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  • Elijah Castle

metoidioplasty 101

Metoidioplasty is one of two genital (also referred to as “bottom”) surgeries available to trans masculine people. The other procedure is called phalloplasty. Neither is better or worse -- just suited better for different people depending on their priorities.


Metoidioplasty (or meta for short) involves using your natal phallus (some may call it the clitoris) which testosterone has enlarged, and releasing the ligaments (suspensory ligament, ventral chordee, etc.) to allow it to be more prominent. It can also involve using a graft from the vaginal mucosa or buccal mucosa to elongate the urethral and allow for the possibility to urinate using your phallus and potentially stand to pee. A scrotum can be created using the labial tissue, and later on, testicular implants can be placed to give the appearance of a fuller scrotum.


Keywords:


Simple release: A procedure in which the ligament holding down the natal erectile tissue is severed to allow the tissue to become more apparent. Generally other components, such as vaginectomy, are not performed in a simple release, as the release refers to the severing of the ligament.

Full metoidioplasty: A procedure which includes not only the release of the natal tissue by severing the ligament, but also can include urethral lengthening, scrotoplasty, vaginectomy, and testicular implants.


Urethral lengthening (UL): Elongating the urethra to potentially achieve the ability to stand-to-pee. This is not a necessary component of metoidioplasty and can be foregone if not desired.


Vaginectomy: Removal and closure of the vaginal canal and entrance. Also unnecessary unless UL is desired, in which case it is necessary to have a vaginectomy in order to stand-to-pee. Completing UL without a vaginectomy drastically increases the risk of complications.


Scrotoplasty: Creation of a scrotum using labial tissue.


Testicular implants: Silicon implants to give the appearance and feel of testicles within the scrotum. Also not a required component. Testicular implants are inserted in a second stage and not in the first stage.


Natal phallus/natal tissue: Refers to what is also known as the clitoris.


Fistula: A complication involving a small wound opening that allows urine to exit from somewhere other than the intended urethral exit.


Stricture: A complication involving narrowing of the urethra due to thickening/build-up of scar tissue.


Generally metoidioplasty penises are, on average. 1-2 inches in length. Because of the size, even if you have UL, your penis may not be long enough to clear the fly of your pants, which can make standing-to-pee difficult. Penetrative sex may also be difficult following metoidioplasty. That is not to say, however, that metoidioplasty is an inadequate surgery. It allows for unassisted erections and is suitable for many people’s needs out of bottom surgery.


What do the stages consist of?


Metoidioplasty is generally completed in 1-2 stages, but can consist of more depending on individual anatomy, preferences, complications, etc. A simple meta can be performed in just one stage.


Stage 1 involves releasing the ligaments (suspensory ligament, ventral chordee), scrotoplasty, vaginectomy, and urethral lengthening. Of course, it may not involve all of these procedures based on your own goals.


Stage 2 involves placement of testicular implants.


Both stages will consist of a 6-8 week full recovery period. You sjpi;d plan for at least 6-8 weeks off work/school after your stage 1, and for stage 2, generally a month or less of recovery from school/work is required. Also, while only 1-2 stages are planned, an extra surgery may be needed to resolve complications.


Metoidioplasty is generally performed in 1-2 stages.


Preparation for Surgery


There is not much that has to be done prior to surgery, as opposed to phalloplasty, which requires at least a year or more of hair removal. However, if you smoke, you should stop as soon as possible. Smoking and nicotine use can greatly increase the risk of complications due to their effect on blood flow and circulation. For the best possible outcomes from your surgery, you should stop smoking far in advance.


Post-Op


Full recovery from metoidioplasty can take 6-8 weeks or more. You will be limited in mobility and likely low-energy for a while. You will be in the hospital for, on average, 1-3 days. You will not be able to lift anything over 5-10 lbs for at least the first few weeks of your recovery, so you will need help doing laundry, getting groceries, doing other household chores, etc., for at least that amount of time. The process of healing and recovering is individual and variable depending on the person, so it is difficult to say exactly how long it will take you to get back to “normal” after surgery. But most people need to take off at least 6-8 weeks from school/work.


You may also have a catheter when you leave the hospital after one or more of your stages -- this will most likely be the case if you undergo UL. Catheters may stay in anywhere from a few days to weeks and even months if you have urinary complications. Most people undergoing UL have a catheter in for about 2 weeks post-urethroplasty.


Complications


The most common complications for metoidioplasty are related to the lengthening of the urethra. The two most common complications with urethral lengthening are strictures (narrowing of the neourethra due to increased scar tissue), and fistulas (a wound opening that causes urine to exit through somewhere other than the urinary meatus). Other complications can be wound separation, loss of sensation (very rare), and tissue damage or necrosis (also rare).

Another complication that can result from meta is loss of erectile quality. Sometimes this can result from cutting of the suspensory ligament. If erectile quality is a concern, this should be discussed with your surgeon prior to surgery.


If getting testicular implants, the risks associated with them can be infection and erosion. Typically, if either of these complications occur, then the implants have to be removed, but can be replaced some time later, after everything has completely healed.


Metoidioplasty is a worthwhile procedure for many who choose to go through it. There is also the possibility of moving on to phalloplasty if desired after metoidioplasty. Metoidioplasty, as with all gender-affirming surgeries, is a big step, and you should have as comprehensive a support network going into this as possible -- a therapist, post-op friends, other friends, at least one caregiver, mental health support for your caregiver, etc. Obviously this may not be realistic for every person, but a large support network is ideal.

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