height, ventral and dorsal inner mucosa, and outer skin lengths. Result: Following frenuloplasty, an increase was detected in the ventral surface ranging from 20% to 177%. This increase was found to be predictable with 62.5% precision (P < 0.01) using the formulation established by assessing the ventral inner mucosa length from pre-procedure values. No significant result was determined in the regression analysis of the patients' other measurements (P > 0.05). Conclusion: Penile length changes that would occur following frenuloplasty can be calculated using a noninvasive method. Frenuloplasty, which would be performed without any vascular change, could be helpful in the surgical planning of some penile surgeries. More studies should be conducted on older boys, in anatomic deviations, and moreover, to establish a reliable formulation.

Keywords: Alterations, frenuloplasty, penis, prediction, skin


How to cite this article:
Akman M. Penile skin length can be predicted before frenuloplasty during routine circumcision. Niger J Clin Pract 2022;25:1792-8

How to cite this URL:
Akman M. Penile skin length can be predicted before frenuloplasty during routine circumcision. Niger J Clin Pract [serial online] 2022 [cited 2022 Nov 26];25:1792-8. Available from: https://www.njcponline.com/text.asp?2022/25/11/1792/361450




   Background Top


The penile skin structure and anatomical condition have a direct impact on the success of penile surgery. The potential of penile skin is the primary parameter to be assessed in surgical planning even in normal cases. In some cases, it is crucial to assess the penile skin capacity and current anatomy. Acquired or congenital anomalies of the frenulum, which is one of these anatomical structures, can be examined under the title of penile surgery as a pathology that needs to be corrected.[1],[5]

The first reserve tissue that comes to mind in penile surgery is the preputium, sacrificed through the circumcision ritual. This is why circumcision is contraindicated in individuals with penile anomalies. Although distant free tissue grafts, such as buccal mucosa, are used, they are not considered the first option. Penis flexibility, recovery, and re-epithelialization power are also crucial to achieving the targeted cosmetic appearance. The aim of our study is to assess the increase in ventral inner mucosa obtained via frenuloplasty, which is a part of the routine circumcision procedure on which there is limited data, and to identify its objective and noninvasive formulation by statistically demonstrating the predictability of this change amount, and to shed light on abnormal cases. In the literature, the effect of frenuloplasty on penile skin is missing. We could not find different studies to compare with our formulation. This study should be thought of as a first step assessment study for cases that need penis skin enlargement.[1],[2],[3],[4],[5],[6],[7],[8],[9]


   Method Top


All requirements of the “World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects” were obeyed, and standard techniques, principles, and medications were used according to the literature and textbooks. In this study, all requirements for applications and medications were strictly obeyed according to National Ethics rules. National Ethics Committee approval was not applicable. Institutional Review Board authorized informed consent forms were obtained from parents, following which they were informed verbally and in writing about the importance and objective of the study. To prevent unnecessary frenuloplasty procedures, boys who did not need routine circumcision with frenuloplasty were excluded from the study.

Fifty-four patients with normal anatomical structures who were admitted to the outpatient clinic for standard religious circumcision procedures between January and March 2021 were included in the study. To prevent unnecessary frenuloplasty procedures, boys who do not need routine circumcision with frenuloplasty were excluded. Frenuloplasty was considered better for the penis cosmetic appearance by the surgeon. The patients' ages (days), weights (grams; gr), and heights (centimeters; cm) were meticulously measured and recorded. All operations were performed as outpatient procedures under local anesthesia. The procedure started with the application of Eutectic Mixture of Local Anesthetics (EMLA®) cream. Circular local anesthesia was completed with a total of 0.9 ml of epinephrine-free lidocaine injections of 0.3 milliliters (ml) from three sites, after waiting for a minimum of 30 min and cleaning the area with povidone-iodine. In these steps, the first measurements were taken. The simple “pull and burn” technique, which was described by Gyftopoulous and was reported to have a lower risk of causing the external opening of urinary meatus (mea) stenosis, was used as the frenuloplasty procedure [Figure 1]. The second ventral measurement was taken in this step. Two or three stitches were used to prevent scar formation in the frenuloplasty area. Circumcision was performed using the dorsal slit technique. Bleeding was brought under control with bipolar electrocautery. All wounds were closed with interrupted 6/0 Vicryl Rapide sutures. Proper wound care was provided using topical antibiotics until the sutures fell off, and attention was paid to the mother's being present as an attendant in the procedure setting. During the procedure, the baby was breastfed or bottle-fed, depending on the need. All procedures were performed by a single surgeon. All measurements were done using a simple sterile millimetric ruler.
Figure 1: Before and after frenuloplasty

