After a bris, I try to explain to parents what things will look like over the next few days, weeks, and months as the circumcision goes through its different stages of healing.
There is swelling, a reminder of what things look like before vs after, there are stages of healing, a couple of long-term reminders: the Chubby Baby Syndrome and the Fusion Challenge.
I often comment about the importance of using a marker to indicate where the edge of the foreskin is before circumcising. When this is done in advance of the bris, and when the mark is actually followed during the circumcision, the incision can be very even and beautiful (to quote a colleague who loves to use the word 'beautiful' to describe his work).
But what are we marking? Why can't a rough estimate be sufficient?
There is a very definite point where the foreskin ends, and that spot is where the skin of the shaft lies naturally beneath the outer edge of the glans/corona. A "beautiful" circumcision has all of the foreskin plus the membrane beneath it removed at exactly that spot.
However, owing to the reality that most circumcisions are not accompanied by a complete removal of the membrane beneath the foreskin, there is a benefit to removing a little more than just the foreskin, because leaving MORE skin plays a significant role in the Fusion Challenge, and especially in the Chubby Baby Syndrome (I get many questions from mothers who ask about the need to pull down the skin over the longer term. Depending on how the circumcision goes, this is an issue for some people, or may never be an issue at all.)
So let's say there is 100% shaft skin to leave behind. A good mohel will actually leave between 88-95% of the original shaft skin, since the remains of the membrane will make a proper fusion with the shaft skin and fill in the remaining 5-12 percent of the shaft as needed.
Without using the marker, the chances of removing 50% or more of original shaft skin are not unheard of. And the incision has a decent chance of being significantly unbalanced - one side having more skin removed than the other (a little uneven is not bad - these things have a tendency to heal nicely nonetheless). This form of operating is a tremendous disservice to any baby.
Being educated about circumcision takes a lot of guesswork out of the process. Best of luck to everyone!
Showing posts with label membrane. Show all posts
Showing posts with label membrane. Show all posts
Thursday, July 30, 2015
Friday, September 16, 2011
The Part No One Talks About (a.k.a. Tzitzin Ha'M'Akvin)
[This does not happen a lot, but it may happen. You need not expect it to happen, but it is always good to be prepared in your mind for a "worst case scenario."]
You've done your research. You hired the mohel everyone raves about. Or at least he has a very good reputation.
And then, at your son's bris, you're not very impressed.
It's not that he's not a nice mohel. And it's not that he isn't clean and neat. It's just that it takes a really long time, and it seems like your baby is losing a lot of blood (he isn't - it always looks worse, even when the procedure and prognosis is 'normal' and 'what is to be expected'). Moreover, what did he just say about "fixing" things?
The particular circumstances might differ from bris to bris (which doesn't matter to you the parent - because all you care about is "this single bris"), but the fact remains that while most brisses go extremely smoothly without any mishaps or missteps, there are some that bring with it their set of challenges.
To bring two simple examples that can not necessarily be anticipated before the foreskin is removed:
1. The baby may have scrotal webbing which extends its way into the shaft. This webbing (a lower skin tissue) would need to be removed to a. loosen up the shaft and b. help things look nicer
2. The baby may take time to clot. While in an ideal world the baby will stop bleeding immediately after the bris, the fact is that some babies are "bleeders" and present more of a challenge in achieving the coveted clottage.
You've done your research. You hired the mohel everyone raves about. Or at least he has a very good reputation.
And then, at your son's bris, you're not very impressed.
It's not that he's not a nice mohel. And it's not that he isn't clean and neat. It's just that it takes a really long time, and it seems like your baby is losing a lot of blood (he isn't - it always looks worse, even when the procedure and prognosis is 'normal' and 'what is to be expected'). Moreover, what did he just say about "fixing" things?
The particular circumstances might differ from bris to bris (which doesn't matter to you the parent - because all you care about is "this single bris"), but the fact remains that while most brisses go extremely smoothly without any mishaps or missteps, there are some that bring with it their set of challenges.
