For many individuals who identify as transgender men, female-to-male (FTM) surgery can be a pivotal step in aligning their physical characteristics with their gender identity. FTM surgery—often referred to as masculinizing surgery or gender-confirmation surgery—is not a single procedure but rather a group of potential surgical interventions aimed at creating masculine characteristics. These interventions can include FTM top surgery, facial masculinization, chest masculinization surgery, body contouring, and various forms of FTM bottom surgery such as phalloplasty or metoidioplasty.
As transgender medicine continues to evolve, healthcare professionals have become increasingly skilled in offering surgical plans that cater to the unique needs of each patient. Whether exploring options like the radial forearm free flap, the anterolateral thigh flap, or the musculocutaneous latissimus dorsi flap, FTM bottom surgery can often include urethroplasty, scrotoplasty, and even the placement of an erectile device or erectile implants for improved sexual function. Ultimately, the goal of FTM surgeries is to help transgender men live more comfortably in their bodies and experience an enhanced sense of well-being.
This comprehensive blog post will delve into the following topics:
- Overview of FTM Surgery
- Phalloplasty Specifics
- Post-Surgery Expectations
- Preparation for Surgery
- Risks and Considerations
- Types of FTM Surgery
- Care Planning Across the Journey
Throughout this guide, we will also discuss critical considerations such as fertility and reproductive hormone preservation, the ability to have an orgasm, and factors affecting sensation recovery. We’ll cover necessary steps before surgery, like hair removal, health evaluation, and informed consent, as well as aftercare processes like follow-up medical care, care planning, and long-term care.
Please note that this article is intended for educational purposes and should not replace professional medical advice. Always consult with qualified health professionals for personalized recommendations and information.
1. Overview of FTM Surgery
What Is FTM Surgery?
FTM surgery, also known as transgender surgery or bottom surgery (when referring to genital reconstruction), encompasses a range of procedures aimed at transforming the feminine anatomy into one that appears more masculine. This can involve procedures on the chest—often called top surgery—and genital reconstruction surgeries like phalloplasty, metoidioplasty, or a combination of steps to achieve the most affirming outcome for each patient’s goals.
For many, FTM surgery represents a critical stage in the medical transition. It can have profound psychological benefits, enabling transmasculine individuals to feel more at ease with their bodies. However, transitioning surgically is an intensely personal decision influenced by factors such as individual health, readiness, social environment, financial resources, and, importantly, gender identity.
Why People Pursue FTM Surgery
Many transgender men experience gender dysphoria—a discomfort or distress caused by a mismatch between one’s assigned sex at birth and one’s experienced gender. Surgical interventions such as chest masculinization surgery or total hysterectomy can greatly alleviate these feelings by creating a body that aligns more closely with a masculine self-perception. For some, FTM surgery also helps reduce the reliance on external prosthetics or binders, providing a sense of authenticity and improved quality of life.
The Role of Healthcare Professionals
Qualified healthcare teams—which can include plastic surgeons, urologists, gynecologists, mental health professionals, and primary care physicians—play a vital role in ensuring successful outcomes. From the initial consultations and gathering of a surgery referral letter to postoperative follow-up care, these teams guide patients through every phase of the process. They also help patients navigate issues like fertility, birth control, and the possibility of fertility and reproductive hormone preservation if desired.
Understanding Gender-Confirmation Through Surgery
It’s important to understand that not all trans individuals opt for surgery, and not all patients choose to undergo every available procedure. Alternatives to surgery might include hormonal therapy alone or partial surgical interventions. Ultimately, the journey is deeply personal, and each individual’s customized plan should be made in consultation with their healthcare team, factoring in informed consent, overall health considerations, and personal goals.
2. Phalloplasty Specifics
What Is Phalloplasty?
Phalloplasty is a type of FTM bottom surgery aimed at constructing a penis that can offer both aesthetic and functional benefits. The procedure typically involves creating a phallus using donor tissue from a skin flap site such as the forearm, thigh, or latissimus dorsi region. Common donor site techniques include:
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Radial Forearm Free Flap: This is arguably the most well-known approach, also referred to simply as the radial forearm flap. It offers a good balance of tissue quality, potential for full sensation, and ease of shaping.
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Anterolateral Thigh Flap: Also known as the anterolateral thigh flap, which uses tissue from the thigh. This flap can provide adequate bulk but may require more extensive nerve work to achieve sensation.
