Female-to-Male Ring Flap Metoidioplasty

Notice: Adult Content

This page contains post-operative pictures of genitals. This page is not work safe.


Ring Flap Metoidioplasty is a technique developed in Japan by Dr. Ako Takamatsu, M.D., Ph.D. Dr. Takamatsu was hosted by Papillon Center in July of 2008 to exchange ideas on GCS and as a result, Dr. McGinn has been offering Ring Flap Metoidioplasty since 2008. This surgery utilizes a flap of skin from the vagina along with the labia minora to create a urethral extention. The clitoral chordee is also released in this procedure. The result is a lengthened phallus with added girth and the ability to urinate while standing. This procedure has a particular advantage over buccal mucosa urethral lengthening in that it does not require a second operative site to harvest the oral mucosa. This eliminates problems such as poor mouth healing and the potential for decreased saliva production. Another advantage of this procedure is that it may be converted to a free flap phalloplasty if the patient�s goals change at a later date. This procedure does however carry a risk for urethra stricture and/or urethral fistula. Several follow up visits are required and patients should be prepared for the potential need for revision and/or fistula repair. Vaginectomy is not part of this surgery, however the vaginal opening is reduced by 80%. PAP smears will no longer be possible following this procedure, so those contemplating this surgery should have had hysterectomy prior to having this procedure. Available openings for this surgery are filled early each year, so please plan ahead.

Scrotoplasty, testicular implants, mons liposuction and phallus repositioning are also available, but must be performed as a second surgery due to the delicate nature of urethral lengthening procedures.


Papillon Center follows the World Professional Association for Transgender Health (WPATH) guidelines for transgender surgery. Two letters of recommendation are required before surgery. These letters can be from: psychologists, therapists, psychiatrists, sexologists or counselors that have been in regular contact with you and have experience dealing with transgender issues. The letters should be in the format described by the Standards of Care. Papillon Center can work with patients that have insufficient recommendations. On-going therapy and support is preferable both before and after surgery. Patients should have also completed their "real-life experience" as well as be on an approved contra-hormone therapy (CHT) regimen. The reason for these requirements is a compassionate one: we want you to have an understanding about what changes you will go through before they are irreversible.
Please see Therapy Letter Requirements for an in-depth overview of surgery recommendation letter requirements.
The metoidioplasty surgery is not a minor surgery and requires a certain body type to be successful; therefore, an in-person consultation is required prior to surgery to determine if you have the right body type for this surgery. Specifically, the ideal candidate must not have had previous penile surgery, must be relatively thin and must have enough penile length to clear the labia.

Also, patients must stop testosterone 1-2 weeks prior (depending on IM or transdermal) and 2 1/2 weeks after surgery to prevent spontaneous erections and poor wound healing. Vaginectomy is not required for this surgery, nor is it performed during this surgery. The vaginal opening IS however, significantly reduced to just a few millimeters. Dr. McGinn strongly recommends either vaginal or laparoscopic assisted hysterectomy prior or during this surgery. PAP smears are no longer possible following this surgery, thus the recommendation for hysterectomy near the time of metoidioplasty.

As with all urethral lengthening procedures, post-op fistula formation is a major concern. Fistula rate for this surgery is 9%. Surgeon's fees for fistula repair are of course waived if fistula occurs and can be performed on an outpatient basis.

It is necessary that the body and mind be in optimal health. Smoking and obesity will increase your chance for complications. Smoking cessation is mandatory one month prior to surgery (as well as six months following surgery). It is also required that body mass index (BMI) be less then 28. Some medications will need to be stopped before surgery. They can generally be continued several days after surgery.

Initial Consultation

A consultation is required to setup a surgery date. It is REQUIRED to have an in office consult for this procedure.

The procedure is outlined, including risks, complications, and possible outcomes. Health is also taken into consideration, especially the topics of sexuality, nutrition, body mass, and smoking. Sexual health is of particular concern as sexual re-education tends to take a substantial role in the recovery of sexual function after surgery.

Dr. McGinn will go over past surgical results, including pictures, as well as expectations and limitations. It is important to be honest and ask questions about subjects that you do not understand.

Scheduling and Time Requirements

This procedure requires a minimum two week stay in the local area, including hospital time. It is advised that if patients are flying to Pennsylvania that they have Flight Insurance due to varying healing times of each individual.


Pre-operative pictures are to the left, post-operative pictures are to the right. Post-operative pictures were taken 5 weeks after surgery.

The videos provided are an example of post-operative urination.

Metoidioplasty Pre-Op
Metoidioplasty Post-Op
Metoidioplasty Pre-Op
Metoidioplasty Post-Op
Metoidioplasty Pre-Op
Metoidioplasty Post-Op

More Information

To schedule an appointment or request more in-depth information, please Contact Papillon Center.