[Female-to-male reassignment surgeries: metaidoioplasty and phalloplasty]

Metoidioplasty is an established gender-affirming genital surgical procedure and represents a less invasive alternative to phalloplasty using pedicled or free tissue flaps. Mobilization and lengthening of the testosterone-enlarged clitoris, combined with construction of an elongated neourethra, results in both esthetic and functional masculinization of the external genitalia. In many patients micturition in a standing position can be achieved. Outcomes largely depend on the individual anatomical conditions. The main advantages of metoidioplasty include preservation of erogenous sensation and orgasmic function, low postoperative morbidity, and avoidance of extensive donor-site scars. However, penile length and rigidity sufficient for penetrative sexual intercourse are generally not achieved. The reconstructive goal of phalloplasty for gender affirmation is to create an esthetically pleasing phallus that allows for standing urination and, if desired, penetration during sexual intercourse. Depending on the technique, pedicled or free flap procedures are used. The most commonly used technique is the free radial forearm flap, which has now become established as the gold standard in many centers.