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The Plastibell is a well-recognized approach to infant circumcision that has been successfully used since the 1950s. It is safe, simple and produces a consistently high quality, cosmetically satisfactory result. It has the advantages of an even circumcision line, minimal post-operative blood loss and protection of the glans (head of the penis) during the procedure. Advantages The advantages of this circumcision method are multiple. For one, the glans is protected from injury due to the plastic ring that is placed during the procedure. Moreover, due to the ligature that is placed around the ring (over the foreskin), hemostasis (control of bleeding) is typically excellent and of minimal concern upon discharge home. Thirdly, the cosmetic result is predictable due to the straight line of the ligature that causes the wound. Once mastered, it is a quick procedure for the physician to perform. Finally, no bandage is required and care and maintenance of the surgical site at home are straightforward. Cosmetically, there is generally no circumcision scar, though as usual with any of the methods, there will be a colour change where the (formerly) inner and outer layers of foreskin meet. Disadvantages The major disadvantage I always counsel parents about is that because healing occurs only after the ring falls off, the glans of the penis may swell and cause the plastic ring to become trapped behind it. I have encountered this FOUR times in now over 3000 infants. Each time was due to an infection that required oral antibiotics, close follow up and manual removal of the Plastibell ring by myself. To prevent this from happening, it is so important to keep the area very clean, to allow lots of diaper-free time and to contact my office (phone, email) should you think your son is becoming tender in the area. He truly should not care about his circumcision by the day after his procedure. If you think he is becoming increasingly irritable, this may be an early warning sign that he needs to be re-assessed. One study of 2000 Plastibell circumcisions reported a complication rate of 1.8%. There also is a report of impetigo caused by Staphylococcus aureus when using the Plastibell. There have been a number of cases reported of children developing necrotizing fasciitis following circumcision with the Plastibell method. (I have never seen this.) There have been cases of necrosis of the glans penis following circumcision with the Plastibell instrument. (I have yet to see this.) The need for blood transfusion has been quoted at a rate of 1 procedure in 30 000. (I have not encountered this.) It is humbly sometimes during a neonatal circumcision that a previously undiagnosed bleeding disorder is discovered. Death has been reported as a result of neonatal circumcision but I am aware of no such cases.

There are many reasons to consider circumcision for your newborn son. Some of these are cultural, ethical and religious in nature. There is now also mounting evidence regarding the medical benefits of circumcision. The American Academy of Pediatrics released a statement in September 2012 that the benefits of neonatal circumcision outweigh the potential risks. See Circumcision Policy Statement. Ultimately it is a personal decision based on personal reasons. Once the decision to circumcise has been made, the procedure is best performed by an expert and experienced operator.

Benefits begin in infancy and continue lifelong: Easy to care for and to keep clean Lower incidence of Urinary Tract Infection (UTI) Circumcision lowers the risk of balanitis (yeast infection) Avoids the possibility of circumcision at an older age which is more complicated and painful. This occurs in approximately 6% of uncircumcised males for medical reasons such as phimosis, a painful condition where the foreskin becomes tight and non-retractable. Circumcision lowers the risk of STDs (sexually transmitted diseases) including HIV (AIDS), HSV (Herpes Simplex Virus), HPV (Human Papilloma Virus) and most others Circumcision reduces the risk of cancer of the cervix in the female partners of circumcised males

As with any surgical procedure, the two most common complications are bleeding and infection. Bleeding usually amounts to spotting for the first several diaper changes and is usually very minimal. The Plastibell's major advantage is the lower risk of bleeding overall compared to some of the other techniques available. Very rarely, an undiagnosed bleeding disorder will present with excessive bleeding at the time of the procedure. Should there be a family history of bleeding disorders that is known, I would defer the procedure to a hospital-based provider following consultation with a pediatrician. Infection is uncommon. With over 3000 procedures performed, I can count on one hand how many infections I have encountered. When an infection does occur, it can look like a more irritable infant accompanied by swelling and tenderness around the site of the Plastibel. A later sign of an infection would present as a Plastibell ring that appears to be constricting your son's penis. This is rare but very important to recognize. It requires careful follow up, oral antibiotics and sometimes manual removal of the Plastibel. Cosmetic concerns are possible, but again, not common. These are more likely if the infant has a short penile shaft to start with, or if the infant’s heritage provides him with a darker skin tone, increasing the possibility of keloid (excessive scarring) formation. More serious complications are almost unheard of in the hands of an experienced operator. I encourage the parents of all of my infant patients to email us with any concerns, send us pictures along with those questions in the days after their son's procedure. My only caveat to this is that should a concern arise on a weekend or holiday, my office nor I will be checking email until the following business day. Should a concern arise over a holiday, I strongly encourage you to go to your local Emergency room. This, over 14 years of performing infant circumcisions, has rarely occurred.

