Metoidioplasty Explained: Procedures, Costs, and Recovery

Metoidioplasty is a life-changing gender affirmation surgery that reshapes female genitalia into a male appearance using existing tissue. With 80% of patients reporting complete satisfaction and another 20% mainly pleased, metoidioplasty has a proven track record of success. This comprehensive guide dives into the what, how, and who of metoidioplasty, from the different surgical options available to the cost breakdown and choosing the right surgeon. Packed with essential information, this article is your ally in navigating the transformative path toward aligning your body with your gender identity.

Table of Contents

1. What is Metoidioplasty?
2. Who is a Good Candidate for Metoidioplasty?
3. Types of Metoidioplasty
4. Metoidioplasty vs Phalloplasty
5. Metoidioplasty Pros and Cons
6. How to Find the Best Metoidioplasty Surgeon?
7. Metoidioplasty Cost
8. Preparing for Metoidioplasty Surgery
9. Metoidioplasty: Surgical Procedure
10. Metoidioplasty: Optional Procedures
11. Metoidioplasty Recovery Process and Aftercare
12. Metoidioplasty Risks and Complications
13. Metoidioplasty Results

What is Metoidioplasty as a Gender Affirmation Surgery?

Metoidioplasty is a female-to-male (FTM) bottom surgery that works with existing genital tissue to form a neophallus. This reconstructive surgery utilizes the testosterone-enlarged clitoris as the foundation for constructing the new penis.

The goal of metoidioplasty is not just to alter the physical appearance of external genitalia. It aims to enhance the patient's comfort in their body and improve their overall quality of life. 

Patients often opt for metoidioplasty because it generally involves fewer complications and a shorter recovery than more extensive procedures like phalloplasty.

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Who is a Good Candidate for Metoidioplasty?

Ideal candidates for metoidioplasty are transgender men and people assigned female at birth (AFAB) seeking genital reconstruction. Those who value sensation over size might prefer metoidioplasty to phalloplasty.

Here are some other factors for candidacy:

• Hormone therapy history. Candidates usually need at least 1 year of testosterone therapy. This hormonal therapy helps enlarge the clitoris, which is crucial for the metoidioplasty procedure.
• Overall health. Good physical and mental health are essential. Candidates should not have severe medical conditions that could complicate surgery or recovery. BMI matters, too — being close to a healthy weight improves outcomes.
• Smoking status. Smoking can impair healing. Non-smokers, or those willing to quit before and after the reconstructive surgery, are preferred.
• Realistic expectations. Understanding the potential outcomes and limitations of metoidioplasty is critical. This includes recognizing that revision surgery might be necessary for aesthetic appearance or functional improvements.
• Commitment to recovery. Post-surgery care is vital. Candidates must be ready for a recovery period involving rest, follow-up visits, and potential complications management.
• Support system. A strong support system from family, friends, or support groups can significantly impact the recovery process and overall satisfaction.

Types of Metoidioplasty

Metoidioplasty comes in several variations, each with distinct advantages and suited to different needs and preferences.

Simple Metoidioplasty

Also known as clitoral release, this procedure involves severing the ligaments that attach the clitoris to the pubic bone. Surgeons then construct the penile using the clitoral skin, labia minora, and labia majora. This type of metoidioplasty does not alter the urethra or vagina, meaning you will retain your original urination method and vaginal structure.

Full Metoidioplasty

Full metoidioplasty involves several steps:

1. The surgeon performs a vaginectomy, removing the vaginal tissue and closing the vaginal opening. 
2. A clitoral release frees the clitoris from its attachments. 
3. Using tissue from the cheek, clitoris, or labia minora, the surgeon extends the urethra through the newly created penis. Urethral lengthening allows urination while standing. 
4. Surgeons can also insert testicular implants if desired.

