Female-to-male bottom surgery is an element of gender-affirming care that helps align anatomy with identity. It covers procedures such as metoidioplasty and phalloplasty to construct a penis, and may include hysterectomy or vaginectomy depending on individual goals.
These medical interventions are performed by specialized teams. Centers like UCLA combine plastic surgery, urology, gynecology, behavioral health, hormone therapy, and primary care to deliver coordinated care and improve overall health.
Hospital stays are often short, with most people going home after a few days. Recovery requires activity limits and follow-up visits to support healing and monitor outcomes.
Evidence shows high satisfaction: a 2018 study reported 94%–100% positive responses across different techniques. Risks rise with cigarette use, so preoperative optimization matters.
This introduction frames bottom work as one part of a broader plan. Each person’s path is individualized, with consultations and careful planning guiding expected results and responsibilities during recovery.
Key Takeaways
- These procedures are aimed at aligning anatomy with personal goals.
- Metoidioplasty and phalloplasty are common options, often paired with hysterectomy or vaginectomy.
- Short hospital stay is typical; recovery includes activity limits and follow-up.
- Satisfaction rates are high, though outcomes vary by technique and patient factors.
- Multidisciplinary teams improve coordination and long-term health support.
Defining female-to-male bottom surgery and its role in gender affirmation
Reconstructive genital operations play a central role in many people’s gender affirmation journeys. These procedures focus on changing genital anatomy to match personal goals and function.
Common types include metoidioplasty, phalloplasty, scrotoplasty, vaginectomy, and hysterectomy/BSO. Teams often stage steps to create a neopenis, form a scrotum, or remove reproductive organs based on medical needs and preferences.
Chest reconstruction (top surgery) reshapes the chest and often has very high satisfaction with low complication rates. Top and genital work are separate but complementary parts of comprehensive care that may also include hormone therapy and behavioral health support.
- Multidisciplinary teams — plastic surgeons, urologists, and gynecologists coordinate plans.
- Outcomes depend on anatomy, available skin and tissue, overall health, and priorities like standing urination or penetrative function.
- Patient-centered planning helps patients set realistic expectations, timelines, and sequence of procedures.
Coordinated care improves continuity, streamlines referrals, and supports pre- and postoperative needs, which can positively influence long-term outcomes for patients.
How to prepare: consultations, care team, and creating a surgical plan
Early consultations shape an individualized timeline that balances goals, donor-site choices, and medical readiness. This stage helps patients set priorities such as standing urination, sensation, or aesthetics and informs the surgical plan.
Choosing a qualified team
Assemble specialists across plastic surgery, urology, gynecology, and behavioral health. A coordinated team supports pre-op work, perioperative care, and long-term follow-up.
Insurance and records
Many U.S. insurers require two surgery letters and recent health records for authorization. Programs like UCLA’s care coordination team help submit documents and schedule consultations.
Pre-op steps
Discuss fertility preservation early. Smoking cessation and medical clearance improve overall health and lower complication risk. Pelvic floor physical therapy is recommended before and after procedures.
For flap-based reconstruction, donor-site options include radial forearm, anterolateral thigh, or latissimus dorsi. Surgeons give a hair removal template; clearance may take several weeks. Tattoos at donor sites can remain if perfusion and skin function test normal.
- Confirm records and letters before booking.
- Follow hair removal and therapy timelines.
- Discuss whether urethral lengthening fits goals and staging.
For further resources, see this FTM resources guide.
What is a female to male bottom surgery?
A personalized set of procedures helps align anatomy with identity. Teams design plans that consider function, scarring, and recovery. Care focuses on goals such as standing urination, sensation, and appearance.
Common types include metoidioplasty and phalloplasty for penis creation. Metoidioplasty uses hormonally enlarged clitoral tissue for a smaller neopenis. Phalloplasty uses skin and tissue flaps from donor sites like the forearm, thigh, or back for a larger result.
Scrotoplasty reshapes labial tissue and may later receive silicone implants. Removal procedures such as hysterectomy and vaginectomy are offered when desired and often sequenced before major reconstruction. Centers coordinate staging to improve safety and outcomes.
- Selection factors: size goals, standing urination, sensation, donor-site scars, and recovery time.