To bring two simple examples that can not necessarily be anticipated before the foreskin is removed:
1. The baby may have scrotal webbing which extends its way into the shaft. This webbing (a lower skin tissue) would need to be removed to a. loosen up the shaft and b. help things look nicer
2. The baby may take time to clot. While in an ideal world the baby will stop bleeding immediately after the bris, the fact is that some babies are "bleeders" and present more of a challenge in achieving the coveted clottage.
Thursday, March 17, 2011
A Long-Term Care Reminder
One question that comes up a lot, particularly when a baby boy is 4-12 months of age is, "Why doesn't it look circumcized?" (I get this a lot more often when I wasn't the mohel, but every now and then if I was)
In most cases, "it" actually does look circumcised, except that a minor issue needs to be tweaked.
Before I continue, let me be clear that this may be difficult to understand without the visual image, but I will do my best!
Clench your fist, and look at the profile of your arm. Imagine the fist is the glans, and your arm is the penile shaft, and you understand what the penis should look like from the side. The glans should sit above the shaft, and its outer rim should be completely separate and distinct from the shaft.
UNFORTUNATELY, not all parents realize this should be the case, until it is slightly too late.
What do I mean by slightly too late? I mean
In most cases, "it" actually does look circumcised, except that a minor issue needs to be tweaked.
Before I continue, let me be clear that this may be difficult to understand without the visual image, but I will do my best!
Clench your fist, and look at the profile of your arm. Imagine the fist is the glans, and your arm is the penile shaft, and you understand what the penis should look like from the side. The glans should sit above the shaft, and its outer rim should be completely separate and distinct from the shaft.
UNFORTUNATELY, not all parents realize this should be the case, until it is slightly too late.
What do I mean by slightly too late? I mean
Tuesday, February 23, 2010
The Most Common Issues After the Bris
There have been a number of times when I have been called to a home where the baby of the house is six months, ten months, even a year old or more. The little guy was circumcised when he was eight days old, but now he does not look circumcised.
And most of the time I was not the mohel - the family heard about me and did not want to bring their mohel back to look at it. (There have been cases where I have been called back when I was the mohel - I trust and hope it is because people feel comfortable contacting me, knowing the care I put into each baby's bris.)
Usually the issue only became apparent in the last few months. "At first it was fine. But lately, we've been having this issue."
Mind you, this happens with circumcisions done by doctors and mohels alike, and is usually due to the parent being unaware that this may happen, more than any oversight in the circumcision or a less than adequate job.
99.8% of the time the bris is fine and no touch-up surgery is required. However, there is something that does need to be done that will bother your baby in the minute it takes to do it, but does not have a healing process and will not cause any bleeding.
Again, this can usully be avoided with proper education.
Because a baby spends so much time on his back, and because his diaper smushes his penis together, and because many babies develop baby fat which is primarily deposited in the groin area, a percentage of babies develop one of a few symptoms that either A. make the shaft and glans of the penis disappear into the scrotum, or B. make it that you can't see the outer rim of the glans, which should appear distinct from the shaft.
If the bris is done correctly, what you should see is described in the second half of this post.
How to Keep it That Way
After the baby heals - say, about a week after the cessation of any ointment application, it is imperative that you make sure the outer edge of the glans remains distinct from the shaft.
All this requires is a gentle pushing of the skin below the glans at every diaper change - and particularly when the baby is in the bath.
Do not do this for at least a week after the actual bris, because any pressure on the penis during the first week of healing could reopen a wound and cause bleeding.
Sometimes not an issue at all
With some babies and with some circumcisions this is never an issue.
With others, no matter how the circumcision is performed, this can be an issue which, if unmonitored, can continue to cause concern for two years of the baby's life. In all this time, the baby is fine! But you, the parent, want to know why things look the way they do, and really want to understand what you are seeing.
Be on top of it, take charge, know what you are looking at and what you need to see. When you are in the know, you will know how to handle the situation such that the asthetic looks of the circumcision will never be a cause for alarm.
