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Metoidioplasty

Surgical Description
Intended Results
Related Procedures
Surgical Complications
Post-Operative Recovery
Post-Operative Results
Eligibility

Surgical Description

Metoidioplasty (meta) is a female to male gender reassignment surgery (GRS). Metoidioplasty surgeons have a high success rate for the before and after surgery results.
Metoidioplasty is a highly customizable female to male surgery that allows each candidate to choose the options that best suit their needs. Because each person who chooses to have metoidioplasty is different, there is a wide range of options that candidates can discuss with their surgeon.
Generally, the enlarged clitoris, which is an effect of testosterone hormone replacement therapy (HRT), is relocated upwards to create a sensate and functioning micropenis. The surrounding skin of the clitoris is removed and “released” from the pubis to give the impression of more length. This results in a circumcised appearance, although patients may opt for an uncircumcised look. The suspensory ligament may be partially divided. Labial ligaments and the urethral plate are released, which allows the penis to extend further outward.
The procedure may involve the creation of a glans and scrotum by using the tissue from the labia majora or labia minora with two testicle prosthesis.
Metoidioplasty generally takes 2-3 hours to complete, is less expensive, and has potentially fewer complications than phalloplasty. The procedure may be done under conscious sedation. General anesthesia may be necessary if the patient opts for primary urethral lengthening, hysterectomy, or vaginectomy.

Intended Results

The final result is a very small, realistic-looking penis (micropenis) that is sensate and can achieve an erection. A goal of FTM metoidioplasty is to preserve the clitoral erectile tissue so that patients may achieve an erection without the assistance of an erectile prosthesis. Nearly all patients are able to achieve post-operative clitoral orgasms. Some patients may be able to use the micropenis for sexual penetration, but it is not guaranteed, as the size, shape, and erectile rigidity of the micropenis ranges by individual.
Actual results are dependent upon various factors. Clitoral enlargement attributable to testosterone HRT helps to increase the size. Patients who are near their ideal body weight, who are not overweight, and who do not smoke have the highest opportunity for success.
Removing the skin and fat of the mons pubis, and pulling the skin upward will improve results in most patients. This results in a curvilinear scar in the pubic area. It is usually performed as a second stage when the scrotal expanders are replaced with permanent testicular implants.
The benefit of metoidioplasty is that it is non-invasive and there are little to no apparent surgical scars. Clitoral sensitivity remains intact. Recipients may undergo later genital reconstructive procedures such as phalloplasty.

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  • Pre-meta (clitoral lengthening)

    The clitoris may be lengthened by severing the suspensory ligament that connects the clitoris to the pubic symphysis. A metoidioplasty that does not involve scrotoplasty and urethraplasty is called a clitoral release.
    The disadvantage of a clitoral release alone is that it does not allow the patient to urinate through the new micropenis. The advantage of a clitoral release performed alone is that there is a reduced risk of complications, and the enlarged clitoris is visually and functionally enhanced. Some patients may be able to use the micropenis for sexual penetration, but it is not guaranteed, as the size and shape of the micropenis ranges by individual.
    Pre-Meta (Clitoral Release)

  • Scrotoplasty

    The goal of scrotoplasty is to create the appearance of a scrotum. Scrotoplasty may be performed at the same time as the metoidioplasty procedure.
    Prior to scrotoplasty, select patients may be required to use tissue expanders in the labia majora. Tissue expanders are inflatable balloons that patients gradually expand at home. This is beneficial because it provides the surgeon with enough tissue to insert prosthetic testicles and reduces problems with the prosthetic testicles. Due to the location of the expanders, patients may need to have a friend or partner help them when inflating the balloons. Permanent prosthesis can be placed in the expanded scrotum after 3-6 months of expanding. Patients can then return home the same day. Although this requires two operations, the results are frequently better. Patients who chose not to use expanders may have to return at a later date to adjust their prosthesis so that they fall evenly (one may rise above the other due to the constricted space).
    Patients may be required to wait 3-6 months after urethral lengthening to have expanders or prosthesis placed.

  • Urethral lengthening (urethral extension)

    Urethral lengthening may be performed at the same time as metoidioplasty. Mucosal tissues from the vaginal canal, mouth, or outer tissues are used to extend the urethra so that patients may urinate through the micropenis. A urethral catheter is placed for assistance in voiding during post-operative recovery.

    Primary Urethral Lengthening

    If a primary urethral lengthening is done with metoidioplasty, a vaginectomy must be performed at the same time. A urethral catheter is placed for assistance in voiding during post-operative recovery.
    Expanders or scrotal implants should not be placed when primary urethral lengthening is performed. They place pressure on the urethra that can complicate the procedure. Implants and expanders should be placed at least 3 months following urethral lengthening.