Ring Metoidioplasty

Similar to a full metoidioplasty, this procedure also involves clitoral release and urethroplasty. However, the key difference is the technique used to cut the clitoral ligaments and the source of the skin graft for the urethral extension, which comes from the anterior wall of the vagina instead of the cheek. The surgeon uses a portion of the labia minora to form the shaft of the neopenis and may remove or utilize excess labia minora skin to cover the suture line.

Centurion Metoidioplasty

This method releases the round ligaments on either side of the labia and repositions them under the clitoris to add girth to the penis. It does not require skin grafts from the mouth or vaginal wall.

Metoidioplasty vs Phalloplasty

Metoidioplasty and phalloplasty are two distinct approaches to genital reconstruction for transmasculine individuals. 

• Metoidioplasty works with existing genital tissue. It releases and repositions the testosterone-enlarged clitoris to create a small penis. This procedure preserves natural sensation and erectile function.
• Phalloplasty, in contrast, constructs a penis using a skin graft from other body areas. It creates a larger, more cis-appearing penis. However, it requires additional surgeries, such as penile implantation, to achieve erections. Phalloplasty may also result in reduced sensation.

Metoidioplasty Pros and Cons

Choosing metoidioplasty as a gender-affirming surgery involves weighing its benefits and drawbacks. Here are the key points to consider:

Metoidioplasty Pros

👍Results in a fully functioning penis that can become erect on its own.

👍Offers a high likelihood of retained sexual sensation by preserving nerves and erectile tissue of the clitoris.

👍Leaves less noticeable scars.

👍Requires fewer surgical procedures than phalloplasty.

👍Shorter healing time and faster return to daily activities.

👍Some individuals can urinate standing, depending on the metoidioplasty technique, body build, and anatomy.

👍Significantly less expensive, ranging from $6,000 to $30,000 versus $20,000 to $150,000 for phalloplasty.

👍Doesn't preclude later phalloplasty if desired.

Metoidioplasty Cons

👎New penis is relatively small in both length and girth (4 to 10 cm), not creating a noticeable bulge in clothing.

👎Requires prior testosterone therapy for clitoral growth.

👎Penetrative sexual intercourse is often not possible due to size.

👎Some may still need to sit to urinate or press on surrounding tissues to allow urine to pass through the penis.

How to Find the Best Metoidioplasty Surgeon?

Choosing the right surgeon for metoidioplasty is one of the most critical decisions in your gender-affirming journey. Here are vital factors to consider:

1. Training and experience

First and foremost, evaluate the surgeon's training and experience. Look for surgeons who have specialized training in gender-affirming surgeries and extensive experience performing metoidioplasty.

2. Range of metoidioplasty procedures

Confirm the surgeon offers the specific type of metoidioplasty you want, whether it’s simple, full, ring, or centurion. Additional procedures like vaginectomy or urethroplasty may also be available.

3. Patient reviews

Research what previous patients have to say about their experiences. Look for reviews and testimonials that discuss the surgeon’s results, instances of complications, and bedside manner.

4. Health insurance

Check if the surgeon accepts your health insurance. Gender-affirming surgeries can be expensive, and having insurance coverage can significantly reduce your out-of-pocket costs. Verify coverage details with both the surgeon’s office and your insurance provider.

5. Eligibility criteria

Many surgeons follow the World Professional Association for Transgender Health (WPATH) standards of care. These standards require to meet specific criteria before surgery, such as:

• Two letters from medical professionals recommending surgery.
• Persistent gender dysphoria.
• 12 months of hormone therapy.
• Age of majority (18+ in the U.S.).
• Ability to make informed consent.
• No conflicting mental or medical health issues (e.g., BMI over 28).

6. Personal consultation

Schedule consultations to discuss the surgeon’s experience, success rates, and procedure details. Ensure you feel comfortable and confident in their care.

7. Hospital affiliations and facility quality

Check the quality of the hospital or surgical facility. Top-rated facilities often have better resources and post-operative care.

