I tried so many things to feel comfortable when I was growing up.
From making a conscious decision to only wear clothes that were comfortable – no matter what they looked like; to binding to try and hide my (then) D-Cup breasts. The choices that I made were simple: do whatever feels comfortable, and right for me.
I believe the same rule applies when trying to consider whether to go for a phalloplasty, or a metoidioplasty.
These two surgeries are so very different, that you really want to make sure you’re doing what’s best for you. Although these days it is possible to change your mind; the consequences of making an ill-informed decision in the first place are not only costly both financially and physically -but they can also have a tremendous detrimental effect on your psychological state of mind.
The information below is not to be taken as the be-all and end-all guide to genital surgeries. It does, however, detail some of the main points for each type of surgery.
This information has been taken and slightly re-phrased from Hudson’s FTM Resource Guide
Metoidioplasty
(Also sometimes spelled “metaoidioplasty,” a term meaning “a surgical change toward the male”)
Developed in the 1970s, a metoidioplasty takes advantage of the fact that ongoing testosterone treatment in a trans man typically causes his clitoris to grow larger (growth varying from person to person). By cutting the ligament that holds the clitoris in place under the pubic bone, as well as cutting away some of the surrounding tissue, the surgeon is able to create a small phallus from the elongated clitoris. This is why the procedure is sometimes referred to as a “clitoral free-up” or “clitoris release”– the clitoris is freed from some of its surrounding tissue and brought forward on the body in a manner that makes it appear like a small penis. Fat may be removed from the pubic mound and skin may be pulled upward to bring the phallus even farther forward, in order to further enhance the result.
A Metoidioplasty may also involve the creation of a scrotum (scrotoplasty) by inserting testicular implants inside the labia majora, then joining the two labia to create a scrotal sac. This can be done in one or two stages – usually depending on the surgeon.
It 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.
Depending on the surgeon and the desires/goals of the patient, the vaginal cavity may or may not be closed or removed using a procedure known as a “vaginectomy.” Often, a vaginectomy is performed in conjunction with a 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. Time required may differ depending on the options chosen by the patient (i.e., if he chooses scrotal implants and/or urethral lengthening), as well as the available tissue for the procedure, and the overall health and condition of the patient. Recovery time is usually between 2 to 4 weeks of very limited activity.
Pros, Cons, and Risks
The advantages of a metoidioplasty are that it results in a natural looking (albeit small), erotically sensate penis. Additionally, since the clitoris is made of erectile tissue, the patient can achieve an unassisted erection when aroused. The procedure takes advantage of existing genital tissue, and doesn’t leave visible scars on other parts of the body.
The disadvantages are that the resulting penis is usually quite small, and as such often cannot be used for penetration. It also may not be a good choice for a trans man whose clitoris has not grown substantially as a result of testosterone therapy (most surgeons recommend being on testosterone therapy for at least 6 months to 2 years in order to maximize growth of the clitoris). And, as with any surgery, there are potential risks of complication, such as the extrusion of testicular implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and potential problems of infection and tissue death (though tissue death is less common in metoidioplasty as compared to phalloplasty). One must also consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).
At the time this article was written, metoidioplasty procedures ranged in cost from about $2,000 (for clitoral release only) to $20,000 (including urethral extension and testicular implants), and perhaps more if hysterectomy/oophorectomy is performed at the same time. Fees will vary among surgeons.
Phalloplasty
A phalloplasty involves the construction of a penis using donor skin from other areas of the body. Depending on the type of phalloplasty procedure, skin is typically taken from the abdomen, groin/leg, forearm, and/or side of the upper torso (latissimus dorsi area) and grafted onto the pubic area. Phalloplasty usually involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.
Phalloplasty techniques vary widely from surgeon to surgeon. Updated and improved surgical techniques (such as microsurgical advances) have improved phalloplasty outcomes in recent years. Be sure to research carefully the surgeons you are considering in order to get an exact account of the procedure as they perform it. Summarized below are a number of terms and procedures related to phalloplasty. Keep in mind that these descriptions are generalized and are meant as a introduction to the topic; this list is not necessarily exhaustive.
