Foreskin restoration

Foreskin restoration is the process of expanding the skin on the penis to reconstruct an organ similar to the foreskin, which has been removed by circumcision or injury. Foreskin restoration is primarily accomplished by stretching the residual skin of the penis, but surgical methods also exist. Restoration creates a facsimile of the foreskin, but specialized tissues removed during circumcision cannot be reclaimed. Actual regeneration of the foreskin is experimental at this time. Some forms of restoration involve only partial regeneration in instances of a high-cut wherein the circumcisee feels that the circumciser removed too much skin and that there is not enough skin for erections to be comfortable.[1]

Dual tension restorer applied to a circumcised penis for non-surgical foreskin restoration

History

In the Greco-Roman world intact genitals, including the foreskin, were considered a sign of beauty, civility, and masculinity.[2] In Classical Greek and Roman societies (8th century BC to 6th century AD), exposure of the glans was considered disgusting and improper, and did not conform to the Hellenistic ideal of gymnastic nudity.[2] Men with short foreskins would wear the kynodesme to prevent exposure.[3] As a consequence of this social stigma, an early form of foreskin restoration known as epispasm was practiced among some Jews in Ancient Rome (8th century BC to 5th century AD).[4]

Foreskin restoration is of ancient origin and dates back to the reign of the Roman Emperor Tiberius (AD 14-37), when surgical means were taken to lengthen the foreskin of individuals born with either a short foreskin that did not cover the glans completely[2] or a completely exposed glans as a result of circumcision.[5] Again, during World War II some European Jews sought foreskin restoration to avoid Nazi persecution.[6]

Non-surgical techniques

Tissue expansion

Non-surgical foreskin restoration, accomplished through tissue expansion, is the more commonly used method.[7]

Tissue expansion has long been known to stimulate mitosis, and research shows that regenerated human tissues have the attributes of the original tissue.[8] Unlike conventional skin expansion techniques, however, the process of nonsurgical foreskin restoration may take several years to complete.

Methods and devices
Application of a typical restoration device, the TugAhoy, called a 'Chinese puzzle' by its inventor.

During restoration via tissue expansion, the remaining penile skin is pulled forward over the glans, and tension is maintained either manually or through the aid of a foreskin restoration device.

Manual methods are often used by men first starting restoration, but can be used at any stage of the restoration process, and refer to the necessity of the restorer to manually maintain the tension by holding the skin tautly with his fingers using one of several variations in finger placement.[9][10]

Many specialized foreskin restoration devices that grip the skin with or without tape are also commercially available. Tension from these devices may be applied by weights, elastic straps, or inflation as a means to either push the skin forward on the penis, or by a combination of these methods.

T-tape with a leg strap

An example of a device using elastic straps is the T-Tape method,[11] which was developed in the 1990s with the idea of enabling restoration to take place more rapidly.

Inflation methods involve sealing off the area between the glans and the skin pulled over it using a clamping device (commonly baby bottle nipples are used), and either inflating the skin or a balloon placed under the skin.

Precautions

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 seriously damaging tissues through 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,[12] to recommending periods of higher tension applied for only a few minutes per day, as with manual techniques.[13][14]

Retaining devices

Instead of growing new skin or until enough skin has been grown through tissue expansion, some men may opt to use a retaining device to hold remaining skin, if available, over the glans in a manner similar to the ancient Greek kynodesme. Since the glans is an internal membrane, originally protected by the foreskin until it is removed during circumcision, the goal of retaining methods is to replicate a protective covering for the glans.

If an insufficient amount of skin exists to retain glans coverage with remaining penile skin, one may use a commercially available artificial glans covering. Examples of such artificial coverings include a prosthetic foreskin made of latex that covers the glans in a moist environment,[15] and an undergarment that wraps the penis in a double-layered soft fabric "hood" to minimize friction on the glans.[16]

Surgical techniques

Foreskin reconstruction

Surgical methods of foreskin restoration, 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.[17] Such techniques are costly, and have the potential to produce unsatisfactory results or serious complications related to the skin graft. The frenulum can also be reconstructed.[18]

British Columbia resident Paul Tinari was held down and circumcised at the age of eight 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.[19][20]

Foreskin regeneration

There has been success in the field of regenerative medicine in the last two decades.