As with any surgical procedure, the 2 most common complications are bleeding and infection. Bleeding usually consists of a few drops of blood during the actual procedure. There may be pinnk noted in the diaper for the first few diaper changes. A red diaper or red thighs would be highly, HIGHLY unusual and if these are noted, you need to bring your infant back to me or to a local emergency room immediately. I can tell you that I have encountered a total of FOUR cases of bleeding of this caliber. All were managed in my office. A couple of these required a suture as part of the process of getting the bleeding managed. Sometimes a drop or two of blood is noted when the plastic ring ultimately falls off. Nothing other than gentle pressure is required in these cases. I have had a total of FOUR infections, requiring oral antibiotic use and manual removal of the plastic ring over a swollen glans. The last time one of my circumcisions became infected was in 2012. More serious complications are almost unheard of in the hands of an experienced operator. There is always the possibility of an imperfect cosmetic result, asymmetry of the tissues surrounding the glans or a result that looks different than the infant's brother (s). All boys are born with different shapes and sizes of penises. I do my very best to be as careful and symmetric in my procedures as possible. Even with careful attention to details during the procedure, variations and imperfections are part of the risks of removing tissue from a wiggly, dynamic organ like the penis!

The ideal age is between 2-21 days (0-3 weeks) of age and at most 42 days of age (6 weeks), provided he weighs no more than 12 lbs as we will have difficulty fitting him into the restraint system used. If the baby is unwell, this may require a minor delay until he has recovered. The younger the baby is, the easier it is on him, and the adage “the sooner, the better” certainly applies.

Each baby is different. We try to minimize any trauma and make every effort to keep your son maximally comforted. During the procedure, most babies do not like having their diaper removed and their diaper area wiped/cleaned. Neither do they like being placed in the Velcro arm and leg restraints, but they also do not like being taken out of them after the procedure is complete! Other than this, there is a lot of variability in terms of how each baby responds to the procedure. Most remain awake, with some simply looking around or with their eyes half closed as they suck on their soothers (dipped in sugar water for distraction). Some do in fact sleep through segments of the procedure but this is less common. Afterward, your baby may act very normally, sleeping and feeding as per usual. Some, though, are irritable in the hour or so after the procedure. As a general rule, I find that most babies are largely unaware of any discomfort by the evening of the day the procedure was performed.

It is thought that a sucrose solution helps to minimize discomfort, so this is routinely used during our procedures. I also inject a lidocaine solution in a ring block around your son's penis before beginning. 0.5 ml of infant TEMPRA or TYLENOL may be given to your son immediately after the procedure is complete. This dose may be repeated in 4-6 hours. Sometimes, none is needed at all.

Because the surgery is deemed medically unnecessary, it is not covered by OHIP. As of March 1st, 2024, the cost of the procedure is $450 paid in full prior to the procedure.

Well, this is what I was trained in. But I also very much appreciate its advantages and I find that the cosmetic results are superior to results I have seen by other methods. One of the nice things about this technique is the bleeding risk is lower than, say, the Mogen technique. Because the plastic ring placed on your son's penis acts, along with a suture string, as a tourniquet, bleeding is less of a concern both during and after the procedure. We will only see a couple of drops of blood during the procedure and you, as a parent, should never have any active bleeding afterward. The other advantage is that by nature of the Plastibell's design, it is very difficult for me, as the operator, to damage the end of your son's penis. This is a possible risk of other techniques out there.

