A Comprehensive Guide to FTM Bottom Surgery

Medically reviewed by Jennifer Richman on April 30, 2024.

What is FTM Bottom Surgery?

Female-to-male (FTM) bottom surgery refers to procedures that alter the external and/or internal reproductive organs. These gender-affirming procedures for trans and non-binary individuals include hysterectomy, metoidioplasty, phalloplasty, and others such as vaginectomy, mons resection, scrotoplasty and more.

The purpose of this page is to give a broad overview of the different bottom surgery procedures that fall under this category: the ones we do and do not offer at the Gender Confirmation Center (GCC), common motives behind undergoing them, candidacy requirements, general recovery guidelines and more.

To clarify, the term “FTM” is generally considered to be antiquated. After all, medical transition does not turn patients into men. Surgeries are affirmative; they are meant to help treat dysphoria and allow patients to feel greater congruence with their body. Likewise, many of our transmasculine bottom surgery patients do not consider themselves to have ever been women. Rather, surgery gives them the chance to experience alignment with their gender.

Not to mention, patients do not need to identify as men or even trans masculine to undergo any of these procedures. Regardless of your identity, if any of the bottom surgery procedures listed below would help you experience greater gender alignment, you can request a free, in-person consultation with Dr. Ley (she/her/they) today.

Types of FTM Bottom Surgery

What is commonly referred to as masculinizing or “FTM” bottom surgery can be categorized into two types. Extirpative procedures involve the removal of reproductive organs (i.e., hysterectomy, oophorectomy, vaginectomy). Reconstructive procedures (i.e., metoidioplasty, phalloplasty) have functional and aesthetic purposes: they can enlarge the penis and/or help with functions like standing to urinate or facilitate penetrative sexual intercourse.

There is no prescribed surgical path that trans and non-binary patients must follow to live as their gender. Rather, patients choose which procedures to undergo based on their unique needs (such as reducing gender dysphoria), embodiment goals and whether or not they qualify for the surgery. Below we discuss common motives for undergoing each procedure.

Removal of Reproductive Organs

Hysterectomy and Oophorectomy

Why do patients undergo these procedures? 

• Individuals who do not wish to undergo a pregnancy or have no desire to have their own genetic children may consider a hysterectomy (removal of the uterus) and/or oophorectomy (removal of one or both ovaries).
• For some individuals, the presence of a uterus and/or ovaries is a cause of gender dysphoria.
• While the surgery can be gender-affirming for transmasculine patients, it is also performed to address other gynecologic conditions such as pelvic pain or concerns about uterine cancer.
• Please note that the GCC does not offer either of these procedures at this time. Patients that are interested in undergoing a vaginectomy with Dr. Ley, we recommend that you undergo a hysterectomy with a board-certified gynecological surgeon at least 8-12 weeks prior.

What do the procedures entail? 

• Hysterectomy is a surgical procedure that involves the removal of the uterus. Sometimes this also includes removing the cervix located at the bottom of the uterus, as well as the fallopian tubes (salpingectomy) which connect the ovaries on either side of the uterus. You can learn more about hysterectomy here.
• Oophorectomy entails the removal of ovaries, which can also be performed during a hysterectomy. Whether an oophorectomy should be performed simultaneously with a hysterectomy is still a matter of debate in the medical community, considering its potential negative effects on bone density. You can learn more about bone health in trans individuals here.

Vaginectomy

Why do patients undergo this procedure? 

• Patients who experience dysphoria from having a vaginal opening or canal may seek to have this organ removed or closed.
• Dr. Ley’s patients who would like to undergo a primary urethral lengthening (PUL) as a part of a metoidioplasty or phalloplasty must undergo a simultaneous vaginectomy. A PUL facilitates a patient’s ability to urinate standing up. This is because preserving the vaginal canal while extending the urethra results in a very high risk of surgical complications.
• Some surgeons perform vaginectomy as a part of a urethral lengthening because the vaginal mucosa or lining can also be used to extend the urethra.

What does the procedure entail?

A vaginectomy cannot be performed in patients with an intact uterus since it would prevent access to the cervix and inhibit cervical cancer screening. Additionally, patients who are still capable of menstruating would end up with an accumulation of blood in their uterus. Depending on the surgeon’s experience, this procedure can be performed transvaginally or abdominally:

• Transvaginal Vaginectomy: A common approach used in patients with a prior hysterectomy or in patients also undergoing phalloplasty. It involves making an incision at the vaginal opening, excising the surrounding vaginal epithelium (canal), and removing it completely, or using a part of it to reconstruct the urethra during a phalloplasty procedure.
• Abdominal Vaginectomy: This approach is used in patients who will simultaneously undergo a hysterectomy, or in cases where more visualization of the upper part of the vaginal canal is needed.