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 of regenerative medicine include Dr. Anthony Atala of the Wake Forest Institute for Regenerative Medicine (WFIRM).[21]

In early 2010, Foregen, an Italian non-profit lobbying organization dedicated to finding interested research groups for the purposes of regrowing the human male foreskin using the regenerative capabilities of the extracellular matrix, in the hopes of eventually being able to provide regeneration to circumcised men, was founded. Unable to do so, Foregen transitioned to a non-profit, dependent upon charitable donations to accomplish its research, with its own facilities. A clinical trial had been scheduled for late 2010, before it transitioned into its own research organization, but there were insufficient donations to follow through.[22] The goal was reached in June 2012 and they managed to obtain a laboratory and cooperation from biochemists and regenerative medicine experts. Results from their first clinical trial, decellurizing bull foreskins to create the extracellular matrix, were released in February 2013 and as of March 2018, had completed trials on cadaver human foreskins, which was published in 2017, and was in the process of peer review as of 2018.[23] Clinical trials on human subjects might be achieved by 2020.[24]

The proposed method would involve placing the patient under general anaesthesia. The penile skin would be opened at the circumcision scar, while the scar tissue is surgically debrided. A biomedical solution would then be applied to both ends of the wound, causing the foreskin to regenerate with the DNA in the patient's own cells. A biodegradable scaffold (i.e., the de-cellularized foreskin of a cadaver)[25] would be used to offer support for the regenerating foreskin.[26] While social forums have assisted in the discussion of current tools and hurdles towards this method,[27] scientific and medical institutes as well as bioengineering companies must be involved for a more professional and meaningful discourse and plan of action, including a more reliable method of acquiring cadaver foreskins.

Foreskin regeneration along with laboratory-grown penises (regeneration of the entire penis) could be possible soon. In 2014, it was announced that it might be possible five years from the initial announcement.[28] It is unclear whether or not having a restored foreskin with full coverage of the glans could interfere with fitting a foreskin scaffold on the penis and subsequent regeneration.[29]

Foreskin regeneration is experimental at this time and as of November 2020, no published medical sources describe having fully regenerated or successfully reattached a functional foreskin.

Results
Stages of non-surgical restoration

Time required

The amount of time required to restore a foreskin using non-surgical methods depends on the amount of skin present at the start of the process, the subject's degree of commitment, the techniques used, the body's natural degree of plasticity, and the length of foreskin the individual desires.

The results of surgical restoration are immediate, but often described as unsatisfactory and most restoration groups advise against surgery.

Physical aspects

Restoration creates a facsimile of the prepuce, but specialized tissues removed during circumcision cannot be reclaimed. Surgical procedures exist to reduce the size of the opening once restoration is complete (as depicted in the image above),[30] or it can be alleviated through a longer commitment to the skin expansion regime to allow more skin to collect at the tip.

The natural foreskin is composed of smooth dartos muscle tissue (called the peripenic muscle[31]), large blood vessels, extensive innervation, outer skin, and inner mucosa.[32]

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 completely removed in the majority of circumcisions and cannot be regrown, so the covering resulting from stretching techniques is usually looser than that of a natural foreskin. Nonetheless, according to some observers, it is difficult to distinguish a restored foreskin from a natural foreskin because restoration produces a "nearly normal-appearing prepuce."[33]

The process of foreskin restoration seeks to regenerate some of the tissue removed by circumcision, as well as provide coverage of the glans. According to research, the foreskin comprises over half of the skin and mucosa of the human penis.[34]

In some men, foreskin restoration may alleviate certain problems they attribute to their circumcision. Such problems 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."[35] One man reported he had a great loss of sensation in the glans because his foreskin was not present.[36]

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 that someone else decided to have performed on them.[17][33][37][38]