Disappearing penis
While less common than the "almost uncircumcised" look, the disappearing penis is essentially when the shaft and glans disappears into the scrotum when the baby is lying on his back. A gentle push on the 3 o'clock and 9 o'clock sides of the scrotum surrounding the shaft - or on the belly just above the "dark hole" will usually cause the shaft to pop out of its hiding place.
What can you do about it?
Firstly - follow above instructions to avoid it happening.
Secondly - if it's too late and the shaft disappears, there are two options.
A. Continue as above every time the diaper is open. Either it will clear up on its own through this counter-attack, or it will clear up on its own when the baby is walking - and particularly when he is out of diapers. Remember, the more time he spends on his back and the more baby fat he accumulates in his legs will both contribute to the disappearing penis look.
B. If it does not go away, corrective surgery is extremely effective. In most cases, however, you will not have to go this route. Consult with an honest pediatric surgeon who does not jump to do unnecessary surgeries, and you will get an honest opinion. Usually it is "wait it out. It will be fine."
Any questions - feel free to call me or email me.
[I am not looking to cause alarm - merely to educate about what is out there. I firmly believe that with proper monitoring, a properly done circumcision will look and turn out absolutely fine. Before you look at the following links, remember these cases are relatively uncommon. Nonetheless they are not so rare as for you to be unaware...
See more on this subject here and here...]
And most of the time I was not the mohel - the family heard about me and did not want to bring their mohel back to look at it. (There have been cases where I have been called back when I was the mohel - I trust and hope it is because people feel comfortable contacting me, knowing the care I put into each baby's bris.)
Usually the issue only became apparent in the last few months. "At first it was fine. But lately, we've been having this issue."
Mind you, this happens with circumcisions done by doctors and mohels alike, and is usually due to the parent being unaware that this may happen, more than any oversight in the circumcision or a less than adequate job.
99.8% of the time the bris is fine and no touch-up surgery is required. However, there is something that does need to be done that will bother your baby in the minute it takes to do it, but does not have a healing process and will not cause any bleeding.
Again, this can usully be avoided with proper education.
Because a baby spends so much time on his back, and because his diaper smushes his penis together, and because many babies develop baby fat which is primarily deposited in the groin area, a percentage of babies develop one of a few symptoms that either A. make the shaft and glans of the penis disappear into the scrotum, or B. make it that you can't see the outer rim of the glans, which should appear distinct from the shaft.
If the bris is done correctly, what you should see is described in the second half of this post.
How to Keep it That Way
After the baby heals - say, about a week after the cessation of any ointment application, it is imperative that you make sure the outer edge of the glans remains distinct from the shaft.
All this requires is a gentle pushing of the skin below the glans at every diaper change - and particularly when the baby is in the bath.
Do not do this for at least a week after the actual bris, because any pressure on the penis during the first week of healing could reopen a wound and cause bleeding.
Sometimes not an issue at all
With some babies and with some circumcisions this is never an issue.
With others, no matter how the circumcision is performed, this can be an issue which, if unmonitored, can continue to cause concern for two years of the baby's life. In all this time, the baby is fine! But you, the parent, want to know why things look the way they do, and really want to understand what you are seeing.
Be on top of it, take charge, know what you are looking at and what you need to see. When you are in the know, you will know how to handle the situation such that the asthetic looks of the circumcision will never be a cause for alarm.
Disappearing penis
While less common than the "almost uncircumcised" look, the disappearing penis is essentially when the shaft and glans disappears into the scrotum when the baby is lying on his back. A gentle push on the 3 o'clock and 9 o'clock sides of the scrotum surrounding the shaft - or on the belly just above the "dark hole" will usually cause the shaft to pop out of its hiding place.
What can you do about it?
Firstly - follow above instructions to avoid it happening.
Secondly - if it's too late and the shaft disappears, there are two options.
A. Continue as above every time the diaper is open. Either it will clear up on its own through this counter-attack, or it will clear up on its own when the baby is walking - and particularly when he is out of diapers. Remember, the more time he spends on his back and the more baby fat he accumulates in his legs will both contribute to the disappearing penis look.