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Measurements were made just before the start of the surgical procedure in patients in whom the depth of local anesthesia was achieved, and the procedure area was cleaned and covered with a sterile circumcision drape. The dorsal and ventral planes were measured separately from the outer skin and inner mucosa. The upper margin of the preputium was marked using a mosquito clamp. With reference to this marked point, the ventral inner mucosa was measured up to the mea, while the dorsal inner mucosa was measured up to the glans margin. Circumcision was started with frenuloplasty, and the distance gained with this procedure was measured. The procedure was completed by continuing with the circumcision. Acetaminophen was used for analgesia after the procedure to be administered if needed. The sutures were not removed and waited to fall off.

Inclusion/exclusion criteria

• To prevent unnecessary surgery, boys who do not need routine circumcision with frenuloplasty were excluded.

• Boys with a percentile value of 25–75 were included, and others were excluded.

• The normal penis structure that does not require general anesthesia was included.

• Any cases of penile deviation were excluded.

Statistical analysis

Statistical analysis was performed using the software Statistical Package for the Social Sciences (SPSS) Version 17.0. A Linear regression test, the Forward Selection Likelihood Ratio method, was used for data analysis. Variance Inflation Factor was used to analyze multicollinearity; the Durbin Watson statistic was used for autocorrelation in the residuals from a statistical regression analysis; and Mahalanobis, Cook's, and Centered leverage values were used to detect outliers. Age, weight, height, dorsal outer skin, dorsal inner mucosa, ventral outer skin, and ventral inner mucosa pre-frenuloplasty length (millimeters; mm) were included in the regression analysis to estimate the value after ventral inner mucosa frenuloplasty as an independent variable. In the inclusion of the values, those with a correlation value < 0.80 were added to the analysis. The results were considered statistically significant at P < 0.05.


   Results Top


Patients were followed up routinely during the post-circumcision period. None of the patients showed complications, and none of the patients required reintervention. There were no emergency department attendances or admissions, there was no scar formation either. In our series, no symptoms or signs of meatal stenosis were present in any patient in follow-up.

It was determined that the age values of the patients ranged between 2 and 409 days (Mean age: 123.69 days) and the weight values ranged between 3100 and 14280 g (Mean weight: 6620.76 g), while the height values ranged between 32 and 80 cm (Mean height: 59.81 cm). The distribution of patients' age (day), weight (gram; g), and height (centimeter; cm) baseline values were calculated [Table 1].
Table 1: Basic evaluations

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By simple assessment, the distribution of ventral outer skin lengths, as well as the increased length distribution values of these values after frenuloplasty, were measured while ventral inner mucosa was considered [Table 1] and [Table 2].
Table 2: Ventral mucosa evaluations

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Statistics

Before and after frenuloplasty, the ventral inner mucosa was 13.56 ± 4.25 mm and 23.33 ± 4.01 mm, respectively. The increase was measured as 9.78 ± 2.54 mm (81.37 ± 37.56%). It was observed that there was a significant increase after frenuloplasty (Wilcoxon; P < 0.001) [Figure 2].
Figure 2: Ventral mucosal alterations, before and after surgery

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Weight, height, age, dorsal inner and outer measurement values, and ventral outer and pre-procedure length values were subjected to regression analysis, and the increase in ventral inner mucosa length value after the procedure was compared separately. In the regression analysis, the P value calculated in the possible change value of dorsal skin and mucosa values and ventral skin length values after frenuloplasty was not found to be significant (P > 0.05).

Following this assessment, it was demonstrated in the analysis of the pre-procedure and post-procedure ventral inner mucosa values that the possible change in the pre-procedure ventral inner mucosa length value and the P value in the analysis of the length change after the procedure could be predicted with a certain precision (P < 0.05) [Table 3], [Table 4], [Table 5].
Table 3: Correlations 1

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Table 4: Correlations 2

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Table 5: Correlations 2

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Regression analysis: In this analysis, to bring the correlation under control, two patients with the largest and smallest pre-frenuloplasty ventral inner mucosa length values were excluded from the study, and 50 patients with all data were included in the model. The correlation problem of pre-frenuloplasty ventral inner mucosa was eliminated. In the established model, it was determined that the pre-frenuloplasty ventral inner mucosa length value was effective on the post-frenuloplasty ventral inner mucosa length value (P < 0.001). The explanatory coefficient (estimation rate) of the model was determined as 62.5% [Table 6].
Table 6: Coefficients a

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Coefficientsa

[INLINE:1]

Based on the results obtained from the regression analysis, it was found that the increase in the post-frenuloplasty ventral skin length of the penis could be accurately predicted by 62.5%.