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Musculocutaneous Latissimus Dorsi Flap: This method taps into the latissimus dorsi muscle in the back to create the phallus.
Stages of Phalloplasty
Phalloplasty is usually done in multiple stages. The first stage involves creating the phallus and, in some cases, performing vaginectomy and urethroplasty to lengthen the urinary tract through the new phallus so that the patient can urinate while standing. Later stages can include:
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Glansplasty: To sculpt a glans-like shape at the tip of the constructed phallus.
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Scrotoplasty: Forming a scrotum using labial tissue, often enhanced by a v-y scrotoplasty technique.
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Testicular Implants: Inserting silicone or saline implants to emulate testicles.
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Erectile Device or Erectile Implants: To enable penetrative sexual function if desired. This might be a pump-based device or malleable rods.
Urethroplasty and Its Importance
One of the most critical elements of phalloplasty is the urethroplasty, during which a channel is created or extended through the new penis. This allows the patient to urinate through the tip of the phallus, closely mimicking cis-male genital function. Although urethroplasty can be complex and may carry risks like infection, urethral strictures, or bleeding, many consider it an essential part of achieving full masculinization and ease in daily activities (e.g., using the urinal in a men’s restroom).
Sensation and Nerve Regeneration
Achieving or preserving sensation in the reconstructed penis often involves the meticulous reconnection of nerves from the donor site to nerves in the pelvic region. Over time, nerve regeneration may result in varying degrees of tactile and erogenous sensation. While results differ among individuals, many patients eventually achieve the ability to have an orgasm depending on factors such as nerve grafting, healing responses, and the presence of sufficient erogenous tissue that remains connected to the body’s existing nerve pathways.
3. Post-Surgery Expectations
Immediate Postoperative Recovery
Following any FTM surgery—be it phalloplasty, scrotoplasty, or top surgery—patients can expect a hospital stay that varies from a couple of days to over a week, depending on the complexity of the procedure. During this period, the healthcare team will monitor surgical sites for infection, excessive bleeding, and reactions to anesthetic. Adequate pain management, typically through medications, will be crucial for comfort and promoting the healing process.
Recovery Period and Follow-Up Care
The recovery period for major procedures like phalloplasty can span several months, involving regular check-ins with the surgical team. Follow-up care often requires local wound cleaning, wearing compression garments if recommended, and keeping surgical sites protected to avoid dehiscence or infection. This stage is also when patients begin to see the initial shape of the new phallus and track their sensation recovery.
Patients may undergo follow-up surgeries to refine the genitalia, place or adjust testicle implants, or enhance the aesthetic outcome. Some individuals also opt for medical tattooing to add natural coloration to the phallus or to create a more defined outline of the glans. In addition to the surgical follow-ups, some health professionals recommend pelvic physical therapy or pelvic floor rehabilitation to help with urinary function and overall healing.
Long-Term Care and Sensation
In the months and years after surgery, ongoing long-term care typically involves annual check-ups or more frequent evaluations if complications arise. Because nerve regeneration can continue for up to two years or more, improvements in sexual sensations may occur gradually. Postoperative emotional health is equally important: many transgender men benefit from continued mental health support to help navigate body image changes, relationship dynamics, and sexual function concerns.
Ability to Have an Orgasm
One of the most frequently asked questions in transgender surgery FAQs pertains to orgasmic ability. While many individuals can retain the ability to have an orgasm—often through the tissue of the original clitoris that has been repositioned or integrated into the new phallus—others may notice changes in how they experience sexual pleasure. Open communication with a healthcare team and, when needed, a sex therapist, can assist patients in adapting to changes in sexual response and function.
4. Preparation for Surgery
Consultations and Mental Health Evaluations
Before any major surgical step, patients typically have multiple consultations with surgeons, mental health professionals, and other relevant specialists. These consultations ensure that all parties understand the individual’s expectations, possible outcomes, and any psychological or medical factors that may influence surgery. A health evaluation could include blood tests, chest X-rays, and electrocardiograms to confirm a patient’s fitness for surgery.
In some regions, patients may be required to obtain a surgery referral letter from a mental health provider confirming the patient’s readiness and alignment of this surgical step with their gender identity. This letter is often part of the informed consent process, ensuring the patient comprehends the benefits, risks, and possible complications.
Customized Surgical Plan
No two patients are identical, and a customized plan is integral to maximizing satisfaction and minimizing complications. Key considerations include:
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Donor Site Selection: Choosing between the radial forearm flap, anterolateral thigh flap, or latissimus dorsi flap for phalloplasty.