B. If it does not go away, corrective surgery is extremely effective. In most cases, however, you will not have to go this route. Consult with an honest pediatric surgeon who does not jump to do unnecessary surgeries, and you will get an honest opinion. Usually it is "wait it out. It will be fine."
Any questions - feel free to call me or email me.
[I am not looking to cause alarm - merely to educate about what is out there. I firmly believe that with proper monitoring, a properly done circumcision will look and turn out absolutely fine. Before you look at the following links, remember these cases are relatively uncommon. Nonetheless they are not so rare as for you to be unaware...
See more on this subject here and here...]
Sunday, January 31, 2010
What Will It Look Like Before and Afterwards?
I try to leave graphic images out of this blog, so I will do my best to explain here what the penis looks like before and after the bris.
BEFORE
Take a look at your baby! Now you know how it looks before the bris!
Just kidding.
The uncircumcised shaft of the penis looks like an inverted hourglass. It is thinner as it hits the scrotum, and thinner at the tip, but significantly fatter in the middle. The reason for this is because the glans, the part of the penis which is revealed after the circumcision, is hidden underneath the foreskin. Were you to slowly (and gently) pinch the tip of the penis, you'd see the "bump" in the middle of the shaft move it's way towards the scrotum. Let go of the tip of the penis, and the bump will slide back to its natural position. That bump is the outer edge of the glans - usually the 1/3 or midway point of a baby's penis.
THE FORESKIN
The foreskin (a.k.a. "prepuce") is an outer coating which covers the glans. It covers around half of the shaft. As only the foreskin is removed during circumcision, when the glans is revealed, one can easily see (contrary to popular culture's 'complaint') that the penis is not "smaller" - it just looks different.
[While I won't put the photo in the actual blog - I believe you can get the idea of what this all means when you look at this photo of a circumcised banana.]
AFTER
Before you read this section, understand that most circumcisions do not necessarily turn out exactly the same. All babies are different, and may have different "surprises" under their foreskins, which are not usually detected until after the circumcision itself.
For example, every baby has a differently shaped glans. Thus the first thing you see will look different from child to child.
Secondly, some babies have a minimal mucosal membrane underneath the foreskin, which might completely come off as well during the circumcision. Others have much more membrane with a significant amount left over after the bris, even if it is no longer coating the glans. Still others have significant tissue webbing, which would be undetected until the foreskin is removed. Depending on the extent of the webbing, it may need to be removed separately after the circumcision.
THREE SECTIONS
After the circumcision, one can usually identify three distinct sections on the circumcised penis.
SECTION #1: THE GLANS is the first things you see. It is the tip of the penis, and it almost looks like an army helmet - were the shaft to be standing upright.
A kosher bris consists of the farther rim of the glans being completely revealed, visible, and distinct, with no skin tags attached to it, and nothing hampering its distinct view.
It is usually a very deep, dark, raw RED COLOR (though it is sometimes PURPLE).
SECTION #2: THE MEMBRANE may or may not be completely removed in the bris process. If some of it remains, it may be slightly swollen, and may seem a little puffy below the glans.
Like the glans, it is typically a dark RED COLOR, though it does not usually have the same deep color of the glans. It will also look raw.
If the Membrane is completely removed, the area below the glans will look empty, but there will usually be a gap of a couple of millimeters between the glans and...
SECTION #3: The SPOT OF THE INCISION. This is the spot on the skin itself where the foreskin ended - or at least where the mohel estimated the foreskin ended. Ideally, the incision mark will be fairly close to the glans - but depending on the size of the baby's shaft, the mohel may have found the need to remove more or less skin in order to avoid future problems which may come from the glans falling back into the shaft and/or scrotum.
Dr. Neil Pollock - a very busy circumciser in Vancouver, has detailed information about this on his website. Feel free to read through the information he has - it can be found here [Start with the "Parents Guide to Circumcision" and move on from there!]