Interestingly, a one-unit increase in the dorsal inner mucosal value has been found to reduce “the percentage increase” by 5.518% [Table 7].
Table 7: Linear regression analysis. Dorsal and ventral inner mucosa relationships

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   Discussion Top


The penile frenulum, or frenum, is a mucosal fold similar to the sublingual frenulum that adheres between the ventral surface of the foreskin and the glans penis and acts as a natural retractor of the foreskin on the glans. During embryological penis development, the growth rate of the preputial skin decreases on the ventral surface, whereas it increases in the dorsal plane. The frenulum is formed during the fusion of the prepuce in the ventral plane of the glans. The frenulum can be considered part of the penile capacity. This structure might develop congenitally short, or it might lead to thickening and shortening of the tissue of the region like in previous infections.[3],[4],[5],[6],[7],[8],[9]

It has been revealed that frenuloplasty with local anesthesia has the lowest complication rate when interventions are performed rapidly. Moreover, there is no information in the literature showing that scar tissue present in the frenulum region leads to major complications in surgery of the region.[10],[11]

The primary advantage of the “pull-and-burn” method, which we used in our study, is that it gradually enlarges the first mucosal tear without damaging the underlying vessels through the applied traction and contributes to penile aesthetics without requiring extensive fulguration. Gyftopoulos et al., who described this technique in their study, suggested that there is no risk of mea stenosis by demonstrating that the ventral venous structure is preserved after the procedure. Gyftopoulos et al. did not focus on length changes in their study.[11],[12],[13]

It has been stated that Frenuloplasty via CO2 Laser coagulation, which is one of the Frenuloplasty methods described by Duarte et al. and successfully applied in three cases, is effective but unnecessarily expensive.[9]

As it has been suggested in the study by Dockray et al., in the literature, there are a series of frenulum surgeries that have been performed in pathologies such as coital pain caused by a short frenulum. Penile ventral changes were not elaborated on in these series. The main subjects of these studies are the correction of the restrictive structure of the frenulum, patient satisfaction, and cosmetic appearance. Likewise, Gallo et al. also conducted similar studies in their research. Length changes were not discussed in either of these two studies.[14],[15]

It has been revealed that frenuloplasty is frequently used in routine circumcision practices. In these studies, the effects of the procedure on mea stenosis were reported in detail. However, in our brief literature review, we did not find a study that included the post-procedure length measurements of the penis ventral. In one study, there was no comment apart from the statement that a small amount of increase was observed in length following frenuloplasty. Our study is the first in this respect. The changes in the penis ventral length generated by frenuloplasty should be investigated further by conducting additional research on the subject.[11],[12],[16],[17],[18],[19],[20],[21]


   Conclusion Top


In penile surgery, the pre-procedure skin capacity of the patient is the primary determinant impacting the targeted cosmetics. Other factors related to the patient or surgery are driven by this factor. In a scheduled surgery, knowing the patient's skin capacity and the potential outcome of the procedure before performing it might be important for the planning to be made.

Frenuloplasty, which is performed during circumcision, is a procedure that can be done easily and rapidly. In our study, routine religious circumcision was performed, and it was determined that the addition of the “pull and burn” technique did not cause any challenges. Changes in the penis size following the frenuloplasty technique performed using the “pull and burn'' method, which is simple and has a low risk of causing mea stenosis, can be predicted to a certain extent before the procedure. It can be helpful in the surgical planning of pathologies such as a buried penis.

Based on the two regression analyses in our study, predictable skin length change was detected with a precision of 62-65%. Thanks to the two formulations, we have suggested statistically that penile skin capacity can be assessed via a noninvasive method. Besides, the formulation may also guide further studies.

Further studies

• Larger series and older groups should be studied to generalize formulation.

• Patient groups with an out-of-limit percentile should be assessed.

• Penis aesthetics, which is formed as a result of frenuloplasty, should be assessed in terms of patient satisfaction.

• There is a need to develop frenuloplasty techniques with further studies where the risk of mea stenosis will not be seen.

• Dorsal and Ventral inner mucosa relationships should be verified.

