What Is a Metoidioplasty?

Transmasculine Genital Surgery Options Other Than Phalloplasty

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There are several types of gender affirming surgeries that are available to transgender men who want to undergo genital surgery, sometimes also known as "bottom surgery." The 2015 U.S. Transgender Survey found that approximately 50 percent of men wanted or had undergone such surgery. Approximately half of those men were interested in a phalloplasty, the surgical creation of a penis using tissue from elsewhere on the body.

The other half were interested in a metoidioplasty.

What Is a Metoidioplasty?

Metoidioplasty is the creation of a phallus (penis) from the hormonally-enlarged clitoris. The clitoris naturally enlarges when a man begins to take testosterone. A minimum of a year on testosterone is a requirement for all transmasculine genital surgeries.

During a metoidioplasty, the clitoral ligaments are detached, which allows the clitoris to lengthen and drop into a position more similar to a natal phallus. On average, the created phallus is between 5 and 7 cm long, which may or not be sufficient to penetrate a partner sexually. (Depending on the man, this is not always a concern.) A plastic surgeon then sculpts the head of the clitoris to more closely resemble the glans penis. At the same time, the labia can be reshaped into a scrotum, with or without testicular prostheses.

Metoidioplasty can be done either with or without urethral lengthening procedures.

Urethral lengthening extends the urethra along the new phallus. Then, men are able to pee from their phallus. Being able to stand to pee is a major reason that men choose to undergo genital surgery. However, urethral lengthening does increase the risk of surgical complications. These complications are usually minor and can include dribbling or spraying during urination.

They may also include urinary blockages or fistula.

Metoidioplasty is usually considered to be a single-stage surgery. However, some men may require additional surgeries in order to achieve their desired results. Additional surgeries may address either appearance or function.

Metoidioplasty vs. Phalloplasty—Pros and Cons

There are advantages and disadvantages to both metoidioplasty and phalloplasty. Therefore, it's important for men to discuss their interests and priorities with their surgeon during the early consultation phase. Most men who choose metoidioplasty are quite happy with the outcome of their surgery. However, depending on surgical goals, as well as body composition and structure, it is not always the best choice.

Some advantages of metoidioplasty over phalloplasty include:

  • Shorter healing time
  • More affordable surgery
  • Lower complication rates, even with urethroplasty
  • No large scars that may be considered disfiguring or stigmatizing. (The scars left by the most common phalloplasty technique are both large and very recognizable to anyone who knows what to look for. For some men, that is not an issue. For others, it may be extremely uncomfortable.)
  • The phallus created by metoidioplasty has natural erectile function, and there is no need for a penile prosthesis.
  • Erotic sensitivity of the clitoris is maintained in the phallus.

Some advantages of phalloplasty over metoidioplasty include:

  • Patients are more likely to be able to sexually penetrate their partners, if this is something of interest to them.
  • The phallus is significantly larger than the one created through metoidioplasty.
  • Some men feel that this surgery creates more "natural" looking genitalia.

Choosing Phalloplasty After Metoidioplasty

For men who initially choose metoidioplasty, it is possible to later undergo a phalloplasty. This is true regardless of whether the man chooses to have a urethral lengthening at the time of the procedure.

 The reverse is not true. The procedure for embedding the clitoris in the penis during phalloplasty makes a later metoidioplasty impossible.

Associated Abdominal and Genital Surgeries

Transgender men seeking bottom surgery may also choose to undergo one or more associated surgeries. Men who do not have any interest in carrying a pregnancy may choose to have a hysterectomy and ovariectomy. These procedures are abdominal surgeries used to remove the uterus and ovaries. For men who might want to have their own biological children, but would find pregnancy dysphoric, gamete banking is an option. This needs to be done prior to ovariectomy and hysterectomy. Ideally, it should also be done before starting testosterone therapy, but that is not a requirement.

Hysterectomy and ovariectomy are also options for individuals who do not want a phalloplasty or metoidioplasty but also do not want to worry about the possibility of cervical, uterine, or ovarian cancers later in life. Removing the uterus, cervix, and ovaries also removes the need for screening. Such screening can be very dysphoric for transgender men.

Vaginectomy is the surgical removal of the vagina. Some surgeons who offer phalloplasty and/or metoidioplasty will offer this surgery as part of a single-stage reconstruction. Others prefer patients to have a vaginectomy in advance, if that is something the patient wants. Of note, some surgeons who perform transmasculine bottom surgeries do not offer vaginectomies and advise against them because of concerns about complications. The research literature is unclear on the risks of vaginectomies in transgender men. The outcome of such procedures is likely very closely related to the skills and experience of the surgeon. Outside the context of gender affirming surgery, this procedure is primarily used to treat certain types of gynecologic cancer. As such, some plastic surgeons may refer patients interested in vaginectomy to a surgical gynecologist.

What additional surgeries men choose is a matter of both individual preference and the choice of surgeon. For example, a surgeon who uses the vaginal lining to create the urethra in a phalloplasty will probably need the patient to undergo a vaginectomy either prior to or at the time of that surgery. On the other hand, a transgender man who wants to maintain the option to carry a pregnancy would not want to undergo any of these additional procedures.

A Word From Verywell

Decisions about whether or not to undergo gender affirming surgeries are a personal choice. That includes both whether you want surgery and which procedures may be right for you. It can be helpful to discuss your goals and concerns for surgery with someone who is knowledgeable about the risks and benefits of the various options. This could include not just the surgeon but your therapist, and/or friends who have gone through a similar decision making process. However, remember that different people have different motivations. The choices that make sense for a close friend may be different from the ones that make sense for you. In addition, the procedures offered by a particular surgeon may not be the ones you want. If that is the case, consider seeking out other options. They may not be the best doctor for you.

It's never a bad idea to consider a second opinion, although getting one is not always a practical option. There are many areas of the country with no surgeons, or only one surgeon, performing these procedures. Some of the big name surgeons do offer phone or Skype consultations, but be aware that you may have to pay out of pocket. The cost may not be reimbursable, and you may need to demonstrate your surgical eligibility before they will discuss your case.

Eligibility guidelines for genital surgeries generally include documentation of gender dysphoria, a minimum of 12 months on hormone therapy, and at least a year of living full time in the gender role you wish to surgically affirm. This is usually provided in the form of a letter from your hormone prescriber and one or two letters from behavioral health professionals.

Sources

Frey JD, Poudrier G, Chiodo MV, Hazen A. An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature. Plast Reconstr Surg. 2017 Mar;139(3):728-737. doi: 10.1097/PRS.0000000000003062.

Frey JD, Poudrier G, Chiodo MV, Hazen A. A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the "Ideal" Neophallus an Achievable Goal? Plast Reconstr Surg Glob Open. 2016 Dec 23;4(12):e1131. doi: 10.1097/GOX.0000000000001131.

James, SE, Herman, JL, Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications. Plast Reconstr Surg. 2017 Oct;140(4):551e-558e. doi: 10.1097/PRS.0000000000003697. 

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