- Donor sites: forearm, anterolateral thigh, latissimus dorsi, or abdomen.
| Procedure | Primary goal | Typical donor site |
|---|---|---|
| metoidioplasty | Small neopenis using local tissue | local genital skin |
| phalloplasty | larger penis creation | forearm, thigh, back |
| scrotoplasty / removal | scrotum formation; organ removal | local tissue; N/A for removal |
Metoidioplasty: procedure steps, urethral lengthening, and expected results
Metoidioplasty reshapes hormonally enlarged clitoral tissue into a small, functional neophallus. The operation begins with clitoral release to free length, then refines surrounding tissue for improved contour and support.
Clitoral release, tissue use, and creation of a small neopenis
Surgeons mobilize the clitoris, preserving nerves and blood supply while releasing ligaments that limit visible length. Local genital tissue forms the shaft and base, avoiding large donor-site scars.
Urethral lengthening options and standing urination
For standing urination, teams may perform urethral lengthening using grafts from the cheek, labia minora, or other vaginal tissue. Those grafts help extend the urethra through the neopenis and reduce tension at closure.
Sensation, erections, recovery time, and potential complications
Because clitoral erectile tissue remains intact, many patients experience erections and preserved sensation. Size is usually smaller than that from phalloplasty, but functional sensitivity tends to be high.
Recovery typically involves a short hospital stay, limited activity, and scheduled follow-up to monitor the urethra and incisions. Common complications include urethral stricture or fistula; early reporting improves management.
Candidate profiles often include people seeking fewer stages, less donor-site morbidity, and strong sensory outcomes. Collaborative planning with the surgical team helps decide whether urethral lengthening and scrotoplasty match urinary and aesthetic goals.
For more detail and resources, see this FTM resources guide.
Phalloplasty: flap choices, staging, implants, and donor-site considerations
Phalloplasty uses skin flaps from other areas of the body to sculpt a functional, aesthetic neophallus. Donor selection balances thinness, vascular reliability, and scar location.
Radial forearm, anterolateral thigh, and latissimus dorsi
The radial forearm free flap (RFFF) offers thin, pliable skin and clear options for nerve coaptation, but often needs a forearm graft. The anterolateral thigh (ALT) flap hides scars and may be thicker. The latissimus dorsi (MLD) flap can close in line without large grafts but may affect shoulder strength temporarily.
Staged approach and implants
Typical staging: stage 1 creates the phallus with an inpatient stay of about 4–5 days. Stage 2 (5–6 months later) may add urethral lengthening, scrotoplasty, and clitoral burying. Stage 3 (roughly 12 months after stage 2) places testicular and erectile implants, which carry infection and device risks and are considered off-label for this use.
Grafts, nerves, sensation, and size
Some flaps require donor-site grafts. Nerve hookup and clitoral burying can enhance protective and erogenous sensation, though recovery may take months. Typical length after reconstruction is about 5–6 inches; girth varies with flap fat content and technique.
| Flap | Advantages | Drawbacks |
|---|---|---|
| Radial forearm | Thin skin, good nerve options | Visible forearm graft, donor-site care |
| Anterolateral thigh | Concealed scar, larger available skin | May be thicker; contouring needed |
| Latissimus dorsi | Linear closure, robust tissue | Potential shoulder weakness; bulkier |
Pre-op planning includes hair removal mapping and perfusion tests; tattoos at donor sites require evaluation. Align flap choice and staging with each person’s priorities—standing urination, return of feeling, scar placement, and recovery timeline—and consult a specialized surgeon for a tailored plan. For more on phalloplasty options, visit this transgender phalloplasty resource.
Related procedures: hysterectomy, salpingo-oophorectomy, vaginectomy, and scrotoplasty
Many centers combine internal organ removal with reconstructive steps to streamline care and reduce repeat anesthesia. This approach helps match the surgical plan to each person’s goals while lowering overall risks.
Timing and reasons for combining procedures
Hysterectomy and salpingo-oophorectomy are often done before phalloplasty when a vaginectomy is planned. Removing or ablating vaginal mucosa creates space and can simplify later urethral lengthening.
Vaginectomy typically means excision of mucosa and closure of the canal. Teams coordinate this step with urethral work to improve urinary outcomes and reduce tension on closures.
