Seminar

METOIDIOPLASTY

METOIDIOPLASTY Sometimes referred to as meto or meta, is an alternative to phalloplasty for Transmen. With the effects of testosterone treatment, the clitoris enlarges to an average of 4-5 cm. The enlarged clitoris is released from its position and moved to more closely approximate the position of a normal penis.

The labia majora can be united to form a scrotum where prosthetic testicles (usually made of silicone) can be inserted. If a metoidioplasty is performed without a urethral lengthening or scrotoplasty (formation of a scrotum from the labia majora), this is sometimes called a clitoral release. It does not allow for urination (through the new penis) while standing. This offers surgery with less risk because the urinary system remains unaltered without a urethral extension and still affords some of the visual effects of a complete metoidioplasty.

Metoidioplasty may additionally involve a urethral lengthening procedure to allow the patient to urinate through the penis while standing. Surgeons may employ tissue from the vaginal area or from inside the mouth/cheeks to create a urethral extension. Usually a catheter is placed inside the urethral extension for 2-3 weeks while the body heals and adapts to the new arrangement.

The vaginal cavity may or may not be closed or removed (this is typically referred as “vaginectomy”, “colpectomy”, or “colpocleisis”). Often, a vaginectomy is performed in conjunction with scrotoplasty and/or urethral lengthening. The typical operating time for a metoidioplasty procedure is about 3-5 hours, and may require additional follow-up procedures and revisions at a later date. Recovery time is usually between 2-4 weeks with very limited activity.

PROS ü Natural looking ü Erotically sensate penis ü Can achieve an unassisted erection when aroused ü Doesn’t leave visible scars on other parts of the body

CONS × Penis is usually quite small; often cannot be used for penetration × May not be good choice for a transman whose clitoris has not grown substantially as a result of testosterone therapy of at least 6 months to 2 years

RISKS o Extrusion of testicular implants o Formation of stricture o Fistula o Potential problems of infection and tissue death

COSTS and RECOMMENDATION Range in cost from about $2000 (for clitoris release only) to $18000 (including urethral extension and testicular implants), and perhaps more if hysterectomy/oophorectomy is performed at the same time.  When considering a metoidioplasty procedure, it is important to research the surgical options carefully and discuss them with the surgeons you are considering. 

preoperative appearance

 

Appearance of the external female genitalia before surgery. Clitoris is enlarged using topical dihydrotestoste rone combined with vacuum device.

  Marked lines show incisions. Urethral plate, mucosal part from urethral opening and glans cap, is marked to be wide. Labia minora are marked for labial skin flaps use.

clitoral lengthening

All clitoral ligaments should be divided to lengthen clitoris. These ligaments are very well developed and make hooded clitoris in normal female. Division should be radical and includes lateral and suspensory ligaments.  

Urethral plate is too short and causes ventral curvature. Plate is mobilized together with spongiosal tissue before cutting to prevent extreme bleeding.      

Appearance after division of ligaments dorsolaterally and short urethral plate ventrally. Clitoris is completely lengthened. Marked places on the dorsum show levels of ligament attachments.

 

Ventral aspect after division of the urethral plate. Gap between glans cap and urethral opening is 6 cm long. Bleeding is minimal thanks to very precise dissection of spongiosal tissue

 

urethral reconstruction

   

Reconstruction of the bulbar urethra. Wellvascularized vaginal flap is created from anterior vaginal wall.    

Vaginal flap and urethral plate are joined to form bulbar urethral part. This way, urethra is lengthened.

urethral reconstruction buccal mucosa

Buccal mucosa graft is placed to cover the gap between glans cap and bulbar urethra.

  Appearance of the donor site after harvesting the graft and closure the defect.

Buccal graft is fixed to the corporal bodies by quilting sutures. It is very important to prevent haematoma formations and for better survival of the graft.

urethral reconstruction clitoral skin flap

Very long skin flap is harvested from the dorsal clitoral skin. Flap is harvested with very wide subcutaneous vascularized tissue

Flap is transposed ventrally by button-hole maneuver and prepared to join with buccal mucosa graft.

Joining of the skin flap and buccal mucosa graft. Glans is also opened for creation of glandial part of the urethra.

Urethral reconstruction is done. All suture lines are covered with vascularized tissue. It is very important in prevention of fistula formation

urethral reconstruction labia minora flap

Flap from inner labial surface is designed in appropriate size.

Flap is dissected from the border between inner and outer labial surface. It is attached to the base for better blood supply support. One edge is joined with dorsal part of urethra formed from buccal mucosa graft

 

Urethra is formed. Suture lines will be covered with outer surface of the labia minora that will be ventral part of the penile skin.

scrotoplasty/testicul ar implants

Reconstruction of the penile skin is done. Scrotum is formed by joining of both labia majora. Perineum is created to be as a male.

Testicle implants are inserted into the scrotum using two similar incisions at the top of the scrotum.

final aspects

Appearance after surgery. Penis is positioned at right position. Very well relationship between penis and scrotum is achieved.

  results

Outcome three months later.

Voiding in standing position.

Three years after metoidioplasty.