Metoidioplasty

Metoidioplasty – Single Stage Reassignment Surgery

Synopsis:

Metoidioplasty is a genital-affirming lower body surgery for female-to-male transgenders. The main purpose of the surgery is to create male-like genitalia that has the capability to urinate while standing and has a satisfactory aesthetic appearance. This masculinizing surgery creates a male penis by lengthening and straightening the clitoris which has been hormonally enlarged.

The ligaments around the erectile tissue of the clitoris are cut to release it from the pubis thus lengthening the shaft. The urethra is incorporated into the penis and the skin from the labia and outer labia is used to add girth to the penis. Metoidioplasty surgery is often combined with additional procedures like scrotoplasty, ligament removal, and urethral lengthening to accomplish satisfactory postoperative results.

The objective is to create a penis that can experience sexual sensation, get erections without implants, and pee while standing, not to achieve penetration. 

There are four basic forms of Metoidioplasty:

  • Simple release
  • Full Metoidioplasty
  • Ring Metoidioplasty
  • Centurion Metoidioplasty

Simple release

The simple release is also called the simple Meta. The simple release surgery involves releasing the clitoris from the surrounding tissue of the pubis. It does not involve modification of the urethra or vagina but increases the length and exposure of the penis.

Full Metoidioplasty

A full metoidioplasty involves surgically releasing the clitoris from the pubis and then using a graft from the inside of your cheek to connect the neophallus with the urethra. A full metoidioplasty may also include removal of the vagina (a vaginectomy) and insertion of scrotal implants.

Ring Metoidioplasty

Ring Metoidioplasty is a procedure that is quite like the full metoidioplasty. In this case, however, the tissue graft is not taken from the inside of your cheek, but instead, a graft is taken from the vaginal wall and combined with the labia majora to connect the neophallus and urethra. The greatest advantage of having a ring metoidioplasty is that your body has to undergo healing on only one site. It also limits the complications that could arise from oral surgery like pain while eating and decreased saliva production.

Centurion metoidioplasty

In the Centurion Metoidioplasty procedure, the ligaments that go up to the labia from the labia majora are released and wrapped around the newly created penis to add extra girth. The Centurion Metoidioplasty does not need a tissue graft from the inner cheek or vaginal wall, which means there are fewer complications, less surgical scarring and pain.

Surgical Readiness Assessment

To assess whether you are ready for Metoidioplasty surgery, you will need to consult with qualified assessors and complete a surgical readiness assessment. If you meet the eligibility and criteria required, a surgeon will take over your case. The surgeon will study the case and may carry out further assessments if needed. Before the actual surgery takes place, you must discuss your needs and expectations with your surgeon in detail. Some points that should be discussed with the surgeon are:

  • The primary surgical goal for the gender-affirming surgery, like sexual penetration, standing to pee, erectile function etc.
  • The surgical procedures are available for your case and the advantages and disadvantages of each technique.
  • Ask to see photographs of successful and unsuccessful outcomes of their patients.
  • Any medications that should be avoided before your surgery.
  • The options you have in case your surgical results are not what you expected in terms of appearance and sexual function.
  • Any possible complications and risks associated with the various techniques.
  • The surgeon’s success and complication rates for the procedure.

Metoidioplasty Surgery Procedure

While surgical techniques employed from one surgeon to another vary, the commonly followed procedure is as follows:

  1. Extended hormone replacement therapy is a prerequisite to enlarge the erectile tissue of the clitoris enough for the surgery. This may take between 1 to 3 years.
  2. During the surgery, the ligaments that hold the clitoris in place under pubic bone are severed.
  3. The clitoris is released from the pubis by cutting the surrounding tissue and used to create a penis.
  4. The urethra is then extended through your penis.
  5. The fat is pulled up from the pubis and used to bring the penis to the front.
  6. The external genitals are removed and grafted around the penis to add girth.
  7. If opted for, the vagina is removed or closed, and the labia are reshaped into a scrotum with or without testicular implants.

Common complications associated with Metoidioplasty

All surgery entails some risks. Common complications may include adverse reactions to the anaesthetic used, clots, infections, blood loss etc. You should discuss the risks with your surgeon. A few complications specifically associated with Metoidioplasty are as follows:

  • Abscess: A bacterial infection causes pus to collect under the site of the incision. It has to be treated with antibiotics or drained by a surgeon.
  • Loss of Sensation:  Even though the risks for this are lower than in a phalloplasty, but some decreased sensation is still possible.
  • Seroma: A seroma occurs when clear fluid collects in the surgical site. Smaller seromas can be sucked or aspirated locally, however surgery might be required if the seromas are larger. 
  • Haematoma: A haematoma is the most common complication after Metoidioplasty. It occurs when blood accumulates in the surgical site. This causes pain and swelling. Like seromas, smaller haematomas can be sucked out locally, however, surgery might be required if the haematomas are larger. 
  • Scarring: Scarring may be prevented with massage exercises and avoiding the sun. However, surgical revision can correct severe scarring.
  • Dissatisfaction:  You might not be happy with the results achieved in terms of appearance or function, in which case you can consult with your surgeon to see if surgical revision is a possibility.

