2. Anesthesia: Inject 0.3 cc of a local anesthetic at 2 o’clock and 10 o’clock positions and for improved rates of successful blocks, and inject 0.1 cc of a local anesthetic at the base of the frenulum. Always perform the frenulum block in the perpendicular plane to the shaft to avoid injecting into the urethra (Figure 45-3).

3. Dissection of the foreskin: When the anesthetic has been in place for 1 to 2 minutes, clamp the tip of the foreskin at 2 o’clock and 10 o’clock positions with hemostats. A third closed straight hemostat is carefully advanced into the opening of the foreskin to coronal sulcus to dissect the adhesions between the glans and the foreskin. Care must be taken not to enter the urethra at any time or pass the tip of the hemostat beyond the proximal end of the glans. Tent the skin as the hemostat is advanced under the foreskin to ensure that the meatus has not been entered. First dissect off the dorsal aspect, then spread the hemostat open, as shown, to sweep the adhesions from the glans (Figure 45-4).

4. Mogen procedure: After releasing the adhesions, mark the foreskin without tension applied along the arc of the glans about 5 mm distal to the coronal sulcus. Slide the foreskin distally past the tip of the penis, and slide it up to the marked foreskin into the minimally opened Mogen clamp, with the sulcus of the clamp facing the penis (Figure 45-5A). Check that the angle of the clamp matches the angle of the glans. Check to make sure that the glans is not trapped within the foreskin to be excised. Clamp and lock the Mogen clamp. Use a No. 11 or No. 15 blade scalpel to cut away the foreskin from the clamp’s outer surface (Figure 45-5B). Remove the clamp after 3 minutes, and carefully open the severed tip of the remnant foreskin. Retract the foreskin behind the glans, and remove any adhesions that may be at the corona of the glans (Figure 45-5C). Check for dehiscence or bleeding.