Foreskin restoration

Foreskin restoration is the process of expanding the residual skin on the penis, via surgical or non-surgical methods, to create the appearance of a natural foreskin (prepuce) covering the glans penis. Foreskin restoration techniques are most commonly undertaken by men who have been circumcised or who have sustained an injury, but are also used by uncircumcised men who desire a longer foreskin and by men who have phimosis.

A series of steps for non-surgical foreskin restoration.

History

In classical Greek times the exposure of the glans of the penis was considered offensive and men with short foreskin would wear the kynodesme to prevent its accidental exposure.

A form of foreskin restoration, historically known as epispasm, was practiced among some Jews in Hellenistic and Roman societies.

Some European Jews sought out underground foreskin restoration operations during World War II as a method to escape Nazi persecution.

The practice was revived in the late twentieth century using modern materials and techniques. In 1982 a group called Brothers United for Future Foreskins (BUFF) was formed, which publicized the use of tape in non-surgical restoration methods. Later in 1991, another group called UNCircumcising Information and Resources Centers (UNCIRC) was formed.

The National Organization of Restoring Men (NORM) was founded in 1989 in San Francisco, as a non-profit support group for men restoring the appearance of a foreskin. It was originally known as RECAP, an acronym for the phrase Recover A Penis. In 1994 UNCIRC was incorporated into this group. Since its founding, several NORM chapters have been founded throughout the United States, as well as internationally in Canada, the United Kingdom, Australia, New Zealand, and Germany.

Surgical techniques

Surgical methods of foreskin restoration, sometimes known as foreskin reconstruction, usually involve a method of grafting skin onto the distal portion of the penile shaft. The grafted skin is typically taken from the scrotum, which contains the same smooth muscle (known as dartos fascia) as does the skin of the penis. One method involves a four stage procedure in which the penile shaft is buried in the scrotum for a period of time. Such techniques are costly, and have the potential to produce unsatisfactory results or serious complications related to the skin graft.

British Columbian resident Paul Tinari was held down and circumcised at eight years old, in what he stated was "a routine form of punishment" for masturbation at residential schools. Following a lawsuit Tinari's surgical foreskin restoration was covered by the British Columbia Ministry of Health. The plastic surgeon who performed the restoration was the first in Canada to have done such an operation, and used a technique similar to that described above.

Nonsurgical techniques

File:Ca before after.jpg

Restoration by using combination of cross-taping and modified T-taping method.

Nonsurgical foreskin restoration, accomplished through tissue expansion, is the more commonly used method of foreskin restoration. Both the skin of the penile shaft and the mucosal inner lining of the foreskin, if any remains after circumcision, may be expanded.

Dual Tension Restorer applied to a circumcised penis for non-surgical foreskin restoration.

The skin is pulled forward over the glans, and tension is applied manually, by using weights or elastic straps. In the second two cases a device must be attached to the skin; surgical tape is often used. An example of a device using elastic straps is the T-Tape method, which was developed in the 1990s with the idea of enabling restoration to take place more rapidly. Many specialized foreskin restoration devices (like Dual Tension Restorer shown in the picture) that grip the skin with or without tape are also commercially available. Tension from these devices may be applied by weights or elastic straps, by pushing the skin forward on the penis, or by a combination of these methods.

The amount of tension produced by any method must be adjusted to avoid causing injury, pain or discomfort, and provides a limit on the rate at which new skin can be grown. There is a risk of damaging tissues from the use of excessive tension or applying tension for too long. Websites about foreskin restoration vary in their recommendations, from suggesting a regimen of moderate amounts of tension applied for several hours a day, to recommending periods of higher tension applied for only a few minutes per day.

Tissue stretching has long been known to stimulate mitosis, and research shows that regenerated human tissues have the attributes of the original tissue. Unlike conventional skin expansion techniques, however, the process of nonsurgical foreskin restoration may take several years to complete. The time required depends on the amount of skin available to expand, the amount of skin desired in the end, and the regimen of stretching methods used. Patience and dedication are needed; support groups exist to help with these (see External links section). The act of stretching the skin is often described informally as "tugging" in these groups, especially those on the internet.

