[ ARC forum 2 ]
Written by Paul B. at 14 Apr 2003 23:21:03: Option - Dorsal Slit.
As an answer to: Re: ANy cures for pimosis? written by Ivan at 14 Apr 2003 18:02:21:
> I don't follow this - the purpose of the stretching exercises is to make new skin grow to allow for looseness and mobility.
Yes, you've picked it dead right there. Surgery merely rearranges the skin, but does not "exercise" it or improve its function. Slow and progressive stretching, when applied to scar tissue (not that scar tissue is necessarily present) actually alters and "normalises" its structure.
In the case of the foreskin, the intent is to stretch to the point where the foreskin can move normally, after which normal "exercise" will maintain and continue the normalisation process (unless some chronic inflammatory process is present, such as the use of soap, chronic presence of Candida due to diabetes, perhaps HPV infection, or the legendary LSA).
> How is cutting then sewing back together going to add additional skin?
It adds nothing, but it makes the hole bigger.
> I know you said that the skin would be stretched before it is sewn back, ... It's not like letting out the seams of your suit after all.
It was a figure of speech on his part.
> It seems like it would have the same springiness as before and snap right back to its prior state. If it were sewn back at an angle from original, then there would be some strange loose flaps. How does this work?
I think you have been well answered by the pictures. You can see that the slit is made and since that slit goes through two layers of the foreskin, then the inner layer is sewn to the outer layer so that in healing, the "vee" becomes permanent.
It would appear that if the photographs are not of Robin himself, that they are an excellent facsimile of what he chose. It is apparent from his ruminations on the site, that he is not entirely happy with the appearance and has agonised at length over the cosmetic result and how it could have been better. For a start, the "strange loose flaps" have been reduced by making not a cut, but the removal of a wedge of foreskin - Robin contemplates what the best shape of the "wedge" might be to optimise the appearance.
This is where preputioplasty comes into play. As Robin observes, this is an overlooked and underdeveloped area of cosmetic surgery, which indicates how much penile function is devalued by embarrassment on both sides (laity and profession). As such, it certainly points out that in contrast to persistent stretching, a dorsal slit generally does involve removal of tissue, so one ends up with less, not more, and therefore, less flexibility.
The pictures also demonstrate a number of aspects of the problem. In his case, there would appear to be a degree of scarring and thickening of the foreskin in the first picture, though this appearance may simply be a result of the retraction manoeuvre. The "short-range" pictures certainly evidence swelling from the operation which has mostly settled by the six weeks.
The last picture shows a result that is obviously fairly functional and the swelling appears to have largely abated, but cosmetically demonstrates the limitation of releasing only the dorsal part. You have to say (as Robin does) that it would be better to perform multiple smaller "plasties" around the periphery.
If you were to do so of course, you would also prefer them to be as small as possible, in which case, you would want to stretch them during the healing process so they gave the maximum "release" and if you follow that line (which is standard surgical practice as for example after all joint replacement procedures), you inexorably come back to the conclusion that the best approach is to do no cutting, but use whatever techniques will amplify the effectiveness of stretching itself.
Such techniques might well include steroid and a dilator worn in-place - the demonstration of what is often termed "pinhole" phimosis in the first picture virtually begs the suggestion to put a tubular dilator in there, doesn't it?