ISSN: 2754-8880
Published 00 11 0000
OPEN ACCESS
Edited by
A.Hussain
Submitted 1 July. 2024
Accepted 5 June. 2025
Citation
F Kon, K Khai, F Hany,
Mohammad Ali.A Case
Report: W-Plasty For
Secondary Phimosis. An
Innovative Approach To An
Established
Challenge.Editorial
article:BJOSS::2025:(5);153-
157
A Case Report: W-Plasty For Secondary
Phimosis. An Innovative Approach To An
Established Challenge
F Kong
1*
, K Khai
1
, F Hany
1
, and M Ali
1
1
Department of Plastic Reconstructive Surgery, Hospital Kuala Lumpur
*
Correspondence author : Email: filifele0023@gmail.com
O R IGI N A L
Abstract
Secondary phimosis is a technical error that occurs when the prepuce’s inner mucosa layer is not
sufficiently removed, and it heals with a fibrotic ring after circumcision. Re-circumcision remains
the mainstay for in managing secondary phimosis however it still may lead to complications such
as formation of fibrotic scar. Here, we propose a new method for revision of secondary phimosis
by implementing the W-plasty technique. W-plasty is a new approach for secondary phimosis.
It not only helps to release the cicatricial scar, but also prevents further scarring in secondary
phimosis.
Keywords : Secondary phimosis, cicatricial scar, post circumcision complication , W plasty
Introduction
Circumcision is one of the most common surgical operations in children for cultural, religious, and
medical reasons in Malaysia. Despite circumcision being one of the most common procedures
today and the presence of the MOH circumcision guideline, complications still occur. There are
early and late complications post circumcision. The early complications were bleeding, hematoma,
wound infections, and glans burn injury. For the late complications of circumcision, meatal stenosis,
incomplete circumcision, and secondary phimosis. Phimosis, which refers to the inability to retract
the foreskin, can be classified into primary (congenital) and secondary (acquired) forms. Secondary
phimosis, as outlined, often results from complications after circumcision procedures like the
Plastibell technique. It occurs due to factors such as improper placement of the ligature or an
ill-fitting Plastibell ring. Revision circumcision remains the mainstay for managing secondary
phimosis. (
1
) Here we are implementing the W-plasty technique, which was described by Borges
in managing secondary phimosis.
Case Presentation
A case of 12 years 12-year-old boy with no medical illness underwent mass ritual circumcision.
The operation was uneventful. However, 2 months post-surgery parent notices unable to retract
the foreskin. He is still able to urinate. He denies swelling of the foreskin and pain during urination
or erection. Clinically, there is redundant foreskin, a pinpoint cicatricial ring at the foreskin and
unable to retract down [Figure 1a & 1b]. He has subsequently been referred to our department
for secondary phimosis. He was then undergoing scheduled corrective surgery with multiple
W-plasty around the cicatricial stenotic ring 3 months later. Intraoperatively, W incision marking
over the stenotic ring over the outer prepuce and redundant inner prepuce. [figure 2]. Prepuce
incision was made with an iris curved according to pre-operation marking W. Inner and outer
prepuce were then approximated with Vircyl 6/0 undyed. Post-operation, he recovered and was
discharged well. He has no recurrent of cicatricial scar and is satisfied with the outcome in 3
months follow up [Figure 5a & 5b].
(a) Redundant Inner Prepuce Post
Circumcision
(b) Black Arrow Indicates Cicatricial
Stenotic Ring And “Mercedes” 3 Points
Incision Marking Made Over Outer
Prepuce
Figure 1
(a) Dorsal view. Black arrow indicates
outer prepuce.
(b) Ventral view. Mercedes 3 points inci-
sion marking made over the inner prepuce
in between the 3 point incision over outer
prepuce skin. Black arrow indicates redun-
dant inner prepuce.
(c) Ventral view. Incision made & flap
raised.
(d) Right lateral view. Incision made &
flap raised.
Figure 2
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Figure 3. Dorsal View Immediately Post Operation.
Figure 4. Right Lateral View Immediately Post Operation.
(a) Dorsal View Of Penis, Post-Surgery 3 Months
Follow Up.
(b) Right Lateral View Of Penis, Post-Surgery 3
Months Follow Up.
Figure 5
Discussion
Secondary phimosis is, indeed, a challenging complication to manage. Once it occurs, the mainstay
of treatment remains re-circumcision, which involves a more extensive surgical procedure. How-
ever, it is essential to acknowledge that re-circumcision may not always prevent the recurrence
of the condition, especially if the underlying cause—such as the initial improper technique or an
improperly sized Plastibell—is not addressed. Recurrence is a critical concern because it may lead
to repeated scarring, increasing the complexity of future procedures and further damaging tissue
integrity.
155/157
The clinical pathogenesis of secondary phimosis primarily revolves around the fibrotic healing
process following circumcision. Kidger et al. explain that this occurs due to inadequate circumfer-
ential foreskin excision, which creates a tension that, over time, forms a fibrotic scar that restricts
the foreskin. (
2
) This results in further complications in the long term, despite the initial success
of the circumcision procedure.
Besides Z plasty, elliptical excision and geometric broken line closure, the W-plasty technique
has also emerged as a widely recognized method for addressing scar. (
3
) Its popularity stems
from its ability to effectively manage scar tissue and reduce tension around the surgical site. The
technique’s ability to break up the scar into smaller, more manageable components helps redirect
anti-tension lines and prevents the creation of a single, large, rigid scar. (
4
) Additionally, as Borges
highlighted, this technique has advantages in camouflaging the scar within natural skin folds and
creases, helping to achieve aesthetically favourable outcomes. (
5
;
6
;
7
) As W-plasty is a scar
excisional technique resulting in a series of triangular flaps by producing a zig-zag effect. Thus,this
technique is only beneficial for patient with adequate remaining outer prepuce skin.
A key aspect of this is ensuring that the initial circumcision is performed with precise surgical
technique and using an appropriately sized Plastibell, and ensuring that the ligature is placed
securely. (
1
) One of the major factors that contribute to this is due to inexperienced medical
personnel. (
8
) Prevention is better than a cure. Here, I would like to stress that strengthening
policies to ensure only qualified and certified practitioners perform circumcisions can reduce the
circumcision complications.
In summary, while secondary phimosis following circumcision is a recognised complication, it can
be managed effectively using techniques like W-plasty. However, the most important step remains
preventing this condition from occurring in the first place through precise surgical methods and
proper post-operative care. Continued research and refinements in surgical techniques and skills
will be crucial in ensuring better outcomes for patients undergoing circumcision procedures.
Conclusion
Re circumcision with the W-plasty technique is an alternative in managing secondary phimosis.
This technique not only helps to release the cicatricial scar but also prevents further scarring in
revision as compared to traditional techniques. However, further randomized controlled studies
should be conducted to further justify the outcome of the W-plasty corrective circumcision for
secondary phimosis. It is also mandatory to remember that circumcision is a surgical procedure
that should be performed by credentialed medical personnel.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
Acknowledgement
The authors would like to thank the clinical team at Hospital Kuala Lumpur for their support in
managing this case. We are also grateful to the patient for their cooperation and for providing
informed consent for publication. No funding was received for the preparation of this case report.
References
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