Limitations

• The low age of our patient group

• Patient percentile values included in the group are fixed between certain values

• Variation in the value distributions of penile skin length in each plan and patient

• Risk of development of meatal stenosis following frenuloplasty

• Cases of anatomical deviation absence

Abbreviations

g: Gram

cm: Centimeter

mm: Millimeter

ml: Milliliter

P: P value or calculated probability

Mea: External opening of the urinary meatus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wu M, Chen R, Xu Y, Shi X, Song R, Sun M, et al. At the forefront of penile surgical reconstruction: A bibliometric study of the 100 most-cited articles. Aesth Plast Surg 2021. doi: 10.1007/s00266-021-02609-5.  Back to cited text no. 1
    
2.
Ruben T. Adamyan RT, Kamalov AA, Ehoyan MM, Urshevich EN, Sinelnikov MY. Scrotal tissues: The perfect material for urogenital reconstruction. Plast Reconstr Surg Glob Open 2020;8:e2948. doi: 10.1097/GOX.0000000000002948.  Back to cited text no. 2
    
3.
Bickell M, Jonathan Beilan J, Wallen J, Wiegand L, Carrion R. Advances in surgical reconstructive techniques in the management of penile, urethral, and scrotal cancer. Urologic Clinics 2016;43:545-9.  Back to cited text no. 3
    
4.
Pyrgidis N, Sokolakis I, Dimitriadis F, Hatzichristodoulou G. Frenuloplasty: From alpha to omega. Int J Impot Res 2022;34:347-52.  Back to cited text no. 4
    
5.
Guo L, Zhang M, Zeng J, Liang P, Zhang P, Huang X. Utilities of scrotal flap for reconstruction of penile skin defects after severe burn injury. Int Urol Nephrol 2017;49:1593-603.  Back to cited text no. 5
    
6.
Dwyer ME, Salgado CJ, Lightner DJ. Normal penile, scrotal, and perineal anatomy with reconstructive considerations. Semin Plast Surg 2011;25:179-88.  Back to cited text no. 6
    
7.
Choi JA, Kwak JH, Lim KR. Utility of groin flap in penile reconstruction. J Wound Manag Res 2020;16:150-7.  Back to cited text no. 7
    
8.
Dockray J, Finlayson A, Muir GH. Penile frenuloplasty: A simple and effective treatment for frenular pain or scarring. BJU Int 2012;109:1546-50.  Back to cited text no. 8
    
9.
Duarte AF, Correia OJ. Laser CO2 frenuloplasty: A safe alternative treatment for a short frenulum. J Cosmet Laser Ther 2009;11:151-3.  Back to cited text no. 9
    
10.
Rajan P, McNeill SA, Turner KJ. Is frenuloplasty worthwhile? A 12-year experience. Ann R Coll Surg Engl 2006;88:583-4.  Back to cited text no. 10
    
11.
Quartey JK. Anatomy and blood supply of the urethra and penis. In: Schreiter F, Jordan GH, editors. Reconstructive Urethral Surgery. Springer-Verlag Berlin Heidelberg: Springer; 2006. p. 11-7.  Back to cited text no. 11
    
12.
Howe RSV. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006;45:49-54.  Back to cited text no. 12
    
13.
Gyftopoulos KI. Meatal stenosis after surgical correction of short frenulum: Is the “pull-and-burn” method the way to go? Urol Ann 2018;10:354-7.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Gyftopoulous K. Male dyspareunia due to short frenulum: the suture-free, 'pull and burn' method. J Sex Med 2009;6:2611-4.  Back to cited text no. 14
    
15.
Whelan P. Male dyspareunia due to short frenulum: An indication for adult circumcision. BMJ 1977;2:1633-4.  Back to cited text no. 15
    
16.
Gallo L, Perdonà S, Gallo A. The role of short frenulum and the effects of frenulectomy on premature ejaculation. J Sex Med 2010;7:1269-76.  Back to cited text no. 16
    
17.
Kayes O, Li CY, Spillings A, Ralph D. Frenular grafting: An alternative to circumcision in men with a combination of tight frenulum and phimosis. J Sex Med 2007;4:1070-3.  Back to cited text no. 17
    
18.
Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol 2011;7:526-8.  Back to cited text no. 18
    
19.
Kajbafzadeh AM, Kajbafzadeh M, Arbab M, Heidari F, Arshadi H, Milani SM. 326 Post circumcision meatal stenosis in the neonates due to meatal devascularisation: A comparison of frenular artery sparing, plastibell and conventional technique. J Urol 2011;185 Suppl: e132. https://doi.org/10.1016/j.juro.2011.02.409.  Back to cited text no. 19
    
20.
Persad R, Sharma S, McTavish J, Imber C, Mouriquand PD. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995;75:91-3.  Back to cited text no. 20
    
21.
McGrath K. The frenular delta. A new preputial structure. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. New York: Kluwer Academic/Plenum Publishers; 2001. p. 199-206.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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