Gillies technique
This refers to one of the earliest types of phalloplasty, in which a flap of abdominal skin is rolled into a tube to create a flaccid penis. Over the years, this procedure was improved to include a urethral extension by utilizing a second section of abdominal skin wrapped “raw side out” to form a “tube within a tube,” nested inside the constructed phallus. This method usually produces a penis that is not erotically sensate (i.e., does not have feeling) and is often not very realistic in appearance. Usually, a flexible rod must be inserted into the penis in order to achieve an erection. The Gillies technique is now outdated, due to advances in microsurgical phalloplasty.
Suitcase handle
In order to help prevent tissue death in the penis, the Gilles procedure was improved by the development of the “suitcase handle” technique, where the rolled flap is left attached to the abdomen at the top and bottom (like the handle of a suitcase) for a number of weeks in order to ensure a proper blood supply. In a second stage operation, the flap (handle) is detached from the top end, and that end is brought down to graft onto the genital area. It is again allowed to develop a proper blood supply over a period of time. In a third operative stage, the other end is detached from the abdomen, leaving the new penis to hang naturally from its grafted place in the genital area. Variations of this technique are used in the pedicled flap procedures described below. Again, this type of phalloplasty is now outdated, due to advances in microsurgical phalloplasty.
Pedicled pubic flap phalloplasty
In this procedure, the penis is constructed from an tubed pedicled flap running from the pubic area to just underneath the belly-button. (The term “pedicle” here refers to the fact that the flap of donor skin is left attached to the body, as described in the suitcase handle technique, in order to improve proper blood supply and prevent tissue death). This procedure may also utilize grafted skin from the thigh area to wrap around the outside of the pedicle, mimicking the loose outer skin of the penis. A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an “inside-out” inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin used in this type of phalloplasty is typically hairy, some patients choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.
Pedicled groin flap phalloplasty
This procedure is similar to the pedicled pubic procedure listed above, except that it employs a skin flap that runs sideways outward from the groin area (usually around the area where the upper thigh meets the pelvic bone). A urethral extension may be created using tissue from the labia or vaginal wall, or simply from creating an “inside-out” inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin used in this type of phalloplasty can be hairy, some patients choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.
Free tissue flap transfer (FTFT)
The FTFT procedure is a more recent and improved approach to phalloplasty which uses a flap of skin and tissue from the groin, thigh, forearm, or upper torso area. In FTFT, a skin flap is removed completely from the donor area and transferred, with its existing nerves and blood vessels intact, to the groin area. There the flap’s nerves and blood vessels are connected microsurgically to the nerves and blood vessels of the groin. This is done with the aim of the new penis becoming erotically sensate, while also helping to ensure proper blood supply to the penis.
Forearm free flap phalloplasty
This procedure is considered by many to produce a more realistic-looking, more erotically sensate phallus than older phalloplasty procedures. This is due to the nature of the skin of the forearm (areas on the underside of the forearm are of good consistency and often are fairly hairless) as well as the nerves and blood vessels that are able to be harvested with that skin. The main drawback to the procedure is that it leaves a very large scarred area on the forearm, and there is some risk of damage to the overall function and feeling of the arm. The donor area on the arm is usually covered with skin from the thigh or groin, leaving a secondary scar in that area as well.
The forearm skin is shaped into the new penis and grafted into place on the groin, where the nerves and blood vessels are microsurgically connected. Some surgeons will connect the brachial nerve of the forearm to the pudendal nerve of the clitoris (with the goal being erotic sensation in the penis). A urethra is typically created using tissue from the labia, the inside of the mouth/cheeks, the vaginal wall, or with a section of relatively hairless skin from the forearm donor site, shaped into an inverted tube. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin on the forearm can be hairy (depending on the patient and the area from which the skin is taken), some patients choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient may have to periodically shave the skin of the penis or use depilatory cream.