Scrotoplasty reshapes labial tissue into a scrotum. Testicular implants are usually placed later to let tissues heal and cut infection risk.
Patients choosing metoidioplasty may combine fewer removal steps than those seeking phalloplasty with a flap. Surgeons and the multidisciplinary team build a tailored plan that balances function, comfort, and recovery.
- Combining steps can reduce total anesthesia events.
- Sequencing optimizes space for reconstruction and urinary function.
- Individual goals guide which procedures are paired and when.
Recovery and aftercare: hospital stay, catheters, physical therapy, and timelines
The early weeks after reconstruction demand close observation, device management, and staged healing milestones. After major stages, most patients stay in hospital for monitoring. Stage 1 phalloplasty often requires about 4–5 days for flap checks and mobility assessments. Other procedures commonly mean shorter stays of a couple of days.
Hospitalization, catheter management, and imaging
Many leave with a suprapubic tube and sometimes a Foley catheter. Around four weeks, teams perform a retrograde urethrogram to confirm urethra integrity before SPT removal. Prompt reporting of changes in urine flow or fever helps catch problems early.
Activity limits, wound care, donor-site healing, and hair
After discharge, activity is limited to protect incisions, the developing scrotum, and the neopenis. Donor sites such as the forearm or thigh may need graft care, dressing changes, and scar support.
Hair removal is planned before the operation using a provided template to reduce hair inside reconstructed tracts. Good wound hygiene and nutrition support tissue healing and overall health.
Pelvic floor therapy and optimizing function
Pelvic floor physical therapy before and after procedures helps address scar tissue, posture, and voiding mechanics. Therapists give individualized home exercises to improve comfort and urinary outcomes.
| Care area | Typical timing | Key actions |
|---|---|---|
| Inpatient monitoring | 4–5 days after stage 1 | Flap checks, vitals, mobility |
| Catheter management | Up to ~4 weeks | SPT/Foley care, retrograde urethrogram |
| Donor-site care | Weeks to months | Dressings, graft checks, scar therapy |
| Therapy and follow-up | Pre-op and post-op weeks | Pelvic floor PT, scheduled clinic visits |
Adherence to follow-up and clear communication with the team reduce complication risk. If wounds look unusual, urine flow changes, or fever develops, patients should contact their surgeon promptly. Careful steps during recovery improve long-term function and satisfaction after surgery.
Risks, complications, satisfaction, and long-term outcomes
Risks range from common surgical problems like infection and bleeding to procedure-specific issues such as urethral fistula or stricture. Pre-op optimization and careful follow-up lower many complications and improve outcomes.
Urethral, graft, and implant issues
Urethral work can cause fistula or stricture. Symptoms include leakage or a weak stream; early evaluation helps timely repair.
Donor sites may scar or experience graft failure. Routine wound checks and dressing care support healing and protect the body.
Erectile and testicular implants after phalloplasty carry infection and rejection risks. Devices may need removal and staged reimplantation after months of healing.
Quality of life, sensation, and reported satisfaction
Sensation varies: nerve repair and clitoral burying can help, but full return is not guaranteed. Some regain strong protective and erogenous feeling over months.
Long-term surveys report high satisfaction and improved quality of life for many patients after gender-affirming procedures. Individual results depend on goals, anatomy, and any complications.
- Follow-up: Keep appointments in the first days and weeks to monitor healing and catch issues early.
- Watch: Urine flow, incision changes, fever, and implant comfort.
- Resources: For further detail on metoidioplasty, see this metoidioplasty overview.
Conclusion
Conclusion
Patients benefit most when early discussions produce a stepwise plan that balances risk, function, and recovery time. A thorough consultation helps clarify goals and builds a staged approach for complex phalloplasty and related work.
Coordinated care — including behavioral health, pelvic floor physical therapy, and diligent follow-up — improves results. Preparing administratively (letters, records) and medically (smoking cessation, hair removal) streamlines the path forward.
Realistic expectations about sensation, urinary function, and recovery help each person stay engaged through staged procedures. High satisfaction and quality-of-life gains are achievable when patients partner closely with their team and report concerns early.
For program details and planning resources, see this surgical planning guide.
