it is the most common surgical operation throughout the world , and is one of the most common rituals in jewish and islamic cultures .
most circumcisions are performed for religious reasons as in islamic countries and few are performed for medical reasons .
although circumcision is considered to be a technically simple and safe surgical procedure , it can occasionally lead to serious complications such as partial or total penile amputation .
glans penis amputation is an extremely rare condition and its reconstruction is a challenge for surgeons .
amputation has resulted from incidents such as during circumcision , strangulation by hair coil , self- or non - self - mutilation , surgical resection for malignancy , and iatrogenic ischemia during hypospadias repair owing to vigorous dissection or tight bandaging .
immediate reconstruction at the time of amputation can be done by reattachment   or replantation .
the first successful microsurgical replantation of an amputated penis was reported in 1977 by cohen and colleagues .
some authors reported proximal lengthening by use of gracilis muscle and scrotal and suprapubic flaps to cover the advanced penis .
others have reported distal lengthening by use of a rectus abdominis inferiorly based island fascial flap covered by a skin graft or a scrotal flap in two stages followed by depilation and a radial forearm free flap by use of a microvascular technique . in this study
, we describe a novel technique for reconfiguration of the glans penis by use of a buccal mucosal graft to cover the distal part of the penis to improve appearance and function in a patient who suffered from an amputated glans during circumcision .
a 2-year - old infant presented to our urology clinic at mayo hospital in hodiedah , yemen , with a lost glans penis that had occurred 1 year previously ( fig .
the parents complained that their infant could not pass urine freely and that the penis was disfigured .
examination of the penis revealed an outstretched length , normal consistency , and no palpable fibrous plaques .
the skin of the shaft was normal in appearance , but the tip showed scar tissue and a stenosed external urethral meatus .
the parents requested improvement of the cosmetic appearance of the glans and relief of the urinary flow obstruction .
the procedure was discussed with the parents and written informed consent was obtained before surgery . with the infant under general anesthesia , a tourniquet was applied around the base of the penis .
a circumferential incision was made at the distal end of the remaining penis around the urethral meatus .
the urethral meatus was freed from the scar tissue at the tip of the penis .
the urethra was dissected for a distance of about 5 mm to free the end of the urethra and was stented with a silicon 8-fr foley catheter .
next the oral cavity was opened , and the cheek and lower lip were exposed . the opening of the stensen duct was identified and protected .
a buccal mucosal segment ( 5 mm  15 mm ) was marked on each side that extended from the interior of the cheek to the inner aspect of the lower lip .
the submucosa was elevated by injection of saline and was then incised and dissected on both sides .
the graft was defatted and fenestrated like a mesh to move easily in different directions during its application to the distal part of the remaining penis and to prevent hematoma formation behind the graft ( fig .
the graft was anastomosed with the urethral mucosa and penile skin by use of vicryl 6/0 interrupted sutures .
follow - up demonstrated healthy - appearing buccal mucosa that appropriately simulated the glans penis .
3b ) and 6 months . follow - up revealed success of the surgery and the infant 's parents were satisfied .
circumcision is the most common surgical procedure in our community . however , because circumcisions are also commonly performed by experienced individuals at home and in hospitals , complications are reported .
we believe that major complications can be prevented when circumcisions are performed by people other than authorized health workers .
we also suspect that antiseptic rules are easily broken during communal circumcisions . as a result ,
the risk of wound infection and transmission of hepatitis b virus infection might increase in these communities .
we think that educating communities about the risks of this matter is important and would be more effective than legislation .
reported serious complications such as partial or total glandular amputation , urethral injury , glandular necrosis , and preputio - glandular fusion .
amputation has also resulted as a complication of hypospadias repair and bladder exstrophy repair . during circumcision ,
glans injury is mostly due to trapping in the circumcision clamp , which usually results in partial or total amputation of the glans penis .
this type of trauma is really uncommon , but may be relatively common in our residential area owing to the large number of circumcisions being done by nonprofessional doctors or paramedicals .
pippi salle et al .   reported the possible mechanism of amputation during circumcision in 6 cases .
they suggested that the amputation is likely due to incomplete release of the physiological balano - preputial adhesions around the frenulum , which would produce traction of the ventral aspect of the glans when the foreskin is pulled in order to secure the clamp .
therefore , they proposed that glans amputations during circumcision may be prevented by careful and complete release of the inner perpetual mucosa from the glans before the placement of the clamp . in our report , total loss of the glans occurred during clamp - assisted circumcision .
this boy was neglected at the time of injury , although immediate reattachment or replantation can be successful because the glans tissue is well vascularized .
the complications of hypospadias repair resulting from a neglected postoperative tight bandage have been well described in several reviews .
loss of the glans can lead to significant long - term psychological and sexual morbidity .
the purpose of treatment is to create a cosmetically and functionally acceptable penile shaft and glans .
when the amputation is at the penile shaft , microvascular replantation has proven to be superior to other methods . at this level , two arteries and a venous anastomosis can be carried out , which leads to an adequate vascular supply to the distal replant .
ince and gundeslioglu   reported that for distal penis amputations in which the repair can not be achieved by replantation , burying the penis underneath the inguinal area may be an alternative salvage operation to replantation .
a buccal mucosa graft has several advantages over other grafts ; hence , it has become the graft of choice in hypospadias repair .
the process of harvesting is simple and does not create a visible donor site scar .
the boy had a loss of the coronal sulcus after reimplantation owing to extensive scarring .
the toronto group advised using buccal mucosa grafting in similar situations such as after severe epithelial denudation associated with balano - preputial scarring .
we believe that a buccal mucosal graft is a good option for reconfiguration of the glans penis when penile length is acceptable .
it is an easy and safe procedure that provides acceptable cosmetic results with a good urinary flow with an orthotopic urethral opening , normal erectile function , and normal urinary flow .
 penile amputation is a rare catastrophe and a serious complication of circumcision . 
 reconstruction of the glans penis may be indicated following amputation . 
 our report discusses a novel technique for reconfiguration of an amputated glans penis 1 year after a complicated circumcision . a 2-year - old male infant presented to us with glans penis amputation that had occurred during circumcision 1 year previously . 
 the parents complained of severe meatal stenosis with disfigurement of the penis . 
 penis length was 3 cm . 
 complete penile degloving was performed . 
 the distal part of the remaining penis was prepared by removing fibrous tissue . 
 a buccal mucosal graft was applied to the distal part of the penis associated with meatotomy . 
 the use of a buccal mucosal graft is a successful and simple procedure with acceptable cosmetic and functional results for late reconfiguration of the glans penis after amputation when penile size is suitable . 
INTRODUCTION
CASE REPORT
DISCUSSION