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The Ultimate Guide to Metoidioplasty: Expert Care for Your Journey

Medically reviewed by Ellie Zara Ley, MD on July 15, 2024.

Simple Metoidioplasty vs Complex Metoidioplasty with Urethral Lengthening, Vaginectomy and Scrotoplasty

A metoidioplasty or “meta” is a gender-affirming bottom surgery procedure that gives the patient’s natal erectile tissue a more prominent, forward position. This is accomplished by releasing the erectile tissue (sometimes called the clitoris or phallus), which has often grown from testosterone hormone therapy, from its surrounding ligaments.

This procedure is often pursued by patients who would experience euphoria from having increased bottom growth and/or from being able to urinate with ease while standing. However, patients who are interested in having a phallus large enough to easily engage in penetrative sex tend to opt for a phalloplasty.

Dr. Zara Ley (she/her/they) is our board-certified gender surgeon who performs metas and other types of bottom surgeries for patients of all gender identities. Dr. Ley is a transgender woman of color and former patient herself who offers a full-spectrum of gender-affirming surgeries. You can request a free consultation with her here.

Understanding Metoidioplasty

What is metoidioplasty?

Metoidioplasty is a surgery for transgender men and non-binary patients that uses their natal genital tissue to create the appearance of a more prominent, forward-facing phallus. This surgery involves releasing the erectile tissue from its surrounding ligaments. If a patient would like to urinate standing up, a primary urethral lengthening (PUL) procedure can be performed to extend the urethra to the tip of the phallus.

Generally speaking, during the first two years of testosterone hormone replacement therapy (HRT), many transmasculine patients will experience bottom-growth. Bottom growth refers to the enlargement of the natal erectile tissue; however, not all patients experience notable bottom growth even if they are on full-doses of HRT.

How metoidioplasty differs from phalloplasty

Metoidioplasty is one of the two types of FTM or masculinizing bottom surgery procedures. They are: (1) the phalloplasty and (2) the metoidioplasty, which is sometimes called a “meta.” The main differences between these procedures are:

• Erogenous sensation: metoidioplasty has the lowest risk of erogenous sensation loss because the original nerve and blood supply to the erectile tissue is kept intact. The radial forearm free (RFF) flap and anterolateral thigh (ALT) flap phalloplasty procedures can also leave patients with erogenous sensation in their new phallus through nerve innervation microsurgery.

• Urinate standing up: If a patient would like to urinate while standing, through the tip of the newly enlarged phallus, a primary urethral lengthening (PUL) can be performed with either a metoidioplasty or a phalloplasty. Please note that Dr. Ley requires all patients that undergo a PUL to undergo a simultaneous vaginectomy or removal of the vaginal canal to prevent urinary complications.

• Penis length: If having a penis that is greater than 3 inches in length is a priority, a phalloplasty may be a better fit for you than a metoidioplasty.

• Erections: Metoidioplasty patients will retain their ability to experience erections. Phalloplasty patients will need the help of a silicone erectile sleeve or an implanted erectile device to experience erections.

• Number of surgeries and recovery length: If you would like to minimize the amount of surgeries you have to go through, a metoidioplasty may be a better fit for you than a phalloplasty. That said, the groin flap phalloplasty involves more surgical stages to construct than the other phalloplasties: RFF and ALT.

• Scar visibility: If having no visible scars or being able to easily conceal your scars is a high priority, a metoidioplasty or groin flap phalloplasty may be a greater fit for you than an RFF or ALT phalloplasty.

• BMI: There is a lower BMI candidacy threshold for metoidioplasty than there is for phalloplasty. Patients outside of these BMI ranges may choose to undergo a metoidioplasty or a mons resection as a first stage procedure while working to lower their BMI for a later phalloplasty.

Types of Metoidioplasty Procedures

Simple Metoidioplasty

A simple metoidioplasty procedure or simple meta involves releasing the enlarged clitoris or phallus from its surrounding ligaments. The phallus is then allowed to move into a more forward and elevated position. Skin grafts are taken from the labia minora to cover the exposed part of the phallus, increasing its girth. Patients can opt to have skin grafts taken from another part of the body if they would like to preserve their labia minora. The glans or head of the phallus will still be exposed.

The illustration below shows a step-by-step break-down of how this procedure is conducted.

Metoidioplasty with Urethral Lengthening

A meta with PUL or complex metoidioplasty is similar to the simple metoidioplasty procedure, but includes two other procedures:

• Primary urethral lengthening (PUL): A skin graft is taken to lengthen the patient’s urethra. In doing so, the urethra will exit at the tip of the phallus, allowing the patient to urinate while standing.

• Vaginectomy: Vaginectomy is the removal of the vaginal canal. Dr. Ley requires that all patients who undergo a PUL also undergo a simultaneous vaginectomy to reduce the risk of urinary complications.

