Female-to-male bottom surgery typically involves one of two main procedures: phalloplasty, which constructs a full-sized penis from tissue taken from another part of the body, or metoidioplasty, which works with existing genital tissue that has grown from testosterone therapy. Both can include urethral lengthening (so you can urinate standing up), scrotum creation, and removal of internal reproductive organs, but they differ significantly in size, sensation, complexity, and recovery.
Metoidioplasty: Working With Existing Tissue
Metoidioplasty is the simpler of the two options. It relies on the fact that testosterone therapy causes significant clitoral growth over time. After at least a year of hormonal therapy, the surgeon cuts the ligaments anchoring the clitoris to the pubic bone, freeing it and repositioning it to look and function more like a penis. The result is typically 4 to 6 centimeters (up to about 2⅓ inches) long, according to Johns Hopkins Medicine.
Because the procedure preserves the original nerve supply, the resulting penis can become erect naturally without any implant. Most people retain strong erogenous sensation. The urethra can be extended using local tissue or grafts so that urination while standing is possible, and a scrotum can be formed from the skin of the outer labia, with testicular implants placed later. Metoidioplasty is a shorter surgery with a faster recovery, but the smaller size means penetrative sex is generally not possible.
Phalloplasty: Building a Full-Sized Penis
Phalloplasty constructs a penis from a large flap of skin and tissue harvested from a donor site on your own body. The surgeon rolls this tissue into a tube-like structure and grafts it to the groin area. The procedure almost always involves multiple staged surgeries spread over months, with each stage allowing grafted tissue to develop its own blood supply before the next step.
The two most common donor sites are the forearm and the thigh. Each has tradeoffs:
- Forearm flap (radial forearm free flap): The tissue is thin and pliable, which makes it easier to shape into a natural-looking penis and to construct the internal urethra. The downside is a noticeable scar on the forearm, and some people experience hand swelling afterward. Lifting restrictions on that arm last weeks into recovery.
- Thigh flap (anterolateral thigh): This provides a larger piece of tissue and leaves a less visible scar in a location easily covered by clothing. However, thigh tissue can be excessively bulky. If it’s thicker than about 1.5 centimeters, surgeons may not be able to use the standard technique for building the internal urethra.
Both donor sites contain sensory nerves that the surgeon can connect to nerves in the groin and existing genitalia, which is how sensation is restored over time.
How Sensation Is Restored
During phalloplasty, the surgeon performs a nerve hookup: sensory nerves from the donor tissue are carefully joined to nerves in the groin area. For tactile or protective sensation (feeling touch, pressure, temperature), the flap nerve is typically connected to a nerve in the groin. For erogenous sensation, a flap nerve is connected to the nerve that originally supplied the clitoris.
Nerve regrowth is slow, often taking a year or more, but the results are encouraging. In studies of forearm flap phalloplasty, virtually all patients regained tactile sensation within a year, and about 71% reported erogenous sensation. Thigh flap results are somewhat lower, with roughly 75% reporting tactile sensation and 60% reporting erogenous sensation. Across all techniques, the majority of patients (83% to 100%) eventually develop at least protective sensation in the new penis.
Urethral Lengthening
If you want to urinate standing up, the urethra needs to be extended from its original opening all the way through the length of the new penis. This is one of the most technically challenging parts of bottom surgery, regardless of whether you’re having phalloplasty or metoidioplasty. Surgeons typically use tissue from the inner labia, the clitoral hood, or grafted tissue to construct the new urethral passage.
Urethral complications are common. In one study of metoidioplasty patients, about 57% experienced some type of urethral complication. Fistulas (small holes where urine leaks through an unintended opening) occurred in roughly 46% of patients, and urethral strictures (narrowing that makes urination difficult) occurred in about 19%. Many of these issues can be repaired surgically, but they’re a significant part of the recovery landscape that anyone considering these procedures should be prepared for. Some people choose to skip urethral lengthening entirely to avoid this risk.
Scrotoplasty and Testicular Implants
Creating a scrotum is usually done as part of the overall surgical plan, either during the initial procedure or as a later stage. The most common technique uses the skin of the outer labia, which is repositioned and shaped into a scrotal sac. One well-established method involves advancing and rotating the labial skin flaps into position beneath the new penis.
Testicular implants (silicone prosthetics that mimic the feel of testicles) are placed in a later surgery, typically about 12 months after the scrotum is initially created. This waiting period gives the tissue time to heal and develop adequate blood flow before introducing implants.
Erectile Devices
A metoidioplasty penis can become erect on its own because it retains the original erectile tissue. A phalloplasty penis cannot, since it’s built from skin and fat that don’t naturally engorge with blood. To achieve an erection firm enough for penetration, an erectile device is implanted in a later stage of surgery.
The most common option is an inflatable penile prosthesis: a cylinder placed inside the shaft, connected to a small pump. Squeezing the pump fills the cylinder with fluid, creating rigidity. This implant surgery is typically the third and final stage of phalloplasty, performed at least six months after the previous stage to allow full healing.
Recovery and What to Expect
Phalloplasty recovery is substantial. Plan on at least five days in the hospital after surgery, though some stages may require longer stays. After discharge, restrictions include not lifting anything heavier than five pounds with the donor arm (if a forearm flap was used), avoiding bending sharply at the waist, and keeping all surgical sites out of submerged water until cleared by your surgeon. A hand splint stays on for about two weeks if the forearm was the donor site.
Because phalloplasty is staged, the full process from first surgery to final implant placement typically spans a year or more, with recovery periods between each stage. Each stage has its own healing timeline, and complications at any point (particularly urethral issues) can add additional corrective procedures. Most people describe the process as a marathon rather than a single event.
Metoidioplasty recovery is generally shorter and less physically demanding, since the surgery is less extensive and doesn’t involve a distant donor site. Hospital stays are briefer, and the healing period between stages (if urethral work or implants are planned) is typically less complex.
Choosing Between the Two Procedures
The decision between phalloplasty and metoidioplasty comes down to priorities. Metoidioplasty offers natural erections, preserved erogenous sensation, a shorter and less complicated recovery, and no visible donor site scar. The tradeoff is a smaller penis that generally can’t be used for penetrative sex.
Phalloplasty produces a full-sized penis with the potential for penetrative sex (once an erectile device is implanted), but requires multiple surgeries over many months, carries higher complication rates, and leaves a scar at the donor site. Sensation outcomes are good but not guaranteed, and the road to full recovery is long. Neither option is objectively better. Each addresses different goals, and some people choose one procedure initially and pursue additional surgery later.