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Urethral Lengthening: Whether or not the patient desires or is a good candidate for urethroplasty.
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Testicular Implants: Deciding if and when to have testicle implants inserted during or after the initial procedure.
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Erectile Implants: Considering the best time to add an erectile device—immediately or in a later surgery.
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Medical Tattooing: Planning for any aesthetic enhancements that might follow initial healing.
It’s crucial to detail each part of the surgical plan to align with the patient’s goals, physical health, and overall transition timeline. Additionally, patients might opt for simultaneous procedures—like a total hysterectomy, salpingo-oophorectomy, or subcutaneous mastectomy—if it is medically appropriate and logistically feasible.
Lifestyle Adjustments Prior to Surgery
Patients are often advised to adopt certain lifestyle modifications prior to major surgery. For instance, doctors frequently recommend nicotine cessation—smoking, vaping, or using other nicotine products can hinder wound healing and compromise blood flow, especially important when dealing with delicate microsurgery for tissue flaps. Maintaining a healthy diet and exercise routine can also boost the body’s healing capacity and reduce surgical risks.
Additionally, hair removal at the donor site (e.g., the forearm or thigh) might be recommended for surgeries like phalloplasty, to minimize the presence of hair on the phallus. Methods can include laser hair removal or electrolysis, often taking several months to complete.
Birth Control and Fertility Considerations
Some transgender men may want to preserve fertility before undergoing procedures like total hysterectomy or salpingo-oophorectomy. Fertility and reproductive hormone preservation strategies—such as egg freezing—could be explored well in advance. Moreover, patients who are sexually active and capable of getting pregnant may discuss birth control options or the timing of potential pregnancies with a healthcare provider.
5. Risks and Considerations
General Surgical Risks
Like any major surgery, FTM procedures come with inherent risks, including:
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Infection
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Bleeding
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Reaction to Anesthetic
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Poor Wound Healing
Working with a trusted health professional and strictly following aftercare instructions can minimize these risks. Another general risk includes erectile dysfunction device complications if implants are placed. These can sometimes malfunction or cause infection, requiring removal or revision.
Complications Specific to Bottom Surgery
FTM bottom surgery introduces additional complexities, particularly with urethral construction. Potential complications include urethral fistulas (abnormal connections) or strictures (narrowing of the urethra) that may necessitate corrective surgeries. Similarly, achieving full sensation in the new penis is never guaranteed, and nerve regeneration can be unpredictable.
In procedures involving scrotum creation, v-y scrotoplasty, or the placement of testicular implants, there is a possibility of implant migration, scarring, or dissatisfaction with the final aesthetic outcome. Each step requires careful planning, surgical precision, and realistic expectations from both surgeon and patient.
Sexual Function and Psychological Adjustments
While many individuals experience improved quality of life after FTM surgery, there can be a learning curve regarding sexual function. Tools like lubricants, therapy sessions, and in some cases pelvic physical therapy, can be invaluable. It’s vital to remember that sexual sensations may differ postoperatively, necessitating time, patience, and exploration.
Psychologically, the transformation can be deeply affirming but might also bring emotional challenges. Body image, acceptance by partners, and integration into social environments are important factors. Continued mental health support can aid significantly in navigating these post-transition aspects.
Breast Cancer Screening and Other Health Maintenance
Even after chest masculinization surgery, breast cancer screening remains a consideration. If breast tissue was present before surgery or if the patient still retains some mammary tissue, screening protocols might need to be discussed with a health professional. Additionally, if the patient retains ovaries and a uterus, gynecological check-ups—although psychologically challenging for some—remain an important aspect of overall health.
6. Types of FTM Surgery
6.1 Top Surgery (Chest Masculinization Surgery)
Top surgery—often a first surgical step for many transgender men—removes or reshapes breast tissue to create a masculine chest contour. Techniques vary, including:
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Double Incision (Subcutaneous Mastectomy): Common for those with larger chests or reduced skin elasticity.
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Peri-Areolar (Keyhole) Technique: Suitable for smaller chests with more elastic skin.
Additional procedures can include repositioning the nipple-areola complex to create a more masculine appearance. While chest masculinization surgery is considered relatively straightforward compared to bottom surgery, it still requires comprehensive care and follow-up to ensure proper healing.
6.2 Bottom Surgery
Phalloplasty and metoidioplasty are two main forms of FTM bottom surgery:
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Phalloplasty: As discussed, it involves constructing a phallus from donor tissue. Common variants include the radial forearm free flap, anterolateral thigh flap, and latissimus dorsi flap.