Fertility Preservation

Before the removal of any reproductive organs like the uterus or ovaries, we encourage patients to discuss fertility preserving options with a physician or reproductive/fertility specialist–especially if having genetic/biological children in the future is something you might be interested in. Learn more about reproductive considerations before bottom surgery here and here. Please note that the GCC does not offer fertility preservation services at this time.

• Cryopreservation: This process allows for cells, tissues, or other organs to be preserved by “freezing” or cooling them to very low temperatures. This technique is used to preserve eggs, embryos, or ovaries for long periods, which can later be thawed and used for reproductive purposes in the future.

• Ovarian stimulation: Hormones (i.e., clomiphene, GnRH agonists, etc) are administered to induce the ovaries to increase the number of available eggs for retrieval, which can be cryopreserved for later use or used for assisted reproductive techniques such in-vitro fertilization or IVF.

• It’s important to note that testosterone can disrupt the hormones required for ovarian follicles to develop and mature, thus impacting the retrieval of eggs. Individuals on testosterone should discuss with their doctor how their hormone therapy can affect options for fertility preservation.

Genital Reconstruction Surgeries

Reconstructing the external genitalia to make the existing glands more prominent or create a phallus can be surgically achieved by undergoing metoidioplasty or phalloplasty. The choice to undergo either procedure will depend on patients’ goals toward external appearance of the phallus, sexual sensation, ability to urinate standing up, penetrative capabilities and/or the amount of surgeries they are willing to go through to reach their final result.  Metoidioplasty and phalloplasty can be accompanied by other reconstructive procedures to help individuals achieve their unique goals. If you are interested in creating a unique surgical plan, you can request a free, in-person consultation with Dr. Ley (she/her/they) today.

Metoidioplasty

What does this procedure entail?

Metoidioplasty, also known as “meta”, is a surgical technique used to lengthen existing genital tissue to create a phallus similar to the size of a thumb. Specifically, the erectile tissue is released from surrounding ligaments, giving it a more forward, prominent position.

This procedure can be performed with or without a primary urethral lengthening (PUL). A meta with PUL involves lengthening the urethra so that urine exits the body at the tip of the penis, which makes it easier for patients to stand to pee. Dr. Ley requires her patients that undergo a PUL to undergo a simultaneous vaginectomy to prevent urinary complications.

The images below illustrate step-by-step how a simple metoidioplasty (without PUL) lengthens the existing erectile issue:

Why do patients undergo this procedure?

• Gender euphoria: Patients who would experience gender euphoria from having an enlarged, more prominent phallus or penis are good candidates for a metoidioplasty. Results are usually about the size of a thumb.
• Accentuate bottom growth from testosterone: While Dr. Ley does not hold this as a requirement, many surgeons suggest that patients be on testosterone hormone therapy for at least 1.5-2 years prior to undergoing a metoidioplasty to maximize “bottom growth.” This allows for a more prominent meta result, although technically, it is not necessary. That said, not all trans and non-binary people who take testosterone experience noticeable growth of their erectile tissue.

• Urinate while standing: If the ability to urinate standing up is important to you, a meta can be performed with a PUL. Please note that Dr. Ley’s meta with PUL patients must undergo a simultaneous vaginectomy, meaning your vaginal canal/opening would be removed.

• Erotic sensation: Since the meta does not remove the erectile tissue from its original nerve and blood supply, there is virtually no risk of long-term loss or reduction in erotic sensation to the genitals.

• Penetrative sex: While penetration is often not as easy as it is with a phalloplasty (whose results are generally larger), some meta patients report that their length gives them penetrative capabilities.
• Lighter recovery than phalloplasty: Metoidioplasty is generally considered a less invasive procedure compared to a phalloplasty, with a shorter recovery time.

• BMI candidacy concerns: Many patients who want to undergo phalloplasty do not qualify due to BMI limitations. At the GCC, Dr. Ley requires that patients have a BMI no greater than 30 to undergo a groin flap or RFF phalloplasty to prevent serious complications (ALT phalloplasty patients must have a BMI ≤23). Patients can have a BMI of 35 or below to undergo a meta with PUL or a BMI of 40 or below to undergo a simple meta. For this reason, many patients choose to start their bottom surgery journey by undergoing a metoidioplasty. From there, once their weight puts them in the proper BMI range for a phalloplasty, they can undergo this surgery at a later time.