Artificial foreskins

Instead of growing new skin, some men may opt to use an artificial covering for the glans. Men who have less extreme circumcisions may also be able to use a device to hold the foreskin over the glans (similar to the ancient Greek kynodesme). Viafin-Atlas sells a "prosthetic foreskin" made of latex that protects the glans in a moist environment. Another product is Manhood. It is an undergarment that holds the skin in place for people who have loose circumcisions. Manhood is also used as a "hood" to protect the circumcised man's exposed glans from chafing and is made of a double layer of soft material. The outer layer chafes against undergarments and minimises friction on the inner layer and consequentally the glans.

Results

Results of surgical foreskin restoration are much faster, but are often described as unsatisfactory, and most restoration groups advise against them.

Results of non-surgical methods vary widely, and depend on such factors as the amount of skin present at the start of the restoration, degree of commitment, technique, and the individual's body. Foreskin restoration only creates the appearance of a natural foreskin; certain parts of the natural foreskin cannot be reformed. In particular, the ridged band, a nerve-bearing tissue structure extending around the penis just inside the tip of the foreskin, which helps to contract the tip of the foreskin so that it remains positioned over the glans, cannot be recreated. Restored foreskins can appear much looser at the tip and some men report difficulty in keeping the glans covered. Surgical "touch-up" procedures exist to reduce the orifice of the restored foreskin, recreating the tightening function of the band of muscle fibers near the tip of the foreskin, though they have not proven successful in every case. A loose effect can also be alleviated by creating increased length, but requires a longer commitment to the restoration program. In addition, several websites claim that the use of O-rings during the restoration program can train the skin to maintain a puckered shape.

Regeneration of the Human Male Foreskin

Recently there has been growing interest in regenerative medicine as a means to regenerate the human male foreskin. This option, unlike foreskin restoration, would result in a true human male foreskin being regrown. Pioneers in the field include Dr. Anthony Atala of the Wake Forest Institute of Regenerative Medicine (WFIRM). .

In early 2010, Foregen, a non-profit organization dedicated to funding a clinical trial for the purposes of regrowing the human male foreskin, had been founded. If they raise enough funds, a clinical trial has been scheduled for late 2010. .

The proposed method would involve placing the patient under general anaesthesia. The penile skin will be opened at the circumcision scar, while the scar tissue is surgically debrided. A biomedical solution will then be applied to both ends of the wound, which will make use of the DNA in the patient's own cells to cause the foreskin to regenerate. A biodegradable scaffold will be used to offer support for the regenerating foreskin..

Physical aspects

The natural foreskin has three principal components, in addition to blood vessels, nerves and connective tissue: skin, which is exposed exteriorly; mucous membrane, which is the surface in contact with the glans penis when the penis is flaccid; and a band of muscle within the tip of the foreskin. Generally, the skin grows more readily in response to stretching than does the mucous membrane. The ring of muscle which normally holds the foreskin closed is often completely removed in the majority of circumcisions and cannot be regrown, so the covering achieved via stretching techniques is usually looser than that of a natural foreskin. According to some observers, however, it is difficult to distinguish a restored foreskin from a natural foreskin because restoration produces a "nearly normal-appearing prepuce."

Nonsurgical foreskin restoration does not restore portions of the frenulum or the ridged band removed during circumcision. Although not commonly performed, there are surgical "touch-up" techniques that can re-create some of the functionality of the frenulum and dartos muscle.

The process of foreskin restoration seeks to regenerate some of the tissue removed by circumcision, as well as providing coverage of the glans. According to research, the foreskin comprises over half of the skin and mucosa of the human penis.

