Overview of Metoidioplasty

Metoidioplasty is a gender-affirming genital surgery for transmasculine and nonbinary individuals that creates a small, functional penis (neophallus) using the hormonally enlarged clitoris. Originally developed in the 1980s as a less invasive alternative to phalloplasty, metoidioplasty prioritizes preserved sensation, natural erection, and lower surgical complexity.

The average penis length after metoidioplasty is typically 3.8 to 5 cm (1.5 to 2 inches), depending on anatomy, testosterone response, and the surgical technique used. While several methods exist, most do not significantly increase length. In fact, a 2023 study found that the post-metoidioplasty neophallus was, on average, only 0.6 cm longer than the pre-operative stretched clitoral length. Each approach offers different advantages depending on patient goals.

What All Metoidioplasty Techniques Have in Common

• Use of the clitoris, which is analogous to the penis, to form the neophallus
• Requires testosterone use for at least 1–2 years preoperatively, to enlarge the clitoris. (This may not apply to those who are intersex.)
• Clitoral ligament release to increase projection and reposition the shaft
• Use of local tissue (e.g., labia minora) for added girth
• Retention of erogenous sensation and spontaneous erection
• No requirement for erectile implants
• Optional complementary procedures for urination, aesthetics, or function

Types of Metoidioplasty Procedures

Simple Release Metoidioplasty

A low-risk, single-stage option involving clitoral release only. No urethral work or vaginectomy is done. Ideal for patients who want visible genital changes with maximum sensation preservation and minimal recovery.

Ring Metoidioplasty

Developed in Japan by Dr. Ako Takamatsu, Ring Meta uses local genital tissue (labia minora + anterior vaginal wall) to create a urethra. It avoids oral grafts and does not include vaginectomy, making it a lower-risk approach for those seeking standing urination and sensation preservation.

Belgrade Metoidioplasty (Full Metoidioplasty)

A standardized, one-stage procedure developed by Dr. Miroslav Djordjevic in Serbia. It includes urethral lengthening using oral grafts, vaginectomy, scrotoplasty with implants, and perineoplasty. Offers a complete, functionally masculinized genital reconstruction in a single operation.

Extensive Metoidioplasty

Developed in Iran by Dr. Shahryar Cohanzad, this method features extensive dissection of the clitoral crura to maximize length. Urethral lengthening is staged, and patients use a penile traction device postoperatively to increase visible length over time.

Centurion Metoidioplasty

This technique developed by Dr. Peter Raphael incorporates the round ligaments to enhance phallic girth. Performed as a single-stage surgery with scrotoplasty and testicular implants, this technique shares many features with the Belgrade method but with the incorporation of the round ligaments.

Extended Metoidioplasty

Developed collaboratively in the Netherlands and the U.S., this modern technique emphasizes length, aesthetics, and low complication rates. Urethral lengthening is not performed, making this suitable to those who are comfortable sitting to urinate.

Total Corporal Mobilization (TCM)

TCM is a new experimental method of metoidioplasty developed by Dr. Ubirajara Barroso in Brazil. Based on mobilizing the internal portion of the clitoris, TCM can increase length while preserving function. Urethral lengthening and other refinements may be added in follow-up surgeries.

Complementary Procedures

Scrotoplasty & Testicular Implants

The most common type of scrotoplasty uses the VY advancement technique developed by Prof. Piet Hoebeke. Bilateral labial flaps are rotated and advanced to form a single scrotal sac. Expanders or staged procedures may be used for larger implants.

Urethroplasty / Urethral Lengthening

Connects the native urethra to the tip of the penis using labial or vaginal flaps, or oral grafts. Foley and suprapubic catheters are used for 2–6 weeks during healing. This is the procedure that enables standing urination.

Vaginectomy

In gender-affirming surgery, vaginectomy typically involves removal of the vaginal lining (colpectomy), closure of the canal (colpocleisis), and creation of a perineum (perineoplasty). Vaginectomy is required by most surgeons if urethral lengthening is performed because it reduces urethral complications.

Mons Resection

This procedure removes excess mons pubis fat and skin to move the neophallus and scrotum into a more forward position. It can greatly improve the aesthetic result, especially in patients with higher BMI.

Comparing Types of Metoidioplasty Surgery

Technique	Urethral Lengthening	Vaginectomy	Scrotoplasty & Implants	Grafts Used	Staging	Ideal For Patients Who...
Simple Release	No	No	No	None	Single	Want low-risk, sensation-preserving genital enhancement
Ring	Yes	Optional	Optional	None	Staged	Want standing urination without oral grafts
Belgrade	Yes	Yes	Yes	Oral mucosa	Single	Want a one-stage, fully masculinizing surgery
Extensive	Yes (Staged)	Yes	Optional	Local flaps	Staged	Prioritize phallic length and are willing to use a traction device
Centurion	Yes	Yes1	Yes	Oral mucosa	Single	Prefer a girthier result with internal ligament support
Extended	No	Optional	Optional	None	Staged	Want more length & sensation with fewer complications
TCM	Variable	Optional	Optional	Oral mucosa	Staged	Want to maximize length by mobilizing internal structures

Notes:

• ¹ Centurion Metoidioplasty uses a different vaginectomy technique that closes the vaginal canal but doesn't remove the lining (colpectomy).
• “Staged” may mean two or more surgeries, depending on which additional procedures are chosen.
• Indicates a standard part of the technique.
• Indicates that the technique excludes this element.

Pros and Cons of Metoidioplasty

Pros:

• Preserves sensation and spontaneous erection
• No need for penile implants
• Can allow for standing urination
• Less invasive than phalloplasty
• Shorter recovery and lower cost
• Less visible scarring

Cons:

• Typically not large enough for penetrative sex
• May require multiple stages or revisions
• Urethral complications are common with urethral lengthening
• Results can vary depending on anatomy and hormone growth
• Not all techniques provide a full scrotum or close the vagina

Risks and Complications

• Urethral fistula (with urethroplasty)
• Urethral stricture (with urethroplasty)
• Implant extrusion
• Wound healing issues
• Dissatisfaction with length, shape, or aesthetic outcome
• Sensation loss is rare, but possible depending on technique

Requirements for Metoidioplasty

To qualify for metoidioplasty, patients typically must meet:

• Be 18 years or older
• Be in good physical and mental health
• Provide a surgical readiness letter (or two, if using insurance)
• Have at least 1 year of testosterone therapy, 2 years preferred (to ensure adequate growth)
• Understand that stopping testosterone may lead to loss of phallic volume
• Each surgeon may have additional individual requirements

Related: The Evolution of Metoidioplasty: Past, Present and Future Innovations

 

Last updated: 06/02/25