What other surgeries can accompany a meta?

• For patients who would like to remove fat deposits and/or skin overhang below their abdomen, Dr. Ley can perform a mons resection and/or panniculectomy. These procedures are typically performed in a second surgery after the initial meta and help to give the penis a more forward, visually apparent position on the body. This helps many patients further relieve feelings of gender dysphoria.
• Patients who are interested in having a scrotum with the appearance of testicles can undergo a scrotoplasty with the insertion of testicular expanders and eventually silicone testicular implants. While a scrotoplasty can be performed simultaneously with a meta, the placement of tissue expanders and silicone implants take place in later stages of surgery.
• A urethral lengthening can be performed simultaneously for patients who would like their urethra to end at the tip of their penis. This facilitates urinating while standing, which is a source of gender euphoria and can help many transmasculine people feel safer using the men’s restroom. This procedure is performed alongside a vaginectomy to prevent surgical complications. However, patients can get a vaginectomy regardless of whether or not they want a urethral lengthening.

Phalloplasty

What does this procedure entail?

Compared to a metoidioplasty, phalloplasty or “phallo” is a more extensive surgical procedure that involves using flaps or other tissues from the body to create a penis. Phallo results typically have more girth and length, though recovery is more intense and patients often require multiple stages of surgery to achieve their final results.

There are several phalloplasty techniques to create the phallus. Depending on individual preferences and amount of tissue available in the donor site, the resulting length can be between 4-6 inches. Please note that a free, in-person consultation with Dr. Ley (she/her/they), is required to determine your candidacy for the different phalloplasty procedures.

• Radial Forearm Free Flap (RFF): The forearm’s skin, subcutaneous tissues (i.e., fat, connective tissue) blood vessels, and nerves are used. This is the most common donor site, resulting in a phallus with a more natural appearance and good sensitivity. This procedure leaves a large, visible scar on the forearm that often looks like a burn mark once healed.
• Anterolateral Thigh (ALT) Flap: The skin, subcutaneous tissue, blood vessels, and nerves on the side of thigh are used, but may result in a phallus that is larger in length and/or girth depending on the amount of tissue present. Less patients qualify for the ALT flap phallo because of anatomical candidacy requirements. The resulting scar is often easier to hide because the thighs are typically covered by clothing.

• Groin Flap Phalloplasty: This procedure involves taking skin, subcutaneous tissue, and blood vessels from the groin area to create a phallus over the course of three surgeries. Because the penis is constructed in three instead of one stage, it has a greater chance of survival. Likewise, the scar is easily concealed by clothing since

Why do patients undergo this procedure?

• Gender euphoria: For many patients, having a penis of 4-6 inches in length brings significant amounts of gender euphoria: feelings of satisfaction, alignment and being more at-home in their bodies. Patients who decide to undergo multiple stages of surgery can have a penis complete with glands, a scrotum, testicular implants and/or an erectile device.

• Penetrative sex: The length of a phalloplasty can make it easier to have penetrative sex. With your surgeon’s approval, usually about 3 months after your phalloplasty is constructed, you can start using silicone erectile sleeves if needed. Likewise, usually at about a year after the phalloplasty is constructed, patients can opt to have an erectile device surgically implanted.

• Erotic sensation: Patients that undergo an RFF phalloplasty are most likely to experience heightened, erotic sensation in their penis after surgery since the clitoral nerves are hooked up (or innervated) to the nerve graft taken from the forearm. However, there is not a 100% chance that RFF patients regain sensation. ALT and groin flap patients have a chance of gaining erotic sensation in their penis if they undergo a urethral lengthening that uses a graft from the forearm (wherein the sensitive forearm nerve is grafted into the penis).

• Urinate while standing: A phalloplasty can be performed with a primary urethral lengthening (PUL) so that urine exits the body at the tip of the penis. This facilitates urinating standing up. Dr. Ley requires that patients who undergo a PUL also undergo a simultaneous vaginectomy to prevent surgical complications.

• Noticeable scar: The RFF procedure leaves by far the largest, most difficult to conceal scar. While this is an issue for some, many RFF patients take pride in their scar and do not find it that obtrusive (as it often looks like a burn mark once healed). Patients that are more concerned about visible scar tissue will most often opt for a groin flap procedure.

