Metoidioplasty

A metoidioplasty creates a neophallus using natural clitoral growth that occurs secondary to testosterone use. The natural length is maximized by release of the suspensory ligaments under the pubic bone, allowing the clitoris to straighten and move forward while preserving sensation. The neo-phallus is further reshaped using surrounding tissue. The final length of the neo-phallus depends on preoperative clitoral growth, which can be optimized with topical testosterone. Typically, the neo-phallus measures between 1.5 to 2 inches in length.

A metoidioplasty can contain some or all of the following procedures:

• Construction of the Neo-Phallus – The clitoris is surgically freed from its suspensory ligaments, repositioned, and reshaped to create a more prominent and forward-projecting phallus.
• Urethral Lengthening (Standing to Pee) – For patients who wish to urinate while standing, the urethra is lengthened using existing genital tissue. This is performed in collaboration with a board-certified urologist.
• Scrotoplasty – The labia are reshaped into a scrotum, which can be left empty or later augmented with testicular implants.
• Perineoplasty – The perineum is reconstructed to improve anatomical alignment and ensure a more natural appearance.
• Monsplasty – Excess tissue in the mons region is reduced to improve the projection of the neo-phallus.
• Testicular Implant Placement – Silicone testicular implants can be inserted in a later stage to enhance the natural look and feel of the scrotum.

• Simple Metoidioplasty – This procedure creates a neo-phallus but does not include urethral lengthening. Patients retain their existing urethral opening and continue to urinate in a seated position. Simple metoidioplasty is less complex and carries a lower risk of complications such as urethral fistulas or strictures.
• Metoidioplasty with Urethral Lengthening – Urethral lengthening involves creating a new urinary channel that allows patients to urinate while standing. The native urethra is connected to the neo-phallus using local tissue, and a catheter is placed inside the new urethra to maintain its structure during healing. A suprapubic catheter is also inserted through a small incision in the lower abdomen to drain urine into a bag while the urethra heals. This catheter remains in place for four to six weeks, after which a urethrogram (X-ray study of the urethra) is performed to confirm that the new urethra is fully healed. Once cleared, patients can begin urinating through their neo-phallus.

To undergo metoidioplasty, you will need to be over 18 and have 2 referrals from qualified mental health professionals attesting to your gender dysphoria and desire to get bottom surgery. The letters will need to correspond to the WPATH Standards of Care guidelines. You will also need to be on HRT for a full year (or detail in writing why you don’t want to be on HRT)

Dr. Keith and Dr. Marano, who you will meet during your consultation in New York City/New Jersey, devote significant time to the consultation process. They will answer all of your questions and concerns in depth and ensure you have realistic expectations for your results. They will assess the donor regions, review your medical and surgical history, and create a customized treatment plan that achieves your bottom surgery goals.

In addition to undergoing a detailed consultation with Dr. Keith or Dr. Marano in NYC, there are a few important steps you will need to take in order to ready yourself for metoidioplasty, outlined below:

• Mental Health Provider Letters – Many insurance providers and surgical guidelines require two letters from a qualified mental health professional confirming a diagnosis of gender dysphoria and the patient’s readiness for surgery. These letters should follow WPATH (World Professional Association for Transgender Health) standards and address the patient’s understanding of the procedure and its implications. Our team will assist in ensuring the proper language is used and the provider is appropriately credentialed
• Well-Controlled Medical or Mental Health Issues / Medical Clearance – Patients with underlying medical conditions (e.g., diabetes, high blood pressure) must have them well-managed before surgery. Medical clearance will be required.
• BMI Consideration– There is no strict BMI requirement for metoidioplasty. However, patients with a higher BMI may have difficulty urinating while standing if the length of the neo-phallus does not exceed the thickness of the mons. This is an important factor to consider for those seeking urethral lengthening.
• Nicotine Cessation – Nicotine must be stopped at least four weeks before and after surgery to prevent serious complications such as wound healing issues and tissue necrosis.
• Hysterectomy / Vaginectomy (If Getting Urethral Lengthening) – A hysterectomy and vaginectomy are required if the patient opts for urethral lengthening. Direct referrals for these procedures can be provided.
• Insurance That Will Cover Surgery – GAMMA works with multiple insurance providers and will assist with pre-authorization and documentation. Patients should verify specific bottom surgery coverage with their insurance carrier

On the day of your metoidioplasty, you will arrive at the hospital or surgical center early in the morning. You will check in and be taken to a pre-operative area, where a nurse will review your medical history, confirm fasting instructions, and start an IV line for fluids and medications.

• Meeting Your Surgical Team – You will meet with your surgeon, anesthesiologist, and nursing staff before the procedure. Your surgeon will review the surgical plan and mark the operative sites. This is a good time to ask any last-minute questions.
• Anesthesia Administration – Once in the operating room, you will receive general anesthesia, meaning you will be fully asleep and pain-free during surgery.
• Surgical Procedure – The length of the procedure depends on whether you are undergoing simple metoidioplasty or metoidioplasty with urethral lengthening. Surgery typically takes between 4 to 6 hours.
• Immediate Post-Operative Care – After surgery, you will be taken to the recovery room, where you will be closely monitored as you wake up from anesthesia. Your surgical team will ensure your vitals are stable and manage your initial pain and discomfort.
• Hospital Stay – Most patients remain in the hospital for approximately three days. During this time, nurses and doctors will monitor your healing, manage pain, and teach you how to care for your surgical sites, drains, and catheters (if applicable).

