Metoidioplasty is a FTM sex reassignment surgery procedure developed in the 1970s an alternative to Phalloplasty. Metoidioplasty takes advantage of the testosterone induced growth of the clitoris, and includes lengthening and straightening of the testosterone-enlarged clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. It is often done in one stage
Anatomy of the Clitoris
Metoidioplasty transforms the clitoris into a small penis by releasing it from the hood and cutting the ligament (chordee) that holds the clitoris in place under the pubic bone to allow the entire penile structure to be free of surrounding tissues, giving it more exposure. Additional length of up to 50% can thus be achieved. The labia minora can also be used as flaps to provide tactile protection and additional girth. Additionally, fat can be removed from the pubic mound and the skin pulled up to reposition the penis farther forward (mons resection and phallus repositioning.)
Typical operating time for metoidioplasty procedure is 3-5 hours, and may require additional follow-up procedures and revisions in later stages.
Scrotoplasty and Testicular Implants
To create the scrotum and testicles, the labia majora are dissected, rotated and descended from their original position. Pockets are created in them with incisions to insert testicular implants. Depending on technique and anatomy, the scrotum may have a bifid apperance but this divided scrotum can be joined at a later stage to create a single scrotum with two testicles.
Expanders may be used to stretch the tissues prior to placement of implants. This adds an extra surgery stage but creates a bigger scrotum that can accommodate larger testicular implants.
Urethroplasty / Urethral Lengthening
Another option with Metoidioplasty is Urethroplasty or Urethral Lengthening. Techniques vary (ie. anterior vaginal wall flap vs. buccal mucosa flap) but the results are the same: extension of the urethra from the native urethral opening to the tip of the penis. A catheter is placed inside the new urethra for 2-3 weeks while the neourethra heals. Urethroplasty adds an extra procedure and/or stage, and carries increased risk of urinary complications such as fistula and stricture.
Metoidioplasty results will depend greatly on surgical technique, surgeon experience, anatomy and genital enlargement from testosterone.
Pros, Cons, and Risks of Metoidioplasty
PROS: Natal-appearing penis, erotic sensation, unassisted erections, easily concealed scars, shorter operative time, shorter recovery time.
CONS: Small sized penis, good hormonally induced clitoral growth required, typically does not produce a bulge, depending on surgical technique scrotum can have bifid appearance until further revision, urethroplasty may not enable standing to void.
RISKS: Fistula (hole) or stricture (blockage) with urethroplasty, migration and/or extrusion of testicular implants. (There are fewer risks associated with the Simple Meta procedure since urethroplasty is not performed.)
Requirements for Metoidioplasty
Basic health requirements:
- Good physical and mental health
- 18 years or older
WPATH Standards of Care requirements:
- Pre-operative psychological counseling and two letters of support
- Hormone therapy (miminum of 2 years for best metoidioplasty results)
- Minimum of 1 year of real life experience (RLE)