Please note that patients must undergo a hysterectomy of removal of the uterus prior to undergoing a vaginectomy with Dr. Ley. You can find a gender-competent gynecological surgeon who can perform this procedure in this provider directory.

Additional Procedures

Meta surgery patients may also undergo any of these additional procedures as a part of their gender-affirming bottom-surgery:

• A mons resection and panniculectomy are procedures that target the mons or upper groin region. They involve excision and sometimes accompanying liposuction of subcutaneous fat and skin overhang, respectively, to help give the phallus a more forward, apparent position on the body.
• A scrotoplasty and testicular implants involve the creation of a scrotum, their expansion and eventual insertion of silicone implants to create the appearance of testicles.

You can request a free consultation with Dr. Ley here to create a surgical plan that meets your unique needs.

Recovery and Aftercare

If you get a simple meta, you will most likely be discharged from the hospital the day of your operation. If you get a meta with PUL you can expect to stay in the hospital for two nights and use a catheter to urinate for 2-3 weeks. It is completely normal to experience swelling and bruising around your genital area; this will slowly decrease over the next few weeks. For most patients, after about 6 months, the swelling is expected to completely resolve and you should be able to clearly see your final surgical result. For some, this may take longer.

Physical and Sexual Activity Limitations

Starting the day after surgery, patients are encouraged to walk lightly to help reduce the risk of blood clots. Lighter physical activities should not be taken up until about 4 weeks post op. If there are no complications, patients can often return to work after about a month post-op, but may be able to return sooner to online or remote work. Many patients who undergo a simple meta can begin to engage in light sexual activity, like gentle manual stimulation, six weeks after surgery. We encourage patients who undergo urethral lengthening to wait 3 months before engaging in any sexual activity alone or with a partner. Likewise, at least three months should go by before a patient can use a penis pump to facilitate their ability to have penetrative sex.

Scarring after Metoidioplasty

One reason why many patients opt for a metoidioplasty instead of a phalloplasty is because both the recovery process is far less intense and scars are much less visible. Light scarring may result from taking the labia to extend the urethra or create a scrotum if a patient opts for those additional procedures.

Risks and Complications

The most common complications, like wound openings, resolve with time and proper home care. Even then, it is normal for complications to result in temporary feelings of frustration, sadness and even regret. It is hard to experience delays in the healing timeline: prolonging when you can get back to work, sit comfortably without a supportive pillow for long periods of time, or engage in sexual activity. We encourage you to be patient with your body as it heals from surgical affirmation, lean on your support network (friends, family and/or mental health professionals) and trust that any pain, discomfort and inflammation will eventually subside with the proper care.

Urinary Complications

Any patient who undergoes urinary lengthening is expected to experience a certain level of discomfort––such as bladder spasms––while they use a catheter. The most common urinary complications that arise usually resolve on their own. We encourage you to share any concerns that arise around irregular urination––like the presence of blood, increased straining, urinary retention, frequent urination or a urinary tract infection––with your surgical team and local provider(s). No concern is too small for us. We are committed to doing everything in our power to support you through the difficulties of your recovery process.

Wound Healing

Additionally, wound opening, however slight, can occur when patients make harsh movements early on that stretch the groin. Wound opening can delay the amount of time required to heal, which can cause frustration and sometimes worry in patients as they experience prolonged discomfort and delays in returning to their normal life. We especially encourage scrotoplasty patients to be mindful of this risk. Thankfully, simple wound care should resolve the issue over time. We do not suture reopened wounds from bottom surgery due to infection risk. We encourage you to practice patience, compassion and trust with your body as it does its best to heal.

Frequently Asked Questions about Metoidioplasty

Do I need to take testosterone and/or experience “bottom growth” to have a metoidioplasty?

Patients do not need to undergo testosterone hormone replacement therapy (HRT) to have a metoidioplasty with the Gender Confirmation Center. Patients who are taking testosterone HRT are recommended to wait 1-2 years after beginning treatment to maximize their chances of bottom growth. That said, the natal erectile tissue (sometimes called a penis or clitoris) does not always grow as a result of exposure to testosterone. Bottom growth is also not a requirement to undergo this surgery with us.

Do I need to have a certain BMI to get a metoidioplasty?

For the health and safety of our patients, we ask that candidates for a simple meta have a BMI no greater than 40 and that candidates for a meta with PUL have a BMI no greater than 35.

What is the risk of sensation loss?

With any metoidioplasty, there is a very low chance of losing any sensation in your penis or other tissue in your groin. Both a simple meta procedure and a meta with PUL are ideal for patients hoping to achieve an enlarged phallic structure with preserved erogenous sensation.