Gender-affirming genital reconstruction for transmasculine individuals primarily involves two distinct surgical pathways: metoidioplasty and phalloplasty. Both procedures aim to create a masculine-appearing neophallus, but they rely on different tissues and offer varied functional and aesthetic outcomes. Understanding the differences between these options is important for individuals making decisions about their transition. The choice depends heavily on a patient’s priorities regarding size, sensation, complexity, and the ability to stand to void.
Metoidioplasty: The Surgical Approach and Expected Results
Metoidioplasty utilizes the patient’s existing genital tissue, which has been naturally enlarged through consistent testosterone hormone therapy. Surgeons release the hormonally hypertrophied clitoris from its suspensory ligaments and surrounding structures. This technique repositions the natal tissue forward to create a small, masculine-appearing neophallus. Maintaining the existing neurovascular bundle is crucial for functional outcomes.
A common goal is urethral lengthening (urethroplasty), which extends the urinary channel to the tip of the neophallus, allowing the patient to stand to urinate. Tissue from the labia minora or a graft, such as buccal mucosa, is often used to construct the new section of the urethra. Scrotoplasty, the creation of a scrotum using the labia majora, may be performed simultaneously, with testicular prostheses implanted later.
The resulting neophallus length typically ranges from 4 to 10 centimeters, averaging around 5.6 centimeters. Since the erectile tissue is retained and repositioned, the neophallus maintains the ability to become firm through natural vascular engorgement. Patients generally report excellent preservation of erogenous sensation because the procedure does not involve severing or grafting the primary sensory nerves. Reliance on the patient’s own tissue makes metoidioplasty a less invasive option than procedures requiring tissue transfer from distant donor sites.
Phalloplasty: Techniques and Goals
Phalloplasty is a reconstructive procedure that involves creating a neophallus using a tissue flap harvested from a donor site on the body. Common techniques use a free flap from the forearm (Radial Forearm Flap, or RFF) or tissue from the thigh (Anterolateral Thigh, or ALT) flap. The primary goal is to achieve a neophallus with size and volume comparable to a typical natal penis, which is necessary to accommodate a future erectile device and allow for stand-to-void functionality.
Creating the neophallus requires microsurgery to connect the blood vessels and nerves from the harvested flap to the recipient sites in the groin area. Blood flow is crucial for tissue survival, and the nerve connection aims to transfer sensation to the new phallus. Urethral lengthening is a standard component when the patient desires to stand to urinate, typically performed using a “tube-within-a-tube” method with the donor tissue. The procedure often includes glansplasty, sculpting the tip of the neophallus to create a more defined glans and enhance the aesthetic result.
Phalloplasty is a modular process aiming to create a fully formed, sensate, and functional neophallus. While the phallic shaft and urethra are created in initial stages, achieving rigidity for penetrative intercourse requires the surgical placement of an internal penile prosthetic device. This device, usually a malleable or inflatable rod, is implanted in a subsequent stage once the neophallus has completely healed. The complexity of this reconstruction makes phalloplasty a multi-stage process over many months or years.
Comparative Outcomes: Appearance, Sensation, and Function
The most significant difference lies in the resulting size and appearance of the neophallus. Metoidioplasty is limited by hormonal growth, yielding a modest result that may not create a noticeable bulge in clothing. Phalloplasty uses a larger tissue flap to construct a neophallus of significant length and girth, offering a result that closely resembles a natal penis.
Sensation differs based on the surgical approach. Metoidioplasty retains the original erogenous sensation, as the highly innervated clitoral tissue is simply repositioned and remains connected to native nerves. Phalloplasty involves a neurovascular transfer, connecting sensory nerves from the donor site to the remaining nerves of the clitoris. This transferred sensation is typically protective (tactile) and may develop into erogenous sensation over months or years as the nerves regenerate.
The ability to void while standing is achievable with both procedures, though with different risk profiles. Urethral lengthening in phalloplasty carries a high risk of complications, such as strictures or fistulas, due to the complexity of creating a long urethra. Metoidioplasty also involves urethral lengthening, but the shorter required extension is associated with a lower rate of these urologic complications. Neither procedure automatically provides the ability for penetrative intercourse; metoidioplasty relies on the natural erectile response, while phalloplasty requires the later insertion of a penile prosthetic.
Practical Considerations: Recovery, Staging, and Costs
The complexity of the surgical plan dictates the timeline and number of procedures required. Metoidioplasty is often a single-stage procedure, combining neophallus creation, urethral lengthening, and scrotoplasty into one operation. Phalloplasty is inherently multi-staged, typically requiring two to four separate surgeries to complete the phallus, urethra, glans, and erectile device placement. This difference in staging directly impacts the overall recovery time.
Initial recovery differs markedly between the two procedures. Metoidioplasty typically involves a hospital stay of about three days, with a shorter overall recovery period before returning to daily activities. Phalloplasty, due to the complexity of the microsurgery and the donor site wound, requires a longer initial hospital stay and a more extensive recovery period, often spanning several weeks for the first stage alone. Full recovery and completion of all phalloplasty stages can take well over a year.
The financial burden also differs significantly, with metoidioplasty generally being the less expensive option. The lower cost is due to the smaller scope of surgery, reduced operating time, and fewer required stages. Cash prices for a full metoidioplasty can range between $19,000 and $42,000, depending on the inclusion of urethral lengthening and scrotoplasty. Phalloplasty, involving multiple complex surgeries and specialized microsurgical teams, is substantially more costly, making insurance authorization necessary for most patients to manage the financial implications.