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Metoidioplasty: This technique uses the clitoris (enlarged through testosterone therapy) to create a smaller phallus. While less invasive and typically preserving the ability to orgasm, metoidioplasty results in a smaller penis that may not allow for penetrative intercourse without an external prosthesis.
Some individuals may also undergo:
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Vaginectomy: Removal or closure of the vaginal canal.
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Urethral Lengthening: To allow for standing urination.
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Scrotoplasty: Formation of the scrotum, often followed by testicle implants.
6.3 Hysterectomy and Salpingo-Oophorectomy
A total hysterectomy involves removing the uterus, and a salpingo-oophorectomy involves removing the ovaries and fallopian tubes. These procedures may be pursued for various reasons, including reducing the need for ongoing gynecological care or eliminating hormone fluctuations. Depending on a patient’s fertility goals, these surgeries might be performed concurrently with other procedures or delayed until a later stage.
6.4 Facial Masculinization and Body Contouring
Though not always categorized under FTM surgery, facial masculinization and body contouring can be crucial for gender affirmation. Facial procedures can include jaw reshaping, chin implants, or brow bone modification. Body contouring may involve liposuction in areas like the hips to reduce curves or the addition of fat grafts to create a more masculine silhouette.
7. Care Planning Across the Journey
The Importance of a Healthcare Team
An integrated healthcare team is vital for overseeing the multiple facets of medical transition. This team may involve endocrinologists for hormonal therapy, primary care physicians for routine checks and breast cancer screening, mental health therapists for emotional support, and specialized surgeons for each procedure. Care planning ensures that you have continuity in your journey, from the moment you consider surgery to the final follow-up medical care.
Follow-Up Surgeries and Revisions
Many FTM surgeries, especially phalloplasty, are multi-stage. It’s common to undergo follow-up surgeries to refine the appearance of the phallus, address complications such as urethral strictures, or insert erectile implants. Anticipating the possibility of revision surgeries can help manage expectations and reduce frustration if complications or aesthetic concerns arise.
Long-Term Recovery and Nicotine Cessation
Healing is an ongoing process that extends well beyond the immediate postoperative window. Long-term recovery includes paying close attention to any changes in the body, addressing minor complications proactively, and engaging in healthy lifestyle practices. For patients who smoke, nicotine cessation remains important because nicotine can hinder surgical success and tissue health. Minimizing alcohol and other substances that affect healing is also beneficial.
Emotional and Mental Health Support
Surgery can be life-changing—potentially bringing a sense of relief and alignment with one’s gender identity, but also presenting emotional challenges. Emotional fluctuations can arise from changes in body image, social relationships, and sexual dynamics. Mental health professionals specializing in transgender care can offer invaluable support in processing these emotions and helping navigate any unexpected feelings postoperatively.
FTM surgery represents a profoundly personal journey tied to identity, self-perception, and overall well-being. From consultations and informed consent to the completion of multiple-stage surgeries, each step requires careful planning, realistic expectations, and close collaboration with a trusted healthcare team. Procedures such as phalloplasty, scrotoplasty, and urethroplasty offer transformative outcomes that can alleviate gender dysphoria, enhance sexual function, and allow many transgender men to live more confidently in their bodies.
At the same time, it’s essential to recognize the complexity of these surgical paths. Factors like donor site selection (radial forearm free flap, anterolateral thigh flap, or latissimus dorsi flap), potential complications (e.g., infection, bleeding, or reaction to anesthetic), and postoperative healing for sensation recovery underscore the importance of thorough preparation. This includes mental and emotional readiness, physical health considerations such as nicotine cessation, and, if desired, fertility and reproductive hormone preservation.
Choosing whether and how to undergo masculinizing surgery is a matter of personal preference and practicality. Alternatives to surgery, such as hormone therapy alone or partial surgical steps, might be more aligned with certain individuals’ goals. Ultimately, the objective is to develop a customized plan that aligns with one’s physical and psychological aspirations, supported by experienced professionals in transgender medicine.
Should you decide to embark on the path of FTM surgery, you’ll find a comprehensive network of specialists and resources to guide you—from the initial surgery referral letter to the final “all-clear” at your last follow-up medical care appointment. Through thorough research, open communication with medical experts, and self-care, FTM surgery can be a fulfilling, affirming milestone in your transition journey.