Post-op care after Metoidioplasty surgery

You should expect to spend three nights in the hospital after surgery, as well as seven more in the recovery residence. The recovery time would be shorter if do not opt for a urethra lengthening. You will also be expected to be on a painkiller and antibiotics regimen to prevent infections. You will also be on medication to make your transition easier, to ease bowel movements, and relax muscles, to prevent nausea and bladder spasms. For the duration of the healing and recovery process, the following symptoms are to be expected:

  • Bleeding
  • Itching
  • Swelling
  • Bruising
  • Numbness
  • Difficulty urinating
  • Occasional nerve sensations
  • Pinkness or redness of the scars  

You should try to check in with your primary care provider regularly for the first few months after your surgery.

How do Metoidioplasty results differ from Phalloplasty?

Metoidioplasty and Phalloplasty are the two most common forms of lower gender reassignment surgeries for AFAB Trans and non-binary people. While Metoidioplasty creates a phallus (or penis) from a clitoris that has been enlarged hormonally after taking testosterone, phalloplasty uses a large tissue graft taken from the torso, arm, or leg to recreate a penis.

If we consider Metoidioplasty vs Phalloplasty, both procedures have their unique advantages and drawbacks.

Pros and cons of metoidioplasty

Some pros and cons of having Metoidioplasty rather than Phalloplasty are as follows:

Metoidioplasty vs Phalloplasty Pros

  • Metoidioplasty results in a new phallus that maintains the erotic sensitivity of the clitoris.
  • The penis is fully functioning that has a natural erectile function, and doesn’t need a penile prosthesis to achieve an erection.
  • Metoidioplasty results in the minimal visible scarring as opposed to the large scars left by phalloplasty.
  • Metoidioplasty is usually a single-stage surgery. Even with any additional surgeries required to achieve the desired results in appearance or function, it still involves fewer surgical procedures than phalloplasty.
  • Metoidioplasty carries a lower risk of complications than phalloplasty, though both procedures carry the risk of usually minor side effects.
  • Metoidioplasty has a shorter healing and recovery time than phalloplasty.
  • It is considerably more affordable than phalloplasty.

Metoidioplasty vs Phalloplasty Cons

  • The new phallus created in Metoidioplasty is fairly small in size, both in terms of length and girth, and can measure anywhere between 3 to 8 cm in length.
  • Patients are less likely to sexually penetrate during coitus, even though they can achieve an erection.
  • Metoidioplasty requires extensive hormone replacement therapy to achieve the clitoral growth required for the procedure.

FAQs about Metoidioplasty

Which is better Metoidioplasty vs Phalloplasty?
Both options have pros and cons, discussed earlier in the article.

How much growth is needed for Metoidioplasty?
Significant clitoral growth following the use of testosterone is required. Usually one needs to be on testosterone therapy for anywhere between one to two years before having Metoidioplasty.

How much does Metoidioplasty cost?
The cost of surgery will vary between depending on your surgeon, location, and the procedures you have performed. The cost of metoidioplasty can ranges from $4,000 for a Simple Release to as much as $60,000 for a full Meta.

What is TransBucket?
Transbucket is an online health care and surgery resource for the Trans community, from FTMs to MTFs to genderqueers, agender individuals, and everyone else who could benefit from exploring real life photo experiences.

Does insurance cover gender assignment surgery?
Federal and state laws prohibit most public and private health plans from discriminating against you because you are transgender. This means, that with a few exceptions, it is illegal discrimination for your health insurance plan to refuse to cover medically necessary transition-related care.

References:

https://www.metoidioplasty.net/

Djordjevic, Miroslav L et al. “Metoidioplasty: techniques and outcomes.” Translational andrology and urology vol. 8,3 (2019): 248-253. doi:10.21037/tau.2019.06.12
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626308/

Morrison SD, Perez MG, Carter CK, Crane CN. “Pre- and Post-Operative Care With Associated Intra-Operative Techniques for Phalloplasty In Female-to-Male Patients”. Urol Nurs. 2015 May-Jun;35(3):134-8. PMID: 26298948.
https://pubmed.ncbi.nlm.nih.gov/26298948/

Monstrey SJ, Ceulemans P, Hoebeke P. Sex Reassignment Surgery in the Female-to-Male Transsexual. Semin Plast Surg. 2011 Aug;25(3):229-44. doi: 10.1055/s-0031-1281493. PMID: 22851915; PMCID: PMC3312187.
https://pubmed.ncbi.nlm.nih.gov/22851915/

Frey, Jordan D. MD; Poudrier, Grace BA; Chiodo, Michael V. MD. Hazen, Alexes MD. A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the “Ideal” Neophallus an Achievable Goal? Plastic and Reconstructive Surgery – Global Open: December 2016 – Volume 4 – Issue 12 – p e1131 doi: 10.1097/GOX.0000000000001131
https://journals.lww.com/prsgo/fulltext/2016/12000/a_systematic_review_of_metoidioplasty_and_radial.9.aspx

Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res. 2020 Aug 21. doi: 10.1038/s41443-020-00346-y. Epub ahead of print. PMID: 32826970.
https://pubmed.ncbi.nlm.nih.gov/32826970/

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