Metoidioplasty : Ring flap technique
Metoidioplasty is one of the most common lower surgeries for a female to male transition. It is a surgical procedure to create a neophallus or a new penis. The procedure involves removing the surrounding skin of the clitoris and releasing it from the pubis to give the appearance of more length. This gives the appearance of the glans ‘tip of the penis’ as a circumcised penis in most patients. The final result is a normal-appearing but small penis.
The ring flap method for metoidioplasty is the most advanced method currently available. This method surgery usually yields a very favorable result. The actual result will depend on various factors, as described below. The outcome is mostly dependent upon how much enlargement of the clitoris has occurred after using testosterone. Urethral lengthening can also be done at the same time or later, to allow the patient to stand to urinate. Urethral lengthening requires complete removal of the vaginal mucosa. The best results from the metoidioplasty are in patients who are thin or near their ideal body weight. In most patients, removal of the skin and fat of the mons-pubis and pulling the skin upwards will improve the result. This procedure will leave a curvilinear scar in the pubic hair and is usually done as a second stage when the expanders are replaced with a permanent testicular prosthesis.
The principal advantage of the ring flap metoidioplasty is that it is less invasive, maintains the sensitivity of the clitoris, and does not create apparent surgical scars. Furthermore, it does not prevent future genital surgery from being done at a later time should one decide. The penis will not, however, appear adult in size, and it is not large enough for vaginal intercourse. The formation of the scrotum (Scrotoplasty) is done during the metoidioplasty. Should you desire, prostheses for testicles could be placed at this time or a later date, since there is frequently only limited place for two tissue expanders in the new scrotum. The permanent prosthesis can be placed in the scrotum at the same time. There is probably no harm in placing two testicular prosthesis. If urethral lengthening is done, the patient must wait three months to have expanders or prosthesis placed.
There are two options of metoidioplasty procedures
- Simple release. This operation releases the clitoris free from the surrounding tissue. And does not extend the urethral or close the vagina. The appearance of the penis is more natural but limited in its length.
- Full metoidioplasty, this procedure releases the clitoris and then uses a tissue graft from inside your vagina and a ring flap of the vulva to make the urethra with the neophallus. If desired, the surgeon may also perform vaginectomy and scrotoplasty at the same procedure.
Figure 1. Schematic of the ring flap
Figure 2. Schematic of full metoidioplasty with ring flap and testicular implants