    Second Stage Urethral Lengthening (Buccal Mucosa Urethral Lengthening)

    In second stage urethral lengthening, patients first receive a metoidioplasty. This frequently means the mons pubis is partially removed. The urethra may be extended 3 months later by using a lining of tissue from the cheek. It is used to construct the neourethra, which is extended through the tip of the penis, allowing patients to stand to urinate.
    Expanders or scrotal implants should not be placed when second stage urethral lengthening is performed. They place pressure on the urethra that can complicate the procedure. Implants and expanders should be placed at least 3 months following urethral lengthening. Expanders or implants may need to be removed temporarily if they are already present.
    A vaginectomy must be performed at the same time if it was not done during a the prior metoidioplasty. This requires that the patient have a hysterectomy/oophorectomy if they have not already done so.
    Dr. Toby Meltzer uses the buccal lining (lining of the mouth) for urethral lengthening.

  • Mons Resection

    A mons resection is best suited for metoidioplasty patients with a prominent fat collection or loose skin over this area. Heavier patients undergoing metoidioplasty may benefit from a mons resection to further elevate the penis and scrotum. As a result, a mons resection allows the penis and scrotum to be relocated to a more forward position. It is frequently done with metoidioplasty if urethral lengthening is not simultaneously performed.
    Since this is a cosmetic procedure, it is rarely covered by insurance.

    Surgical Description

    Mons resection is generally performed under intravaneous sedation followed by an overnight stay in the hospital. Exceptions may be made for patients who have a caregiver. An elliptically-shaped segment of skin and fatty tissue is removed. The skin is then pulled upward, which pulls the penis and scrotum forward. The procedure results in an incision that is disguised by the pubis and abdominal hair.

    Post-operative Recovery

    A drain is placed in the incision for 1 day following surgery to prevent fluid build-up in the region. Patients may feel numbness for a few hours until the local anesthetic wears off. Sutures will dissolve slowly over time. Bruising and swelling should subside over 2-4 weeks, with the final result appearing over 2-3 months.

    Surgical Complications

    Risk of complication varies by individual. Minor complications, such as a localized infection, occasionally occur. Major complications are rare.

  • Vaginectomy

    Vaginectomy in female-to-male patients involves removal of the vaginal canal. The anterior wall of the vagina may be used to lengthen the urethra in order to enable patients to void out of the micropenis. A hysterectomy/oophorectomy must be performed at the same time as vaginectomy if the patient has not already had their female reproductive organs removed.

  • Hysterectomy/Oopherectomy

    Visit the hysterectomy page for more information.
    Hysterectomy/Oopherectomy

  • Testosterone HRT before metoidioplasty

    A surgeon may recommend that surgical candidates undergo at least one year of testosterone hormone replacement therapy before undergoing metoidioplasty. The clitoral enlargement that results from testosterone HRT provides the surgeon with more tissue in which to create a functioning micropenis. Surgeons may also recommend that candidates apply a topical testosterone, called dihydrotestosterone, to encourage clitoral growth. In addition, metoidioplasty candidates may be encouraged to use a pumping device to increase the size of the clitoris as well.
    Testosterone HRT

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Surgical Complications

The degree of risk is impacted by the health of the recipient. It is important to have a consultation with the surgeon before undergoing the procedure so that he or she may evaluate the risks particular to the patient.

Fistula

A fistula is an abnormal connection between two organs or passageways that do not connect. Urogenital fistula is the most commonly reported fistula that occurs in metoidioplasty patients. For more information about fistulas, visit http://en.wikipedia.org/wiki/Fistula.

Urethral Stricture

Urethral stricture is a narrowing of the urethral tube that may cause painful urination or frequent urinary tract infections (UTIs). For more information about urethral stricture, visit http://en.wikipedia.org/wiki/Urethral_stricture.

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Post-Operative Recovery

Recovery for patients undergoing metoidioplasty only

Patients should prepare to take a minimum 7 day leave of absence from work if they are having metoidioplasty without urethral lengthening, vaginectomy, or hysterectomy/oophorectomy. Bed rest and ice packs are recommended for a minimum of 24 hours. Patients should refrain from lifting over 10 pounds for 2 weeks. Sutures should dissolve in 2-3 weeks.