Modified forearm free flap phalloplasty
In order to address the issue of major scarring on the forearm, some surgeons have combined the benefits of forearm free tissue flap transfer with other methods such as the pedicled groin flap. A surgeon may choose to create the main shaft of the phallus from a non-sensate source such as a pedicled groin flap, but in a later surgical stage, use sensate tissue from the forearm to create the head of the penis. In another approach to minimize scarring, tissue expanders may be inserted into the forearm and used over a period of months so that when the tissue is harvested from the forearm, the donor area can be closed without an additional skin graft. Such options should be carefully researched and discussed with the surgeons you are considering.
MLD flap phalloplasty
A recent advance in phalloplasty technique developed by Dr. S.V. Perovic uses an area of donor skin taken from the side of the upper torso, under the arm. This is called a “musculocutaneous latissimus dorsi flap,” or “MLD flap.” One advantage of taking donor tissue from this area is that there is a less conspicuous scar than in the forearm flap procedure. Also, because the MLD flap donor area is a bit larger, this can allow for larger penis size if desired.
The MLD flap procedure is considered by many to produce a more realistic-looking, more erotically sensate phallus than older phalloplasty procedures. This is due to the nature of the skin of the MLD flap (the donor area is often relatively hairless) as well as the nerves and blood vessels that are able to be harvested with that skin. Pre-surgical massage in the donor area is strongly recommended in order to increase skin elasticity and enable the surgeon to close the donor site directly. Patients who are obese may not have a successful or aesthetically pleasing outcome– weight loss and/or lip suction may be required by a surgeon prior to performing this procedure.
The MLD flap phalloplasty is typically a three-stage procedure; 3-6 months recovery time is typically required between each stage. In the first surgical stage, skin from the donor area is shaped into the new penis and grafted into place on the groin, where the nerves and blood vessels are microsurgically connected. The foundation for the new urethra is also created during this stage using tissue from inside the mouth/cheeks. The second surgical stage finalizes the new urethra and connects it surgically with the native urethra. The third surgical stage involves implanting a flexible rod or a pump device that is used in order to achieve an erection.
Because the donor skin on the MLD flap can be hairy (depending on the patient), some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. If electrolysis is not chosen, the patient may have to periodically shave the skin of the penis or use depilatory cream.
Scrotoplasty
In general, the creation of the scrotum is usually accomplished by hollowing out the labia majora, inserting solid silicone implants, and eventually joining the labia to create a single scrotal sac. However, other techniques are sometimes employed to create a scrotum, such as the creation of a scrotal sac from donor tissue from the abdomen or thigh. Sometimes fat is harvested from the pubic mound and transplanted into the constructed sac rather than using implants, though often this does not produce adequate size and symmetry.
Pros, Cons, and Risks
It is important to note that most phalloplasty procedures require multiple surgical visits as well as some revisions. The procedures can involve pain and discomfort, require significant recovery time, and often leave large areas of visible scarring. Because of the nature of using skin grafts, there is always a risk of tissue death and loss of part or all of the penis. Other potential complications include the extrusion of testicular or penile implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and infection. There may also be damage to the nerves of the donor area, resulting in numbness or loss of function. Erotic sensation may be changed or diminished. And the results may not be as aesthetically pleasing as one might like them to be. Also, one must consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).
Phalloplasty procedures also tend to be very expensive (between $50,000 to $150,000 at the time the original article was written) and are often not covered by insurance.
However, if one desires an average-sized penis that looks acceptable in the locker room, through which he can urinate, and with which he can engage in penetrative sex, a phalloplasty is a way to achieve that end. Additionally, many trans men do not feel complete without a penis, and so may pursue a phalloplasty with that in mind. It is often reported by trans men that the forearm free flap phalloplasty and the MLD flap phalloplasty provide the most realistic-looking penis of the options currently available, if you are willing to accept the surgical risks.
So there you go. A quick (ish) rundown of the phalloplasty and metoidioplasty.
Personally – I’m going for the phalloplasty. It ticks more of the boxes for what I am after. As I said before though – it’s a personal choice. Don’t let other people make up your mind for you!
My Transition FtM 