Organizations
See also: Intactivism

Various groups have been founded since the late 20th century, especially in North America where circumcision has been routinely performed on infants. In 1989, the National Organization of Restoring Men (NORM) was founded as a non-profit support group for men undertaking foreskin restoration. In 1991, the group UNCircumcising Information and Resource Centers (UNCIRC) was formed,[39] which was incorporated into NORM in 1994.[40] NORM chapters have been founded throughout the United States, as well as in Canada, the United Kingdom, Australia, New Zealand, and Germany. In France, there are two associations about this. The "Association contre la Mutilation des Enfants" AME (association against child mutilation), and more recently "Droit au Corps" (right to the body).[41]

See also

References
  1. Lerman, Steven E., and Joseph C. Liao. "Neonatal circumcision." Pediatric Clinics 48.6 (2001): 1539-1557.
  2. Circumcised barbarians, along with any others who revealed the glans penis, were the butt of ribald humor. For Greek art portrays the foreskin, often drawn in meticulous detail, as an emblem of male beauty; and children with congenitally short foreskins were sometimes subjected to a treatment, known as epispasm, that was aimed at elongation.
    — Jacob Neusner, Approaches to Ancient Judaism, New Series: Religious and Theological Studies (1993), p. 149, Scholars Press.
  3. Hodges, Frederick Mansfield (2001). "The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme". Bulletin of the History of Medicine. Johns Hopkins University Press. 75 (3): 375–405. doi:10.1353/bhm.2001.0119. PMID 11568485.
  4. Rubin, Jody P. (1980). "Celsus' decircumcision operation Medical and historical implications". Urology. 16 (1): 121–4. doi:10.1016/0090-4295(80)90354-4. PMID 6994325.
  5. Money, John (1991). "Sexology, body image, foreskin restoration, and bisexual status". Journal of Sex Research. Society for the Scientific Study of Sexuality. 28 (1): 145–56. doi:10.1080/00224499109551600.
  6. Tushmet L. Uncircumcision. Medical Times. 1965 [archived 2013-10-23];93(6):588–93.
  7. Collier. Whole again: the practice of foreskin restoration. CMAJ. 2011;183(18):2092–3. doi:10.1503/cmaj.109-4009. PMID 22083672.
  8. Cordes, Stephanie; Calhoun, Karen H.; Quinn, Francis B. (1997-10-15). "Tissue Expanders". University of Texas Medical Branch Department of Otolaryngology Grand Rounds. Archived from the original on 2004-10-11.
  9. "Manual Tugging". RestoringForeskin.org. Archived from the original on 2014-10-21. Retrieved 16 May 2015.
  10. "Manual Methods of Foreskin restoration". Doug's Site. Archived from the original on 21 October 2014. Retrieved 16 May 2015.
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  19. Euringer, Amanda (2006-07-25). "BC Health Pays to Restore Man's Foreskin". The Tyee.
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  21. "Cell and Tissue Types". 23 June 2010. Archived from the original on 2010-07-10. Retrieved 23 June 2010.
  22. "2010 Trial Postponed". Foregen. 21 Sep 2010. Archived from the original on 30 June 2012. Retrieved 12 June 2012.
  23. "Archived copy". Archived from the original on 2018-03-27. Retrieved 2018-03-27.CS1 maint: archived copy as title (link)
  24. "Foregen FAQ: When will the procedure to regenerate my foreskin become available?". Foregen. Archived from the original on 10 March 2019. Retrieved 10 March 2019.
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  34. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br. J. Urol.. 1996;77(2):291–5. doi:10.1046/j.1464-410X.1996.85023.x. PMID 8800902.
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  37. Penn, Jack (1963). "Penile Reform". British Journal of safe Surgery. 16: 287–8. doi:10.1016/S0007-1226(63)80123-X. PMID 14042759.
  38. Boyle, G.J.; Goldman, R.; Svoboda, J.S.; Fernandez, E. (2002). "Male Circumcision: Pain, Trauma and Psychosexual Sequelae". Journal of Health Psychology. 7 (3): 329–43. doi:10.1177/135910530200700310. PMID 22114254.
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Bibliography
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