Page 485 - Read Online

Page 2 of 8 Bizic et al. Plast Aesthet Res 2020;7:43 I http://dx.doi.org/10.20517/2347-9264.2020.80
[1]
professionals and must come after at least 12 months of substitution hormonal therapy . Preoperative
consultation with the selected surgeon performing gender affirmation surgery (GAS) is welcome in order
to reconcile the patients’ expectations of surgery outcomes and the possibilities of modern medicine, to
[2]
prevent any postoperative disappointmen . Even though under testosterone therapy transmen’s body
encounters a lot of changes, some individuals still require facial and body masculinization procedures or
frontline hair procedures.

It is still difficult to assess the real prevalence of gender dysphoria, but the latest studies report an increase
in prevalence for individuals assigned male at birth to 0.014-0.015, while, for individuals assigned female at
birth, it is 0.002-0.003. The self-report of transgender identity in children, adolescents, and adults, ranging
[3,4]
from 0.5% to 1.3%, has also increased according to recent studies .

Phalloplasty, as previously said, is still a challenging procedure, reserved for highly specialized institutions
and surgeons. The first phalloplasty was performed in the 1930s by Bogoras, followed by years of refining
surgical techniques to satisfy patients’ expectations of functionality and esthetics. However, there is no
replacement for erectile, urethral tissue, and nerves that would provide ideal male genitals for males
[5,6]
requiring genital reconstruction . The reconstruction of the neophallus should be performed as a one-
stage procedure, yielding sensation (tactile and erogenous), functional neourethra (ability of stand-up
[5,7]
voiding), penetrative sexual intercourse, and minimal scarring of the donor site . Unfortunately, to this
[8]
day, there is no single surgical technique to satisfy all these goals of male genitalia reconstruction .
Male genitalia reconstruction in transmale individuals can be performed by two surgical approaches:
phalloplasty and metoidioplasty (a variant of phalloplasty). Phalloplasty involves the creation of an adult-
sized neophallus using local or outlying tissue flaps, as either pedicled or free flaps with microvascular
anastomosis. Rigidity for penetration during sexual intercourse is obtained after penile prosthesis
implantation. Metoidioplasty involves creation of the neophallus using the hormonally-hypertophied
clitoris, with or without urethroplasty, and scrotoplasty, with or without testicular prostheses implantation.
In the majority of patients, metoidioplasty enables voiding in standing position and full erogenous
[5,9]
sensation, but penetration during sexual intercourse is possible in only rare cases (by self-report) .
The first report of using clitoris in male genitalia reconstruction was in 1973, and as a term “metoidioplasty”
was first introduced by Lebovic and Laub, originally from the Greek words “meta” (change), “aidion” (female
genitalia), and “plasty” (formation) [10,11] . Metoidioplasty can be considered as the method of choice, for
those individuals requiring male genitalia reconstruction in single surgery to complete their transition and
who do not wish to have stigma scars outside the genital area.

This narrative review aims to evaluate all available techniques of metoidioplasty and to report the
postoperative results and complications. The paper was approved by the Institutional Review Board (No.
2-1-1/2020).

Preoperative evaluation
Transmale individuals undergoing genital reconstruction in GAS are required to have spent at least one
[1]
year on hormonal substitution therapy according to the WPATH SOC . For those who have chosen
metoidioplsty as the surgical technique, additional preoperative short-term use of vacuum pump
in combination with local application of dihydrotestosterone gel is recommended to provide better
postoperative results [5,12] .

Knowledge of female and male anatomy and embriology is of essential importance for surgeons performing
transgender genital reconstructive surgeries. Female and male external genitals, i.e., the clitoris and penis,