Preparing for insertion of the bell. Next, use a straight clamp to create a crush line on the dorsal aspect of the foreskin at the 12 o'clock position. Again, tent the skin up as you advance the lower blade of the clamp in order to avoid entry into the urethra. The crush line should stop about 1 cm distal to the coronal sulcus (Figure 6).3,6 You need only keep the clamp on for a few seconds to create the crush line. Next, cut down the middle of the crush line with scissors that have at least 1 blunt-tipped blade (Figure 7). You are creating an opening through which the bell will later be inserted; it need only be large enough to accommodate the bell. If the cut edge of the crush line bleeds, briefly crush that edge again with the clamp.
With the 2 o'clock and 10 o'clock clamps still attached, the foreskin can now be retracted to remove any additional adhesions—which there usually are. Although a blunt-edged probe may be used to remove these remaining adhesions, I prefer firm pressure with gauze (Figure 8). Failure to break down all of the adhesions is cited as the primary reason for a poor cosmetic result.6 As before, respect the ventral frenulum, since it tends to bleed if disturbed; however, do free up adhesions just lateral to the frenulum.
Inserting the bell. With the glans exposed, determine which size bell will best cover the glans completely (1.3 cm is the most commonly used size). Too small a bell will force you to pull more foreskin than underlying mucosa through the hole in the base plate, and too large a bell will tent the foreskin up away from the shaft, making it hard to see landmarks. I wipe the edge of the bell with the petroleum gauze (this helps it slip off the foreskin at the end of the procedure) and apply the bell to the glans. Make sure that the bell completely covers the glans and that the arms of the bell remain perpendicular to the axis of the patient.
Placing the base plate over the bell. The next step is to place the base plate over the bell. There are many variations on how to do this. I teach the safety pin method, since this technique seems easiest to grasp conceptually.
With your nondominant hand, hold the bell with the foreskin protracted back over it and the clamps still attached. Next, pierce the distal corners of the cut dorsal foreskin with a safety pin. Make sure to pierce through the outer foreskin and inner mucosal layers of each corner (Figure 9). Secure the safety pin and align it parallel to the stem of the bell. Remove the 2 o'clock and 10 o'clock clamps. Lower the hole of the base plate over the stem of the bell and the safety pin until it rests against the flare of the bell. Draw the foreskin evenly through the hole bilaterally using your ink mark as a guide. Use of another clamp can help with this step (Figure 10).