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Metoidioplasty Procedures

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 performed in one stage.

Metoidioplasty Explained

Metiodioplasty
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.

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 body 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.

Types of Metiodioplasty Surgery

There are several variants of metoidioplasty:

1. Clitoral Release or
Simple Meta

Clitoral release only (no urethroplasty or scrotoplasty)
2. Ring Metoidioplasty
Clitoral release
Clitoral lengthening
Urethroplasty
Scrotoplasty (optional)
Testicular implants (optional)
3. Full Metoidioplasty
Vaginectomy
Clitoral release
Clitoral lengthening
Urethroplasty
Scrotoplasty
Testicular implants
4. Centurion Metoidioplasty
Vaginectomy
Clitoral release
Clitoral lengthening
Clitoral girth augmentation
Urethroplasty
Scrotoplasty
Testicular implants

Vaginectomy: An umbrella term referring to surgery procedures that remove all or part of the vagina. The most common vaginectomy performed on FTM transsexuals is colpocleisis, where the vaginal mucosa is removed, the vaginal walls are fused, and the vaginal opening is closed.

Urethroplasty: Extension of the urethra to allow urination while standing.

Scrotoplasty: Creation of testicular sac, with or without implantation of testicular prosthesis.

Mons Resection: Optional procedure that allows the penis and scrotum to be moved to a more forward position and improves access and visibility of the penis by removing excess skin and fat.

 

Comparing Penis Tissues to Clitoral Tissues

 

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 and scrotoplasty are 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)

Each surgeon may have their own specific requirements in addition to these. Inquire directly.

Web Articles

Female-to-Male Urogenital Reconstruction: “The Centurion Procedure” [PDF]
Tex McFaden, D.O., Director, Research & Clinical Trials, American Institute for Plastic Surgery