8. Geographic location

Consider the location of the surgeon’s practice. Closer proximity can reduce stress and make follow-up visits easier. On the other hand, surgeries in countries like Thailand and Turkey can be 3-5 times less expensive than in the US or Europe due to flourishing medical tourism and lower living costs. This reduced expense does not equate to lower quality. Thailand, for instance, is the field’s pioneer y and is still considered the sex change capital of the world.

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Metoidioplasty Cost

On average, metoidioplasty costs range from $6,000 to $30,000. Several factors influence the total cost, including:

• the type of procedure;
• additional procedures;
• insurance coverage;
• surgeon’s fees;
• hospital charges;
• prescription medications;
• geographical location.

Metoidioplasty cost by country

Costs vary significantly by country due to differences in living costs, medical tourism prominence, and healthcare infrastructure. The United States and the United Kingdom are among the most expensive countries for metoidioplasty, while Thailand and Turkey offer more affordable options. You can compare costs in the table below:

Country	Average Metoidioplasty Cost
United States	$19,000 – $43,000
United Kingdom	$12,000 – $43,000
Thailand	$5,400 – $12,000
Turkey	$4,000 – $10,500

Thailand and Turkey also provide all-inclusive metoidioplasty packages that typically include:

• pre-surgery consultations;
• post-operative care;
• medications;
• meals during hospital stay;
• transfers between the airport, hotel, and hospital;
• language support.

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Does insurance cover metoidioplasty?

An insurance provider may classify your metoidioplasty as a reconstructive procedure and offer coverage. Over 90% of insurance companies that have policies for gender-affirming surgery cover metoidioplasty.

Preparing for Metoidioplasty Surgery

Proper preparation is essential for a successful metoidioplasty. Your surgeon will work closely with you to ensure you complete all necessary steps for a successful metoidioplasty. Here’s what you may need to do to get ready:

• At least one year of testosterone treatment to enlarge the clitoris, which is essential for creating the neophallus during metoidioplasty.
• A comprehensive physical exam and review of your medical history.
• Undergo a mental status exam and obtain referral letters from 2 mental health providers.
• Detailed discussions about the procedure, risks, benefits, and post-surgery care to ensure informed consent.
• Follow the advice to reduce risks, such as quitting smoking and making other lifestyle adjustments.

Metoidioplasty: Surgical Procedure

💉Anesthesia:

• Simple metoidioplasty. Performed under conscious sedation, where a patient will be awake but mostly unaware.
• Complex procedures. Urethral lengthening, hysterectomy, and vaginectomy require the use of general anesthesia.

⏳Duration: The metoidioplasty surgery takes 2.5 to 5 hours, depending on the surgeon and the specific procedures.

🏥Hospital stay: Most doctors perform metoidioplasty as an outpatient procedure, allowing you to leave the hospital the same day. However, some doctors may recommend staying overnight for observation.

Metoidioplasty: Optional Procedures

Surgeons can perform several optional procedures as part of metoidioplasty:

• Vaginectomy — the removal and closure of the vaginal canal for a more masculine appearance.
• Urethroplasty — the extension of the urethra through the neopenis to enable standing urination.
• Scrotoplasty with testicular implants — creation of a scrotum using the labia majora, followed by implant insertion for a complete masculine look. If a patient chooses scrotoplasty, tissue expanders may be inserted into the labia during the first surgery to prepare for larger testicle implants in a follow-up procedure 3-6 months later.
• Hysterectomy — removal of the uterus and possibly the cervix.
• Bilateral salpingo-oophorectomy (BSO) — removal of the fallopian tubes and ovaries, eliminating reproductive organs.
• Mons resection — removal of skin and fatty tissue from the mons pubis to shift the penis and testicles forward, increasing visibility and access.

After a metoidioplasty, some people choose to undergo a phalloplasty to add length and girth to the penis. If size is a primary concern, experts often recommend starting with phalloplasty. This approach can reduce the overall number of surgeries needed.

Choosing which, if any, of these optional procedures to include in your metoidioplasty is entirely personal. You may opt for all the procedures to achieve a comprehensive transformation or select only those that best align your body with your sense of self.