WHAT YOU WILL SEE
Aside from the dark red colors and the swelling, the scab tissue which sometimes develops in the area will typically be of a yellowish/ greenish hue. This is normal.
It is not advisable to pick at this, or to rub it as it will only cause the penis to bleed. A warm bath is good and promotes healing. Otherwise, like any scab, it is best to put bacitracin on it for a few days and then stop using ointments when the danger of infection is gone and it just needs to continue healing on its own.
BEFORE
Take a look at your baby! Now you know how it looks before the bris!
Just kidding.
The uncircumcised shaft of the penis looks like an inverted hourglass. It is thinner as it hits the scrotum, and thinner at the tip, but significantly fatter in the middle. The reason for this is because the glans, the part of the penis which is revealed after the circumcision, is hidden underneath the foreskin. Were you to slowly (and gently) pinch the tip of the penis, you'd see the "bump" in the middle of the shaft move it's way towards the scrotum. Let go of the tip of the penis, and the bump will slide back to its natural position. That bump is the outer edge of the glans - usually the 1/3 or midway point of a baby's penis.
THE FORESKIN
The foreskin (a.k.a. "prepuce") is an outer coating which covers the glans. It covers around half of the shaft. As only the foreskin is removed during circumcision, when the glans is revealed, one can easily see (contrary to popular culture's 'complaint') that the penis is not "smaller" - it just looks different.
[While I won't put the photo in the actual blog - I believe you can get the idea of what this all means when you look at this photo of a circumcised banana.]
AFTER
Before you read this section, understand that most circumcisions do not necessarily turn out exactly the same. All babies are different, and may have different "surprises" under their foreskins, which are not usually detected until after the circumcision itself.
For example, every baby has a differently shaped glans. Thus the first thing you see will look different from child to child.
Secondly, some babies have a minimal mucosal membrane underneath the foreskin, which might completely come off as well during the circumcision. Others have much more membrane with a significant amount left over after the bris, even if it is no longer coating the glans. Still others have significant tissue webbing, which would be undetected until the foreskin is removed. Depending on the extent of the webbing, it may need to be removed separately after the circumcision.
THREE SECTIONS
After the circumcision, one can usually identify three distinct sections on the circumcised penis.
SECTION #1: THE GLANS is the first things you see. It is the tip of the penis, and it almost looks like an army helmet - were the shaft to be standing upright.
A kosher bris consists of the farther rim of the glans being completely revealed, visible, and distinct, with no skin tags attached to it, and nothing hampering its distinct view.
It is usually a very deep, dark, raw RED COLOR (though it is sometimes PURPLE).
SECTION #2: THE MEMBRANE may or may not be completely removed in the bris process. If some of it remains, it may be slightly swollen, and may seem a little puffy below the glans.
Like the glans, it is typically a dark RED COLOR, though it does not usually have the same deep color of the glans. It will also look raw.
If the Membrane is completely removed, the area below the glans will look empty, but there will usually be a gap of a couple of millimeters between the glans and...
SECTION #3: The SPOT OF THE INCISION. This is the spot on the skin itself where the foreskin ended - or at least where the mohel estimated the foreskin ended. Ideally, the incision mark will be fairly close to the glans - but depending on the size of the baby's shaft, the mohel may have found the need to remove more or less skin in order to avoid future problems which may come from the glans falling back into the shaft and/or scrotum.
Dr. Neil Pollock - a very busy circumciser in Vancouver, has detailed information about this on his website. Feel free to read through the information he has - it can be found here [Start with the "Parents Guide to Circumcision" and move on from there!]
WHAT YOU WILL SEE
Aside from the dark red colors and the swelling, the scab tissue which sometimes develops in the area will typically be of a yellowish/ greenish hue. This is normal.
It is not advisable to pick at this, or to rub it as it will only cause the penis to bleed. A warm bath is good and promotes healing. Otherwise, like any scab, it is best to put bacitracin on it for a few days and then stop using ointments when the danger of infection is gone and it just needs to continue healing on its own.
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