• Surgical staging and recovery: Patients who undergo a phalloplasty should have the proper social support and financial resources to be able to undergo and recover from multiple surgeries. Undergoing any major surgical procedure is both mentally and physically taxing. However, phalloplasty patients often have to go through multiple stages of surgery to reach their desired result.

What other surgeries can accompany a phalloplasty?

• Urethral lengthening: The urethra is lengthened within the shaft of the penis to allow for urination in a standing position.

• Vaginectomy: The vaginal canal is removed and the walls are closed to keep other pelvic organs in place. A hysterectomy must be performed at least 8-12 weeks prior with a gynecological surgeon.

• Scrotoplasty: The scrotum is created using the labia majora about six months before or after the construction of the penis.

• Testicular implants: After the scrotal sack is created, tissue expanders can be placed about three months later. About 4-5 months later, silicone implants can be placed that have the shape and firmness of testicles.

• Clitoroplasty: The clitoris can be “buried” or positioned under the phallus (but may also be left exposed) to preserve its sexual function.

• Glansplasty: This procedure is performed to create the “head” of the penis.
• Erectile devices: Implantable devices can be used to achieve rigidity in the penile shaft. Inflatable prosthetics use a pump (with the pump strategically placed as one of the testicular implants) to fill the device with saline, maintaining the penile shaft in an erect position. The saline can later be drained to return the prosthetic to a flaccid state. This technique does have a relatively high complication rate. Non-inflatable prosthetics use a bendable silicone rod to move the penis in an erect position but generally maintain its rigidity. The downside of the semi-rigid rod is that patients often do not feel comfortable wearing tight shorts or pants as the penis always appears to be erect.

The phalloplasty recovery process is longer compared to a metoidioplasty. Each additional procedure carries its own risks for complications that may require revisions in the future. Learn more about revisions here.

Preparing for FTM Bottom Surgery

Preparing for FTM bottom surgery is a multifaceted process that requires careful consideration and planning. Here are some key steps:

1. Fertility Preservation: Consult with reproductive/fertility specialists to consider fertility preservation options.
2. Surgical Consultations: For bottom surgery procedures, consultations must be in-person to determine surgical candidacy and make a surgical plan. Dr. Ley (she/her/they) is a former patient and one of the only trans surgeons of color who offers these procedures. You can request a free consultation with her to have any of your questions about bottom surgery answered.
3. Hair Removal Preparation: Patients that would like to undergo an RFF phalloplasty or have a urethral graft taken from the forearm must undergo hair removal to this area prior to surgery. For more information, click here.
4. BMI Requirements: Unlike other surgeries offered at the GCC, there are strict BMI requirements for many bottom surgery procedures due to the high risk of complications and surgical failure, especially in the case of phalloplasty. You can read about Dr. Ley’s BMI candidacy requirements here.
5. Support letter: Bottom surgery patients, especially when seeking out insurance approval, often need to present one or more support letters from a licensed mental health professional. For more information on the requirements for the procedure you are interested in, you can request a consultation and our team can get back to you.
6. Lifestyle Adjustments: Quit smoking and make any necessary lifestyle changes to optimize your overall health and reduce complications during recovery. Please note that before undergoing microsurgery (e.g., nerve innervation for an RFF phallo), patients need to take a nicotine and cotinine exam, as any tobacco use can cause surgical failure.
7. Support System: Regardless of whether or not you will be spending time in the hospital after surgery, bottom surgery recovery is known to be very physically and emotionally taxing. Having a strong support network of family, friends, support groups and/or a mental health professional is crucial. Organizations like Quest House in San Francisco offer bottom surgery patients a safe place to stay while they recover.
8. Leave Planning: Consider your options for medical leave as the recovery process may take longer than expected if complications arise. Prior to your operation, your surgeon’s office will let you know how much time you will need to take off from work and provide you the proper documentation to solicit leave.
9. Financial Planning: Explore insurance coverage and plan for the costs associated with the surgery, potential follow-up procedures or revisions and taking time off from work. Please note that the GCC only offers phalloplasty for patients with insurance coverage at this time due to hospital restrictions.