*Before discharge, your surgeon will review your post-operative instructions, including activity restrictions, wound care, and follow-up appointments. You will need a trusted friend or family member to accompany you home or to your recovery accommodations.

Recovery from metoidioplasty is a gradual process that requires patience, adherence to post-operative instructions, and regular follow-ups. The timeline varies depending on the surgical approach, the number of stages completed, and individual healing.

• Pain Management – Pain will be managed with medications and gradually improve over weeks.
• Dressings & Showering –  There will be daily dressings changes to perform at home. Showering is allowed after discharge from the hospital, with precautions.
• Drains & Catheters – Patients may have surgical drains to remove excess fluid and prevent complications. These are typically removed within 1–2 weeks. After urethral hook-up (second stage), a suprapubic catheter (a tube placed directly into the bladder) is used for urination while the urethra heals. It remains in place for about 4 weeks, depending on healing progress. A foley catheter will also be placed through the new penile urethra for additional support.
• Swelling and Healing – Swelling is most pronounced in the first 2–3 weeks and gradually subsides over the next 3–6 months.
• Activity Restrictions – No heavy lifting, strenuous exercise, or sexual activity for at least 6–8 weeks. Light walking is encouraged to promote circulation and prevent blood clots. Patients should avoid bending, squatting, or straining during the first several weeks. Gradual stretching and mobility exercises may be recommended to prevent stiffness at the donor site.

Timelines

• Time off work: Desk jobs require 4-6 weeks off work. Physically demanding jobs can require 6-8 weeks or longer

• Time to sexual activity – You will be required to wait at least 3 months to allow for proper healing.

*Full healing and final results occurs approximately 12–18 months after the final surgery

Dr. Keith and Dr. Marano will go over these risks in greater detail during the consultation process so you are fully aware and informed. Possible risks include:

• Urethral Fistula – An abnormal connection between the urethra and skin, leading to leakage.
• Urethral Stricture – Narrowing of the urethra, which may require revision surgery.
• Pain – Most commonly in the donor site, scrotum, and surgical areas.
• Tissue Necrosis – Partial or complete loss of tissue due to poor blood supply.
• Wound Separation – Incisions may take time to heal properly.
• Discharge – Temporary discharge from healing surgical sites.
• Bleeding – Post-surgical bleeding that may require intervention.
• Infection – Can occur at the donor site, urethra, or phallus.
• Sensation Loss – Varies based on nerve connections and healing

You will be recuperating for about six weeks, during which time you should avoid strenuous activities and attend all follow-up visits. Dr. Keith and Dr. Marano will customize a timeline for when you can return to normal activities, including traveling.

Insurance carriers will typically cover gender affirmation surgery, including metoidioplasty, when it is performed to treat gender dysphoria, a condition in which the patient’s outer traits do not reflect their authentic gender identity. You’ll need letters from mental health providers detailing your decision to undergo metoidioplasty. Our team can go over the insurance requirements in greater detail during your consultation.

• Resources – For patients traveling to NYC for surgery, GAMMA provides recommendations for LGBTQ+ friendly accommodations, post-op caregivers, and recovery services. Our team can also assist with logistics such as medical transport and aftercare arrangements.
• Requirements – Out-of-town patients must plan to stay in NYC for at least two weeks after surgery to ensure proper healing and attend necessary post-operative appointments. We encourage having a trusted friend, family member, or professional caregiver for the first few days post-surgery.

Our team at Gender Affirming Medical and Microsurgical Associates (GAMMA) in New York City and New Jersey is known for providing the highest-level care in an affirming environment. We utilize today’s most progressive and cutting-edge techniques to provide the highest level of service possible. Our goal is to help transgender, nonbinary, and gender nonconforming individuals achieve their unique appearance goals and thrive with confidence, security, and peace of mind.

Dr. Drew Marano

Dr. Drew Marano is an accomplished, board- certified, and fellowship-trained plastic and reconstructive surgeon who has devoted his career to the art of gender affirmation surgery. He graduated from Rutgers New Jersey Medical School at the top of his class, receiving AOA honors before embarking on a competitive six-year Integrated Plastic and Reconstructive Surgery Residency at Columbia University/Cornell University in New York City. Following his residency, Dr. Marano was selected as the first-ever Harvard University Complex Gender and Microsurgery Fellow, during which time he underwent advanced training in groundbreaking and innovative surgical techniques. He is a prolific author, researcher, and lecturer who has contributed to over 40 publications and presentations at regional and national meetings. Dr. Marano offers ongoing support for transgender patients as they navigate their unique and rewarding journey of transitioning.

Dr. Jonathan Keith

Dr. Jonathan Keith is a renowned, fellowship-trained, board-certified plastic surgeon known for his progressive approach to microvascular surgery. He is an active member of the World Professional Association for Transgender Health and the founder of the Rutgers Center for Transgender Health. In 2018, Dr. Keith created the first multidisciplinary clinical program for transgender patients in New Jersey and was the first surgeon in the state to perform a female-to-male phalloplasty for gender affirmation. Regarding his extensive educational background, Dr. Keith completed a demanding seven-year residency at the University of Pittsburgh, one of the nation’s most elite and well-regarded plastic surgery training programs. As a testament to his skill and artistry, in 2012, he received the Stephen S. Kroll Fellowship in microsurgery at the University Hospital of Gent, Belgium. Today, Dr. Ketih performs a range of complex and delicate procedures to assist transgender and nonbinary individuals in achieving their ideal appearance, including DIEP flaps for breast reconstruction, vaginoplasty, and phalloplasty.