CO₂ laser frenuloplasty for cryotherapy-induced frenulum perforation: a case report

Introduction

The penile frenulum is a small, sensitive fold of tissue that connects the glans to the ventral side of the penile shaft, serving to prevent excessive retraction of the foreskin during an erection (1). This delicate structure is prone to injuries, which can occur due to trauma or medical treatments (2). These injuries, whether tears or perforations, often necessitate effective repair to restore functionality and relieve discomfort. Traditionally, frenulum repair involves scalpel surgery (3,4), but CO₂ laser frenuloplasty has emerged as an innovative alternative, offering enhanced precision and faster recovery (5,6). This article examines a case of frenulum perforation post-cryotherapy for condylomas, highlighting the use of CO₂ laser frenuloplasty and its clinical outcomes. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-165/rc).

Case presentation

A 25-year-old male patient, following aggressive cryotherapy for recurrent genital condylomas in the frenulum region, experienced damage resulting in the formation of a hole in its median portion (Figure 1A). This damage necessitated an effective treatment approach to restore functionality and relieve discomfort. The patient was enrolled in the Dermatology Unit of the University of Campania Luigi Vanvitelli, and he was treated with a CO₂ laser frenuloplasty known for its precision and efficacy in delicate mucosal tissues. The CO₂ laser frenuloplasty was conducted in a single session, with the laser set to a power of 0.3–1 W and a frequency of 10 Hz (using the Glide CO₂ laser system, DEKA M.E.L.A Srl, Florence, Italy). To ensure patient comfort and minimize discomfort during the procedure, 0.5 mL of lidocaine was meticulously administered as local anesthesia. The procedure involved making an incision in the median area of the frenulum to divide it into two parts, followed by vaporization of the proximal and distal ends of the frenulum using the laser. These settings were carefully chosen to balance effective tissue ablation with minimal thermal damage to surrounding tissues. The laser’s ability to coagulate blood vessels during the procedure significantly reduced intraoperative bleeding, contributing to a cleaner surgical field and potentially quicker healing. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. Ethical approval is not necessary as study device is already European conformity (CE) marked since 14/04/2021.

Figure 1 Perforation of the frenulum induced by aggressive cryotherapy for genital warts (A), immediately following CO₂ laser session (B), and once healed at 1 month follow up visit (C). This image is published with the patient’s consent.

Immediately following the procedure, the patient exhibited expected signs of localized inflammation and mild swelling at the surgical site. The absence of significant bleeding and the clean surgical margins were notable (Figure 1B). The patient was prescribed a topical healing gel containing cicatrizing agents and topical antibiotics to prevent infection and promote faster healing. No oral antibiotics were deemed necessary, aligning with best practices to minimize unnecessary antibiotic use and reduce the risk of resistance. At the 1-month follow-up, the patient reported substantial improvement in symptoms. Photographs taken at this time showed well-healed tissue with minimal scarring, indicating successful integration and regeneration of the frenulum (Figure 1C). The patient experienced no significant pain or functional limitations. The use of the topical gel appeared to have contributed positively to the healing process, keeping the site infection-free and supporting tissue regeneration.

Discussion

CO₂ laser frenuloplasty offers significant advantages over traditional scalpel surgery, including enhanced precision, reduced bleeding, and faster recovery due to minimal tissue damage. The laser’s dual function of cutting and coagulating provides a clear surgical field, while its sterilizing effect lowers post-operative infection risk. Additionally, the minimal scarring achieved improves cosmetic outcomes (7,8).

Beyond frenulum repair, CO₂ laser technology has potential applications in other urological conditions. It could be beneficial in treating urethral structures, Peyronie’s disease, and balanitis xerotica obliterans, where precision is crucial for minimizing tissue damage (9).

The ability to target specific areas without affecting adjacent tissues makes it ideal for delicate surgeries.

This case study demonstrates how CO₂ laser technology has revolutionized frenuloplasty, indicating a distinct change from traditional surgical techniques and demonstrating the technology’s potential to enhance surgical results and patient satisfaction, supporting a broader use of CO₂ laser technology in clinical practice.

Our results show that just at 1-month follow-up, the patient reported substantial improvement in symptoms. In this case the laser’s ability to coagulate blood vessels during the procedure significantly reduced intraoperative bleeding, contributing to a cleaner surgical field and potentially quicker healing.

Our results agree with the findings of Omi et al. 2014 (10) and Amato et al. 2024 (7) who have already emphasized how this technology can improve patient outcomes and surgical precision. These results are supported by our data, which demonstrate how the CO₂ laser can be used to precisely and carefully modify tissue. This is essential since it reduces the risk of secondary intention fibrosis and bleeding.

The successful treatment of a short frenulum using CO₂ laser was reported also in the study of Duarte and Correia [2009] (6).

Additionally, our study also differentiates traditional ablative CO₂ laser treatments, which include vaporizing tissue, from the study laser technique. Our method extends the frenulum in a novel way by taking advantage of the CO₂ laser’s thermal impact without burning the tissue. This method works especially well for frenula that have experienced trauma or prior surgical procedures.

Furthermore, the CO₂ laser has a considerable impact on collagen dynamics because it influences the generation of important factors involved in collagen synthesis as well as fibroblast proliferation. In particular, the laser suppresses the release of transforming growth factor-beta1 (TGF-β1), a cytokine that promotes collagen synthesis, and enhances the production of basic fibroblast growth factor (bFGF), which is known to decrease collagen formation. This double action helps maintain a balanced structure of collagen, limiting both excessive fibrosis and abnormal wound healing (11,12).

Our findings contribute to the growing body of scientific data, reinforcing the premise that CO₂ laser frenuloplasty is not only an option, but even a better choice in some clinical settings, particularly when traditional procedures pose significant risks or limits.

Further studies are needed to confirm the long-term benefits of CO₂ laser techniques in broader urological contexts. However, its minimally invasive nature and precision suggest that it could play an increasingly important role in future urological care, offering better outcomes and faster recovery for patients (7,8).

Conclusions

CO₂ laser frenuloplasty proves to be an effective, minimally invasive option for treating frenulum damage. The precise control over tissue ablation and coagulation provided by the laser resulted in successful healing with minimal complications. This case supports the continued use and further exploration of laser technology in delicate mucosal surgeries. It underscores the importance of precise surgical techniques and targeted post-operative care in achieving optimal patient outcomes.

Additional studies with larger cohorts are recommended to confirm these findings and refine treatment protocols.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-165/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-165/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-165/coif). T.Z. and I.F. are employed at EI.En. Group. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. Ethical approval is not necessary as study device is already CE marked since 14/04/2021.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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