Recovery for patients undergoing metoidioplasty with urethral lengthening, vaginectomy, or hysterectomy/oophorectomy

Patients should prepare to take a minimum 14 day leave of absence from work if they are having metoidioplasty with urethral lengthening, vaginectomy, or hysterectomy/oophorectomy. Bed rest and ice packs are recommended for a minimum of 24 hours. Patients should refrain from lifting over 10 pounds for 2 weeks. Patients who opt to have a metoidioplasty and hysterectomy simultaneously should refrain from heavy lifting over 10 pounds for at least 4 weeks. Sutures should dissolve in 2-3 weeks.

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Post-operative Results

Patient Studies by Dr. Djordevic and Dr. Perovic in the Journal of Sexual Medicine

2011: A Study of 273 Metoidioplasty Patients between 2005-2011 [1]

The average length of the neophallus of surgical patients ranged from 4-10 centimeters.  The mean size of the neophallus in metoidioplasty performed by Dr. Djordevic was 5.7 cm. There was no significant deviation between the neophallus sizes reported in surgeries performed in an earlier 2009 study. Most patients were satisfied with the results.
100% of patients were able to achieve postoperative erection. Unlike phalloplasty, most of the metoidioplasty patients were unable to perform penetrative sex since the neophallus is too small. 96% of patients were able to urinate without difficulty while standing. A few patients experienced dribbling and spraying that later resolved without medical intervention.
Less than 5% of patients experienced complications from urethroplasty. All urethroplasty complications were successfully resolved by minor surgical intervention.

2011: A Study of 167 Urethral Reconstruction in Metoidioplasty Patients between 2003-2011 [2]

Three different methods of urethral reconstruction were compared:

  • I – tubularization of the longitudinal dorsal clitoral skin flap (21 patients)
    • 57.15% success rate
    • 12.57% of patients in this group developed fistulas
    • 4.79% of patients experienced urethral stricture
  • II – combination of longitudinal skin flap and buccal mucosa graft (41 patients)
    • 79.05% success rate
    • 12.57% of patients in this group developed fistulas
    • 19.04% of patients experienced urethral stricture
  • III Combination of labia minora flap and buccal mucosa graft (105 patients)
    • 90.47% success rate
    •  8.57% of patients developed fistulas
    • 4.87% of patients experienced urethral stricture.

The results indicated that the method of choice for urethroplasty occurred in group III (combined buccal mucosa graft and labia minor flap). This method resulted in a lower incidence of post surgical complications.  91% of patients were able to urinate while standing. The overall success rate for all groups was 82.64%.

2009 Publication: A Study of 82 Metoidioplasty Patients between 2002-2007 [3]

The 2009 study revealed that the average length of the neophallus ranged from 4-10 centimeters, with a mean size of 5.7 cm. All patients were able to urinate while standing, although 23 out of 82 patients experienced dribbling and spraying in the initial post-recovery phase. 2 out of 82 patients experienced urethral strictures (narrowing of the urethral tube that may cause painful urination or frequent urinary tract infections).  7 out of 82 patients developed fistulas that required a minor revisionary surgery. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients retained sensation and the ability to achieve an erection. Testicle prostheses implantation was successful in all patients.

References

[1] http://www.genitalsurgerybelgrade.com/ftm_surgery_detail.php?Metoidioplasty-3 (2005-2011)
[2] Miroslav, Djordjevic, MD, DusanStanojevic, MD, Marta Bizic, MD, Vladimir Kojovic, MD, Alexandar Milosevic, MD. Urethral reconstruction in metoidioplasty: comparison of three different methods. WPATH Symposium. 2011
[3] Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, and Perovic SV. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. Journal of Sexual Medicine, 2009. [First published online in 2008]

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Eligibility

Most surgeons follow the WPATH Standards of Care to determine eligibility for pre-metoidioplasty. The prerequisite standards include pre-operative psychological counseling, two letters of support, hormone therapy, and at least one year living as male. Inquire with your surgeon for their specific requirements.
As with all surgeries, the best candidates are individuals in stable health. Obesity and smoking are associated with an increase in adverse surgical outcomes. Patients should be at least 18 years old for optimal results. Genital growth following hormones will increase the results of the procedure. Thus, patients are encouraged to delay pre-metoidioplasty until they have been on testosterone treatment for at least 2 years. This ensures that clitoral growth attributed to HRT is at its threshold size. Some surgeons recommend that candidates “pump” before the procedure. Pumping the clitoral area increases blood flow to the organ, which increases growth beyond HRT results.
Patients should be willing to accept the limitations of the surgery. The procedure results in a very small micropenis. It will likely not be large enough for penetration, although this has been disputed, as many trans men have been able to perform intercourse after they fully recover.

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