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Metoidioplasty Recovery Process and Aftercare

Immediate recovery: What happens after metoidioplasty

👉Following the procedure, doctors suture the incisions and apply protective bandages.

👉As the anesthesia wears off, the patient gradually regains consciousness, though they may experience grogginess.

👉 Medical staff closely monitor the patient's vital signs and manage pain as they regain consciousness.

👉Once the surgical team determines the patient is stable and no longer requires continuous monitoring, they can be discharged. Typically, patients remain in the hospital for 1 to 3 days before going home.

Follow-up care

After metoidioplasty, the clinical team will provide instructions on monitoring for signs of infection. The patient should exercise extreme caution when standing, sitting, or walking. Patients will attend follow-up appointments with their surgeon to check for swelling, signs of infection, and other potential complications.

The following are general aftercare instructions for patients who have undergone metoidioplasty:

• avoid straining incisions;
• walking is encouraged (about 1 hour per day);
• eat normally when your appetite returns and drink plenty of water;
• shower daily starting 2 days after surgery;
• no baths or pools for 6 weeks;
• gently wash between skin folds with mild soap;
• use gauze over incisions when wearing underwear;
• wear slightly loose boxer briefs for comfort;
• do not drive until off prescription pain medication and the urinary catheter is removed.

Your surgeon will provide more detailed, personalized instructions and discuss potential complications to watch for.

Recovery timeline

🗓️Week 1: Patients should be able to walk and do light activities.

🗓️Week 1-6: Avoid strenuous physical activities like exercise and contact sports.

🗓️Month 3: Patients can resume sexual activity.

🗓️Months 12-18: Full healing.

💼Work: Patients will likely need 1-2 weeks off work. Physically demanding jobs may require up to 8 weeks off.

✈️Travel: For patients who travel for surgery, doctors may advise them to stay in the country between 10 days to 3 weeks.

Metoidioplasty Risks and Complications

Like any surgery, metoidioplasty carries certain risks, including:

• infection;
• bleeding;
• swelling;
• healing issues;
• allergic reaction to anesthesia;
• scarring.

Before the procedure, the surgeon will discuss possible complications, such as:

• The buildup of blood (hematoma) or fluid (seroma), which may require draining or additional surgery.
• Problems with sexual function.
• Temporary or permanent changes in sensation (more common with phalloplasty).

Specific complications associated with urethral lengthening include:

• Urethral stricture (narrowing) or obstruction due to scarring.
• Increased susceptibility to urinary tract infections (UTIs).
• Development of urethral fistulas (abnormal openings in the urethra).

Complications from metoidioplasty are rare. According to Translational Andrology and Urology, urethral fistulas occur in 7-15% of procedures, while urethral strictures develop in 2-3% of cases. Thorough discussions with an experienced surgeon can help prepare you for potential outcomes and ensure you have a plan in place to address any issues that may arise.

Metoidioplasty Results

Metoidioplasty can provide significant benefits for individuals seeking gender-affirming surgery. The procedure offers several positive outcomes:

Success Rate

Metoidioplasty has a high success rate, with nearly 80% of patients being totally satisfied and 20% mainly happy with their surgical results. 

Mental health

One of the primary benefits of metoidioplasty is the significant relief from gender dysphoria. Sex reassignment surgery is associated with:

• a 42% reduction in psychological distress;
• a 44% reduction in suicidal thoughts.

Sensation and sexual arousal

Studies indicate that 100% of individuals who undergo metoidioplasty retain erogenous sensation. The shaft contains clitoral tissue and nerves, allowing for natural erections after the procedure.

Size and penetrative ability

The resulting penis size after metoidioplasty typically ranges from 4 to 10 centimeters. While this size may not always allow for penetrative sex, it is possible for some individuals. One study shows that 51% of patients reported successful penetration during intercourse.

Urination

Metoidioplasty redirects the urethra through the neophallus, enabling urination through the newly created penis. Studies show 89-100% of patients can urinate standing up after the procedure.

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