An adhesion is a scar. In relation to an infant circumcision, adhesions are common and can form in the weeks and months after a baby boy is circumcised. They can form up until toddlerhood. Typically these are tissue connections that develop between newly epithelialized shaft tissue and the now exposed head of the penis. Adhesions are subtle and often missed by anyone who does not routinely perform infant circumcisions. They are a cosmetic issue, not a functional one. Many men are walking around the Earth with penile adhesions they are not even aware of. Because I have performed your son's circumcision, I like to follow up a month after the procedure to assess for the development of these. You are welcome to call us, email us at any time after your child's circumcision and subsequent follow up appointment if you think there is a cosmetic concern that has developed. Adhesions generally are very easy to correct, so long as they are identified early.

I ask that you bring the following on the day your son’s circumcision is scheduled: Your baby! An extra, clean diaper Vaseline Infant Tylenol or Tempra (look on the package for the dosing “80 mg/ml”. His dose will be 0.5 ml). A soother (we use this to deliver sugar water to the baby during the procedure). This is an important pain-control technique.

Infant Tempra or Tylenol need not be given before the circumcision. It may be given after the circumcision if needed. (See Aftercare for more information). Try to avoid feeding your baby in the 1 to 2 hours before his procedure.Feeding him afterward will be soothing for both of you. Going into the procedure on a near-empty stomach will help minimize the risk of regurgitation and aspiration while the procedure is underway.

A Plastibell infant circumcision is accomplished in 10 simple steps: 1. Your son is placed on the Circumstraint device which is a large piece of smooth plastic moulded to accommodate your infant’s body. Velcro straps help to gently restrain his legs and arms for the duration of the procedure. 2. A freezing needle is used to provide a ring block to the penis after the area is cleaned with an alcohol swab. 3. A warm sterilizing solution is used to re-clean the entire area. 4. The adhesions between the foreskin and the glans of the penis are then divided with a blunt probe. The dorsal aspect of the foreskin is then crushed with a special clamp to prevent bleeding in Step #5 below. 5. The foreskin is cut from its edge down to 2/3’s of its length to provide easy access to the head (glans) of the penis for Step #6 below. 6. The foreskin is pulled gently back, uncovering the entirety of the glans. 7. A plastic ring (the Plastibel) is then fitted over the glans and the foreskin is pulled back overtop of this. 8. A suture (string) is then wrapped around the foreskin, over the ring and tied tightly, securing the ring onto the penis. 9. Excess foreskin is cut just distal to this suture leaving the ring securely in place. 10. The ring will fall off on its own, at home in 4 to 14 days. Following the circumcision, I will bring your infant back to you and allow you to feed him and give him his Tylenol (0.5 ml/dose). In 10 to 15 minutes, I will return to see you and together, we will examine his diaper area and I will point out various things on his penis specific to the Plastibell technique. Please understand that the penis immediately after the procedure will not look circumcised. In fact, it will look quite distorted. Rest assured that the end result will be very much to your satisfaction once the ring has fallen. Also be reassured that there is almost nothing you can do to prematurely dislodge the ring.