Recovery and Aftercare

The recovery process after masculinizing or “FTM” bottom surgery can be lengthy and challenging. Adhering to your care team’s post-operative instructions is essential for optimal healing and long-term results. You can find more specific recovery instructions for metoidioplasty here and phalloplasty here. Below are some key aspects of the recovery and aftercare process:

1. Initial Hospital Stay: Some procedures (i.e., simple metoidioplasty) can be performed as an outpatient procedure, meaning you will be released home the same day as your surgery. With most bottom surgery procedures, patients can expect to remain in the hospital for at least 1-2 days after surgery for close monitoring and initial recovery.
2. Medications: Your surgeon will prescribe pain medication to help manage any pain and discomfort that are common in the initial weeks following surgery. Antibiotics may also be prescribed in order to prevent infections.
3. Wound Care: Proper wound care, including application of ointments, dressing changes and hygiene, is crucial to prevent infections and promote healing. You and your support person will receive detailed instructions from your nurse after your surgery.
4. Catheterization: Depending on the procedure performed, a catheter may be in place for days or weeks after to allow for proper urethral healing and function.
5. Activity Restrictions: Strenuous activities, heavy lifting, and sexual activity will be restricted for several weeks or months to allow for adequate healing.
6. Follow-up Appointments: Follow-up appointments with your surgeon are essential to monitor healing progress, address any complications, and discuss potential revisions or additional procedures. Our office will contact you to schedule all necessary post-operative appointments, whether they are in-person or virtual.
7. Psychological Support: Seeking counseling or support groups can help manage the emotional and psychological aspects of the recovery process. Especially as patients navigate pain, discomfort, being bed-bound, activity restrictions and more, it is normal to experience temporary feelings of depression or even regret while you recover. Once patients heal, they express overwhelming amounts of joy and satisfaction.

It’s important to be patient and allow your body the necessary time to heal and adjust to the physical changes of bottom surgery. Adhering to your surgeon’s instructions and seeking support when needed can help ensure a successful recovery and long-term satisfaction with your results.

Frequently Asked Questions (FAQ)

Will I be able to achieve erections and experience sexual pleasure after FTM bottom surgery?

While the ability to achieve erections and experience sexual pleasure can vary from individual to individual, many patients report positive outcomes in terms of sexual function and satisfaction after metoidioplasty or phalloplasty. For metoidioplasty patients, the new phallus can maintain its ability for erections and sexual stimulation as the natal erectile tissue is preserved. For phalloplasty patients, nerve innervation surgery (e.g., in an RFF phallo) connects the penis to the clitoral nerve, giving it the possibility of heightened sensation. Not all phalloplasty types have this result. Some phallo patients report needing to use silicone erectile sleeves or surgically inserted erectile devices to have penetrative sex.

How long is the recovery period after FTM bottom surgery?

The recovery period after masculinizing bottom surgery can be extensive, especially if you undergo multiple stages of surgery. The specific timeline depends on the type of surgery performed (metoidioplasty or phalloplasty), any complications that may arise, and individual healing rates. It is crucial to follow your surgeon’s post-operative instructions and attend all follow-up appointments to ensure a successful and complete recovery.

Will I be able to urinate standing up after FTM bottom surgery?

For both metoidioplasty and phalloplasty patients, the ability to urinate standing up is achieved through primary urethral lengthening (PUL) or reconstruction. By extending the urethra so it ends at the tip of the penis, patients are able to more easily urinate while standing, experience greater gender euphoria and often feel safer using the men’s restroom. To prevent urinary complications, if you request to undergo a PUL with the GCC, you will need to undergo a simultaneous vaginectomy.

What payment plan, financial aid and financing options are there for masculinizing bottom surgery?

Most surgeons’ offices only make payment plans leading up to the procedure. This means that before a patient goes under anesthesia, they must pay their full financial contribution, which represents a significant barrier for many who need bottom surgery. We recommend patients who are in need of assistance reach out to trusted medical creditors like CareCredit or nonprofits that provide grants for gender-affirming surgery. For more information, click here.

What if I have to travel for surgery or have few people to care for me during recovery?

Having a strong support network is essential when recovering from bottom surgery. Patients will likely need help with household chores, preparing meals, bathing themselves and more. Not to mention, regardless of whether or not you have to stay overnight in the hospital, the amount of time patients spend bed-bound, in pain and dealing with inflammation can be very emotionally taxing. For those who are traveling into the San Francisco Bay Area, we recommend that you consult our free travel packet PDF for tips on saving money and finding trans-friendly resources. Likewise, if you are coming into the Bay Area for masculinizing bottom surgery, we highly recommend patients look into Quest House, which provides lodging and support during recovery.