Too Much or Too Little
Good circumcision outcomes are when the correct amount of foreskin is removed. Removing too much or too little foreskin is the most common concern or complaint parents have after a circumcision. Because there is a wide range of “normal amount” of skin left after circumcision, there is a wide range of opinions on “what looks normal” for a circumcised penis. For this reason, there is no single standard for a successful circumcision outcome.
Furthermore, appearance very much depends on the anatomy of the child – the thickness of the pubic fat pad around the base of the penis. Because the penis is attached to the pubic bone it does not ‘float’ with skin level. The thicker the fat pad the more the penis goes into the fat pad and skin over the top of the penis. This can cause even the most well-executed circumcision to appear as if too much skin remains — even to the extreme where it is hard to determine if circumcision was even done.
The best way to judge the amount of remaining skin is to push down on the fat pad at the base of the penis with two fingers and then inspect. Typically, the circumcision outcome is acceptable if the glans is mostly exposed and the skin remaining is satisfactory when pushing down on the pubic fat pad. If the penis skin is too tight, with or without depressing the pubic fat pad, then it is likely that too much skin was removed. In many cases, this is an ‘eye of the beholder’ assessment.
Revising a circumcision almost always involves an outpatient surgical procedure with anesthesia. Of course, it is easier to remove excess skin than to correct a circumcision outcome where too much skin was removed. In fact, in most cases, it is best not to surgically revise a circumcision when too little skin remains. With time (care and erections), the too-tight skin will relax and stretch and not require revision.
Too Little Foreskin Removed
Too little foreskin may be removed during a newborn circumcision, leaving the appearance of partial circumcision or a look similar to a newborn who is born with a “natural circumcision.” This is not a medical concern, but when the desire is the appearance or benefit of circumcision, having too little foreskin removed may be a concern for the parents. Certainly, this is preferable to having too much removed.
Irregular or “Lopsided”
Newborn circumcision may cause too much or too little skin to be present at any point around the 360º circle of the penis. If the clamp or ring is not carefully and evenly placed, it will result in asymmetry or differing amounts of skin around the penis. This can cause an unsatisfactory appearance and added care issues (see Care).
Newborn clamps and rings are intended for use on uncircumcised penises where normal and equal amounts of the foreskin are present around the complete 360º circumference of the penis.
If a mild birth defect is present (i.e. chordee or webbed penis) prior to infant circumcision, the procedure is more likely to result in an irregular or lopsided appearance. The provider should take into account any slight variations in the uncircumcised penis when performing the procedure.
Note the presence of more white shaft skin near the abdomen and significantly less white shaft skin near the scrotum– this was a “crooked” circumcision resulting in a less than ideal outcome.
Penile adhesions are considered normal physical attachments of the inner foreskin and the glans (head) of the penis. These adhesions occur when the skin and glans “stick” together. They do not become permanent attachments and will separate over time when under tension. With pulling penis skin downward (retracting the skin), penis cleaning and hygiene care, and with erections the adhesions usually separate on their own. Many times the adhesions will separate in one area and still be attached in other areas. Over time the remaining adhesions will separate.
Many primary care providers recommend lysis or intentional separation of the adhesion to expedite the process and avoid collection of smegma (dead skin material) under the adhesions. Others feel it is best to leave them alone and let the adhesions separate naturally. Either way is reasonable, but parents need to be aware that the adhesions commonly reattach if not separated daily or if not under natural tension to prevent re-adhesion. Regardless of how the adhesions separate, the area will swell and look red and look like an area of infection, which is not usually the case. The swelling and redness are expected and should only require that the areas be kept clean with soap and water. It is also a good idea to allow air to the area and to sometimes apply a small amount of a non-medicated ointment like vaseline to avoid reattachment.
Adhesions of the foreskin to the head of the penis can make it difficult to picture or predict how the circumcised penis will look without the adhesions. If extra shaft skin is still present after a circumcision the adhesions may not separate as early because of the decreased tension on the area and lessened chance of spontaneous separation. Parents need to understand that adhesions are not a medical concern and that if the skin is under tension it will separate sooner, and if extra skin or surrounding fat pad causes the penis to be inward (hidden), then separation may take longer.
Penile Skin Bridges
Penis or foreskin bridges can occur following circumcision. These skin bridges occur shortly after a circumcision when the raw or unhealed circumcision tissue remains in contact with the head or glans of the penis for a short length of time. Children are ‘super healers’ and this contact of raw tissue or skin can permanently grow together and form a bridge of tissue. Penile skin bridges are different from adhesions. Adhesions do not become permanent attachments whereas foreskin bridges are permanent until cut or removed.
We are not providing medical advice; if you need advice, please consult with your child’s physician or care provider regarding personal concerns, risks, and outcomes.