Mater Hospital Outpatient Department, The Range QLD 4700, AustraliaAustralia
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Circumcision is one of the most common surgical procedures worldwide, and like all other operations, there is a risk of complication. Our patient had an excessive skin excision circumcision which led to a symptomatic partially buried penis. A free split skin graft was successfully applied to correct a large circumferential skin defect with relief of symptoms, preservation of function and good cosmetic outcome.
Keywords: surgical procedures; operations; skin excision; buried penis
Male circumcision is a common surgical procedure having been performed on 30% of the worldwide population. 1,2 It is subject to continue debate with varying public attitudes with some evidence supporting circumcision for hygiene purposes and prophylaxis of penile cancer. As with all surgical procedures, there is a complication rate and depending on the skill and training of the individual performing the circumcision, this can be as high as 15% with the median complication rate being 1.6%.3 While a common procedure, if done incorrectly, it can have long-term, and debilitating complications, affecting sexual function, as well as significantly impacting the mental and emotional state of the individual.
Figure 3. Day 2 Post-Operation. Figure 4: 6 Weeks Post-Grafting. Figure 5: 6 Months Post-Proce- dure Showing Healed Skin Graft.
Deficit and the Harvesting of Skin from the Anterior Abdominal Wall.
Excessive excision of skin during circumcision results in a buried penis, leaving insufficient skin to accommodate the full length of the penis particularly during an erection. This can result in pain associated with erections, decreased penis length, impaired sexual function and poor aesthetic appearance. There is little data available on the rate of this complication, but the rate of complication is likely very under-reported and under-treated. This case report describes the use of split skin graft to correct a complication of excessive skin excision during circumcision. There have been numerous techniques described to correct this complication including; healing by secondary intention, dorsal Z-plasty for small skin deficits, and skin re-surfacing. 4 Techniques that have been described to correct this defect are complex and have high rates of failure, complicated and poor cosmetic results. The challenges with providing skin coverage for the penis shaft differ from other parts of the body in that the penis requires the ability to accommodate the elongation and engorgement during erection, as well as cosmesis, and preservation of sensation.
To correct a skin defect from a buried penis, the use of autologous free skin grafts from a hairless and subtle donor site have the benefit of being able to correct a greater defect than Z-plasty or scrotal skin advancement, while preserve the sur rounding anatomy and give a greater cosmetic outcome. The use of split skin graft for skin resurfacing of the penis is not a frequently described method in the literature with only two cases reported in the last five years. 5,6 However, as demonstrated by this case, it is a simple yet effective technique that can be utilised to correct a large skin defect as well as to maintain the function of the skin excised during the circumcision.
The donor site we recommend is the skin above the level of the inguinal region, easy to harvest and good quality skin due to his elasticity, softness and hairless, making this region ideal to replace the skin in the penile shaft with good cosmetic and functional effect. This region can provide grafts big enough to cover the whole shaft of the penis without leaving big and anaesthetic scars in the harvesting area. The use of split skin graft decreases and diminishes the scaring and retraction of the graft compared with the full thickness.
This technique can be used in paediatric and adult patients that need a big size graft. We have been using this method in a Burmese patient with an indurated shaft of the penis due to injection of Benzene that covers the full length of the penis. A split skin graft from the groin was used to cover the full length of the penis, from base to glans with a good cosmetic and functional result and with a small lineal scar in the donor site.
Radical skin excision during routine circumcision is an under reported complication, one that can have profound effects on the individual including pain, self esteem and sexual function, and mostly left untreated, with a great impact in the individual. This complication can be avoided by taking extra precautions during circumcision. We can see in this case, free split skin grafting is an alternative method for correcting large skin deficit of the penis following excessive skin excision of circumcision, and is suitable for use in children and adults.
The authors declare that they have no conflicts of interest.
Consent has been taken from the patient for purpose of using patient photographs for publication in print or on the internet.