In some men, foreskin restoration may alleviate certain problems they attribute to their circumcisions. Such problems, as reported to an anti-circumcision group by men circumcised in infancy or childhood, include prominent scarring (33%), insufficient penile skin for comfortable erection (27%), erectile curvature from uneven skin loss (16%), and pain and bleeding upon erection/manipulation (17%). The poll also asked about awareness of or involvement in foreskin restoration, and included an open comment section. Many respondents and their wives "reported that restoration resolved the unnatural dryness of the circumcised penis, which caused abrasion, pain or bleeding during intercourse, and that restoration offered unique pleasures, which enhanced sexual intimacy."

Foreskin restoration can be a means for a man (with a 'tight' circumcision) and his sexual partner to experience the rolling and gliding action of the penile shaft skin along the erect shaft. This mode of stimulation is not available to a 'tight' circumcised men without loosening of the penile shaft skin. Loose circumcisions do have gliding effect but not of the rigid band of skin in the foreskin.

Some men who have undertaken foreskin restoration report a visibly smoother glans, which some of these men attribute to decreased levels of keratinization following restoration. A study that investigated the effect of glans coverage on levels of keratinisation found no difference in keratin levels within the group studied.

Although some research studies have found no measurable difference with respect to glans sensitivity, some men have reported a qualitative improvement in sensitivity of the glans. Some have suggested that the perceived sensitivity gains of the glans are psychological, with glans sensitivity itself being unaffected. According to some, however, protecting the glans from dryness and abrasion with clothing can allow the glans texture to change to a quality similar to that of intact genitalia among men who undergo this process.

Emotional, psychological, and psychiatric aspects

Foreskin restoration has been reported as having beneficial emotional results in some men, and has been proposed as a treatment for negative feelings in some adult men about their infant circumcisions.

Such negative feelings were discussed in the poll mentioned above. Respondents suffered from: emotional distress, manifesting as intrusive thoughts about one's circumcision, including feelings of mutilation (60%), low self-esteem/inferiority to intact men (50%), genital dysmorphia (55%), rage (52%), resentment/depression (59%), violation (46%), or parental betrayal (30%). Many respondents (41%) reported that their physical/emotional suffering impeded emotional intimacy with partner(s), resulting in sexual dysfunction. Almost a third of respondents (29%) reported dependence on substances or behaviors to relieve their suffering (tobacco, alcohol, drugs, food and/or sexual compulsivity).

In "Prepuce Restoration Seekers: Psychiatric Aspects," a 1981 report published in the Archives of Sexual Behavior, four men seeking surgical foreskin restoration were examined. The report provides descriptions of the motivational forces behind the desire for foreskin restoration among these four men.

Criticism

Kirby states that restoration procedures are "certainly feasible, but they are not without considerable risks, not least of which is loss of sensation of the penile shaft", and comments that "the placebo effect ... cannot be discounted."

See also

• NORM-UK
• Circumcision
• Foreskin
• Foreskin restoration devices
• Penis
• Ridged band
• Phalloplasty
• T-Tape
• Point of equilibrium of foreskin

Books

• Griffin, Gary M. (1992). Decircumcision: Foreskin Restoration, Methods and Circumcision Practices. Los Angeles: Added Dimensions Publishing. ISBN 1-879967-05-7.
• Bigelow, Jim (1992). The Joy of Uncircumcising!: Exploring Circumcision: History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights. Aptos, CA: Hourglass Book Publishing. ISBN 0-9630482-1-X. (foreword by James L. Snyder)

External links

• NORM - National Organization of Restoring Men (U.S.)
• CIRP Foreskin restoration for circumcised males
• NORM-UK - National Organization of Restoring Men (UK)
• Payne, Roy M. (2001-03). "My responses to a few Frequently Asked Questions about Non-Surgical Foreskin Restoration:" (PDF). {{cite web}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Brandes, S.B. (1999). "Surgical methods of restoring the prepuce: a critical review" (PDF). BJU International. 83 (Suppl. 1): 109–13. doi:10.1046/j.1464-410x.1999.0830s1109.x. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)