The Real You: FTM Bottom Surgery

Reviewed by Mark P. Solomon, MD, FACS

Not all transgender men choose to undergo genital reconstruction surgery, but those who do meet with several choices based on their needs and goals. These genital reconstruction surgeries are often referred to as “lower” or “bottom” surgeries.

Here the most common of these procedures are described in general terms. Each procedure is tailored to the needs of the individual.

Metoidioplasty

Basics: Capitalizing on the clitoris-enlarging effects of testosterone replacement therapy, your surgeon will move the clitoris to create a micropenis. The surrounding skin of the clitoris is removed and “released” to give the impression of more length. There are variations of metoidioplasty. This surgery takes two to three hours to complete and may be done under conscious sedation (where you are awake, but not necessarily aware). In some cases, general anesthesia is needed if other procedures such as primary urethral lengthening (so you can stand while urinating), hysterectomy (removal of the uterus) or vaginectomy (removal of the vagina) are performed simultaneously.

Pros: The new penis can achieve erection, but is very small. That said, clitoral erectile tissue is intact so you can achieve an erection when aroused without the assistance of an erectile prosthesis. Postoperative clitoral orgasms are possible. This procedure is less expensive, and has fewer potential complications than phalloplasty.

Cons: The new penis is small and not likely capable of penetration.

Considerations: This is typically only a valid choice if the clitoris has grown substantially as a result of testosterone therapy.

Cost: Metoidioplasty cost varies based on whether other procedures — hysterectomy, urethral lengthening, vaginectomy, etc. — are performed simultaneously.

Neophalloplasty

Basics: Essentially just a flap of tissue taken from a donor site such as the arm, abdomen, hip, or torso. These areas are generally large enough to provide enough tissue to construct a penis. (You may need to undergo electrolysis prior to the procedure to remove hair from the graft site.) Using various methods, this tissue is transferred to the pubic area. Microsurgical transfer using magnification and small specialized instruments is often required.

The tissue is then attached to the pubic area. This surgery may involve a urethral lengthening procedure so you can urinate through the newly created penis while standing. Erections are possible with a malleable rod that is implanted permanently or inserted temporarily, or via an implanted pump device. There are many different neophalloplasty techniques.

Pros: Neophalloplasty will create an average-sized penis that is capable of urination and “penetrative” sex.

Cons: Significant recovery time; scarring in the donor area; frequent urethral complications.

Considerations: Phalloplasty will involve multiple surgical visits as well as some revisions.

Cost: Phalloplasty procedures may run as high as $150,000 depending on the nature of the surgeries and what else is done at the same time.

Some transgender men also request a scrotoplasty. This procedure involves the dissection and rotation of the labia majora (vulva), the insertion of two testicular implants followed by the connection of the two to create a single scrotal sac. All surgery has inherent risks including risk of bleeding, infection and cosmetic dissatisfaction with the results.

There is no “perfect” procedure. It is important to weigh the relative benefits and drawbacks of each when making a decision. Choose a surgeon who has experience performing genital reconstruction and a solid reputation within the transgender community.

Learn more about costs, criteria and prerequisites for bottom surgery.

About the Reviewer of This Article

Mark P. Solomon, MD, FACS, is a Philadelphia and New York plastic surgeon who is certified by the American Board of Plastic Surgery. He routinely treats transgender men and women.