Foreskin restoration

Motivation

Foreskin restoration can be attempted for several reasons, among them being a desire to create the appearance of a natural foreskin (prepuce) covering the glans, or to increase sexual sensitivity of the glans and the interior of the restored foreskin, or to reduce discomfort due to exposure of sensitive areas during everyday activities. Foreskin restoration techniques are most commonly undertaken by men who have been circumcised or who have sustained an injury, but are also used by men who desire a longer foreskin and by men who have phimosis. Bigelow lists:

as reasons that circumcised men choose to restore their missing foreskin.

History

Foreskin restoration is of ancient origin and dates back to the reign of Emperor Tiberius, when surgical means were taken to lengthen the foreskin of individuals with either a short foreskin that did not cover the glans completely or a completely exposed glans as a result of circumcision. In classical Greek and Roman societies, exposure of the glans was considered improper, and did not conform to the Hellenistic ideal of gymnastic nudity. Men with short foreskins would wear the kynodesme to prevent exposure. As a consequence of this social stigma, an early form of foreskin restoration known as epispasm was practiced among some Jews in Ancient Rome. Again, during World War II some European Jews sought foreskin restoration to avoid Nazi persecution.

Tissue expansion

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

Tissue expansion 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.

Methods and devices

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 refers 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.

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. 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. In 2009, a method known as Reverse Taping Method, RTM, was introduced to the restoration population that restores the foreskin to intact appearance, many times in under 2 years and was found to be very lifestyle friendly. RTM could be worn under just about anything from slacks to swim briefs and the ability to urinate and apply skin emollients while the taping was on made it a very healthy and rapid restoration method.

Tissue expansion through inflation devices have gained popularity in recent years among men of the forum www.restoringforeskin.org. 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. This causes circumferential skin stretch which is thought to stimulate mitosis. Men using this technique report fast skin regenerative growth, and in particular it is thought to be beneficial to stimulate growth of inner skin (mucous membrane) tissues which are vital to restoring the lubrication function of the foreskin.

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 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, as with manual techniques.

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, and an undergarment that wraps the penis in a double-layered soft fabric "hood" to minimize friction on the glans.

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. 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.

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.

Foreskin regeneration

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 of regenerative medicine 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 using the regenerative capabilities of the extracellular matrix, in the hopes of eventually being able to provide free regeneration to circumcised men, was founded. A clinical trial had been scheduled for late 2010, but there were insufficient donations to follow through. 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 were released in February 2013, and they are preparing for a human application trial. Clinical trials on human subjects might be achieved by 2019.

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) would be used to offer support for the regenerating foreskin. While social forums have assisted in the discussion of current tools and hurdles towards this method scientific and medical institutes, and bioengineering companies must be involved for a more professional and meaningful discourse, and plan of action.

Foreskin regeneration along with laboratory-grown penises (regeneration of the entire penis) could be possible very soon. In 2014, it was announced that it might be possible 5 years from the initial announcement. 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.

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, in particular the ridged band, an innervated structure encircling the penis along the cusp of the foreskin, which among other functions serves to contract the opening around the glans. Surgical procedures exist to reduce the size of the opening once restoration is complete (as depicted in the image above), or it can be alleviated through a longer commitment to the skin expansion regime to allow more skin to collect at the tip. The circumcision scar becomes hidden as shaft skin begins to fold, mimicking the natural function and appearance of the foreskin.

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

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."

Non-surgical 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 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."

One man reported he has great loss of sensation in the glans because his foreskin is not present. 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.

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.

Organizations

Various groups have been founded since the late 20th century, especially in North America where circumcision has been routinely performed on infants. In 1982 the group Brothers United for Future Foreskins (BUFF) began to publicize non-surgical restoration. 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, which was incorporated into NORM in 1994. Several NORM chapters have been founded throughout the United States, as well as internationally 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).

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