I would suggest changing your son’s diaper once he has had his first post-circumcision pee. Subsequent diapers can remain on for the usual 3-4 hours. Bleeding – Spotting is normal for the first 24 hours and is no reason for concern. If active bleeding (blood flowing) is noted, firm pressure should be applied to the penis with a clean washclothfor 3-4 minutes and if the bleeding continues, your physician or I should be contacted immediately. Bandage – no bandaging is necessary. All that I ask of you as the parent is that, for the first 24 hours post-procedure and with each diaper change, you smear Vaseline within the diaper where you estimate the penis will touch. This is to prevent the head of the penis from sticking to the diaper. Temperament – Your baby may be slightly fussier than normal for the first 12-24 hours. He should be held, cuddled and fed and can be given 40 mg (½ ml = 0.5 ml) of acetaminophen liquid (Tempra, Tylenol) every 4-6 hours if necessary. Most babies behave no differently after the circumcision than before. Bathing – Sponge baths are suggested until the plastic ring falls off. During this time, the penis can be cleaned if necessary by squeezing warm water over it from a wash cloth. Immersion in a bath may take place particularly if there is a large stool and provided the diaper area is patted dry thereafter. Diluted infant soaps are permitted to clean the diaper area. Air-drying throughout the day and particularly after diaper changes is encouraged. Urination – Urine is normally sterile but due to its acidity, may cause some stinging for the first couple of pees. Stooling – The scrotum tends to prevent stool from contacting the penis, however, this may occur. If so, squeeze water over the penis from a warm washcloth and then wipe or dab the penis gently with the washcloth until clean. In general, immediate diaper changing is recommended after each stool, particularly until the clear plastic ring falls off. Baby Wipes and Barrier Creams (Sudocrem, Zincofax, Vaseline, Penaten) – These are permitted on the buttocks and groins but should not be applied directly to the penis. Healing – Complete healing will take from 10 – 14 days. The wound site at this point is a mucosal surface just like your lips and the inside of your mouth. Therefore, the changes that occur will be present immediately following the circumcision and the following will be noted: redness – this is normal and make take two weeks to disappear. swelling – primarily on the underside. This will appear as a shiny pink roll (or lip) of tissue between the head and shaft of the penis and may not always be symmetrical. The swelling may not start to diminish for three or four days after the ring has detached. scabbing – due to the mucosal nature of this skin, if present at all, the scab will be a whitish or light yellowish crust or film. It will be noticeable mostly on the underside but may be on top or even on the head of the penis as well. This crust will be adherent to the penis and will disappear on its own. It should not be removed. This is normal and called “granulation tissue.” infection – this is uncommon and occurs in approximately 1% of cases. The early warning signs of infection include an irritable baby, especially when the penis and area are cleaned or pressure to that area is applied, and a swollen glans. If at any time the clear plastic ring appears to be getting tighter on the penis and the glans (head) of the penis resembles a mushroom cap, this is a potential infection and I would like to see your infant within 24 hours. Topical and/or oral antibiotics may then be prescribed and I will want to see your baby daily until resolution. A foul odour or discharge are not normal and also point to an infection.

After the circumcision, you can reach me by email or phone with any questions.

Every baby has unique anatomy. I use my expertise to examine the baby’s anatomy to achieve the best possible aesthetic result. Each baby is different. The more challenging circumcisions to perform are on infants who have short penile shafts. A webbed penis is another variant that may cause me to hesitate in performing your son's procedure. Rotated Penis – This occurs in approximately 15% of babies, usually counter clockwise. This is a normal variant which I will point out to you if present. Sometimes, close to the time the plastic ring is detaching, you may inadvertently pull the ring off abruptly when you are changing your son's diaper. I have also heard from families of the infant kicking his ring off near the end of its life. In all of these cases, there has been a little bit of bleeding. In NONE of these cases, was anything other than application of pressure to the area required. There have been TWO cases where the plastic ring detached from the infant's penis in an unusually short time. The first came off in TWELVE hours. The second came off in SIX hours. This is very very uncommon. There was nothing to be done for the first case. But in the case where the ring was off in 6 hours, I did need to re-assess this infant in my office and place a suture to manage the bleeding that ensued. The head of the penis (glans) is a very vascular organ. This means there are a lot of small blood vessels under the surface. Depending on ambient temperature and state of arousal, the colour may appear pink, red or bluish. This is of no concern. Adhesions – Occasionally, the skin on the shaft of the penis will seem to creep forward and stick to the corona (base of the glans). If this happens, I can show you how to gently push the skin back to prevent permanent adhesions. Upon entry into the surgical room, I will examine your infant son. Occasionally, I will identify a congenital anomaly that is a contraindication to performing a circumcision. I would, in this instance, bring your son back uncircumcised. I will explain the pathway forward for you and you will receive a 100% refund. This has happened approximately TEN times in my entire career. Sometimes, a de novo bleeding disorder is suspected as I inject freezing lidocaine around your infant's penis. This will look like bleeding from all points where I injected the freezing and in amounts higher than typical. I would then also bring your son back to you uncircumcised and you would receive a full refund for the procedure. This has happened in a total of TWO infants in my entire career. By 6 to 9 months of age, some babies develop a lot of fat around their genital area. They may go on to develop a buried penis as a result. This is simply where their penis slips into this fatty tissue, like the head of a turtle. It is a normal variant but may be more pronounced in infants who have been circumcised because the foreskin, that would have given an illusion of more length, is longer there. It is in these babies, where adhesions are more likely to develop. It is very important that with diaper changes, the tissues around your son's penis are pushed back so that proper cleaning can happen and that you visualize the exposed penile head and identify the edge of the penile head.