Genital affirmation surgery for trans men to create a phallus typically involves two main techniques: phalloplasty and metoidioplasty. While significant progress has been made, these procedures are still not as advanced as genital surgeries for trans women (such as vaginoplasty), due largely to the technical challenges of constructing a functional penis. Continue reading to discover the differences of phalloplasty and metoidioplasty and which one suits your goals.
Metoidioplasty: Creating a Micropenis
Metoidioplasty constructs a micropenis using the patient’s clitoris. The first step requires masculinising hormone therapy to enlarge the clitoris. Results vary widely, with growth ranging from about 1 cm to as much as 6 or 7 cm. At IM GENDER, we generally advise against metoidioplasty when hypertrophy is minimal, as a very small penis may not allow standing urination or achieve the aesthetic appearance desired by the trans man.
Metoidioplasty is technically simpler than phalloplasty. It doesn’t require tissue grafts from other parts of the body. Everything is done using local tissue. The resulting micropenis maintains sensation, as it is still the clitoris, now surrounded by skin. When combined with the construction of a scrotum and insertion of testicular implants, the result can be quite masculine. In summary, metoidioplasty offers a sensitive but small penis that allows standing urination. While this procedure was more common 15–25 years ago, dissatisfaction with size has led us to focus on improving phalloplasty techniques to better meet patient expectations.
Phalloplasty: When Size Does Matter
Phalloplasty allows the creation of a penis closer in size and appearance to that of a cis man. Unlike metoidioplasty, phalloplasty enables the placement of a hydraulic prosthesis for sexual penetration. These prostheses are similar to those used for erectile dysfunction in cis men but are adapted for phalloplasty.
Creating a neophallus of realistic size requires autologous tissue transfer. Several donor sites can be used via microsurgery—most commonly the back, leg, or forearm. At IM GENDER, we prefer the radial forearm flap, as it offers unmatched versatility and natural proportions in both length and width.
The radial flap contains at least three nerves, which can be connected to the dorsal clitoral nerve and other sensory nerves to provide erogenous and tactile sensation (temperature, vibration, pain, etc.). We have now performed nearly 100 radial flap phalloplasties at IM GENDER with excellent results, making it our first-choice technique.
Phalloplasty is a complex procedure, requiring around 7 hours in theatre and a hospital stay of at least one week. Complications occur in about 20–25% of cases but are usually resolved within the first month.
Complications of metoidioplasty and Phalloplasty
Both techniques carry risks, especially since the neophallus must allow the passage of urine. Common complications include urethral stenosis (narrowing) and fistulas (urine leakage). These are relatively rare in phalloplasty and usually manageable in the early weeks.
Testicular Implants
At IM GENDER, we recommend placing testicular implants in two stages: the first three months after surgery, and the second at four or five months. Placing both at once may create pressure and oedema, leading to implant rejection. In cis men, the testicles are not symmetrical—this allows natural movement. By staging the implants, we recreate this effect and achieve a more natural look and feel.
What About the Donor Site (Arm)?
Many patients are concerned about the appearance of the donor site. At IM GENDER, we apply aesthetic techniques such as lipotransfer to the arm and micropigmentation of the penis (e.g., tattooing dorsal veins for realism). These refinements are published in international journals. You can see before-and-after results via this link.
Choosing the Right Technique
Before deciding, it’s essential to assess each patient’s personal needs and goals. At IM GENDER, we use a detailed assessment scale to understand:
- What the patient wants
- Their current anatomy and health
- What each technique can realistically offer
We encourage shared decision-making, supported by medical evaluation and peer contact. We connect new patients with others who have undergone both surgeries, including those who experienced complications. Our goal is for every patient to have the information they need to make an informed and confident decision.