Female-to-male gender-affirming surgery isn’t a single operation. It’s a collection of procedures that most people pursue in stages, sometimes over several years. The surgeries fall into a few main categories: chest reconstruction (top surgery), genital reconstruction (bottom surgery), and internal procedures like hysterectomy. Each one produces different visible results, leaves different scars, and involves a different recovery process. Here’s what each procedure actually involves and what the results look like.
Chest Reconstruction (Top Surgery)
Top surgery is the most common gender-affirming procedure for transmasculine people, and it’s often the first surgical step. The goal is to remove breast tissue and reshape the chest to look typically masculine. The technique a surgeon uses depends mostly on how much tissue needs to be removed.
For people with small chests and elastic skin, a keyhole incision works well. The surgeon makes a small cut along the lower edge of the areola, removes tissue through that opening, and lets the skin retract on its own. Scarring is minimal, often just a thin line around part of the nipple.
A periareolar (circumareolar) incision suits people with moderate chest tissue. The surgeon cuts around the full circumference of the areola, removes tissue, and can slightly reduce the areola size. This leaves a circular scar around the nipple that fades over time.
The double incision is the most common technique overall, typically used for larger chests or chests with significant skin laxity. The surgeon makes two horizontal incisions across the lower chest, removes tissue and excess skin, then repositions the nipples as free grafts. The nipples are placed slightly more lateral than their original position to match a masculine chest contour, though exact placement can be adjusted based on preference. This technique leaves two horizontal scars across the chest, roughly following the lower border of the pectoral muscles. Those scars are the most visible of any top surgery method, though they flatten and lighten significantly over the first year. True scar maturation takes about 12 months, even if they appear healed much sooner.
After any top surgery technique, most people wear a compression garment for four to five weeks to manage swelling. The final chest shape continues to settle for several months.
Metoidioplasty: The Smaller Bottom Surgery
Metoidioplasty is one of two main options for genital reconstruction. It works with what testosterone has already done. After roughly a year of hormone therapy, the clitoris typically grows significantly. During metoidioplasty, a surgeon cuts the ligaments anchoring that tissue to the pubic bone, which frees it and allows it to extend outward. The result is a small phallus, usually one to three inches, that has natural erotic sensation because no nerves are cut or rerouted.
Several optional additions can be performed at the same time or in stages. Urethral lengthening connects and extends the urethra through the new phallus using local tissue or grafts from elsewhere in the body, which allows standing urination. Scrotoplasty reshapes the outer labial skin into a scrotum, and testicular implants can be inserted later to create a more typical appearance.
The visual result of metoidioplasty is a smaller phallus that looks natural in proportion but won’t have the size of a typical adult penis. The trade-off is a shorter surgery, fewer complications, and fully preserved sensation. Many people choose this route specifically because they prioritize sensation and a simpler recovery over size.
Phalloplasty: The Larger Reconstruction
Phalloplasty constructs a full-sized penis using tissue transplanted from another part of the body. It’s the more complex bottom surgery option, often requiring three to four staged operations spread over a year or more.
The most common technique uses tissue from the inner forearm, known as a radial forearm flap. This method, first developed in 1984, remains the standard because forearm skin is thin, pliable, and well-supplied with nerves and blood vessels. The surgeon shapes the tissue into a “tube within a tube,” creating both the shaft and an internal channel for the urethra in a single stage. The forearm donor site is then covered with a skin graft, usually taken from the thigh, leaving a visible rectangular scar on the inner forearm.
Other donor sites include the thigh and the back (below the shoulder blade). Thigh tissue is easier to conceal under clothing but tends to be thicker, which can affect the final shape. Back tissue provides a good skin match but involves more complex microsurgery.
Nerve Hookup and Sensation
During phalloplasty, surgeons connect nerves from the donor tissue to nerves in the pelvis. This process, called nerve coaptation, allows two types of sensation to develop over time: protective (tactile) sensation, which lets you feel touch, pressure, and temperature, and erotic sensation, which develops more gradually as nerves regenerate. Full nerve regrowth can take one to two years, and the degree of sensation varies from person to person.
Erectile Devices
Because a constructed phallus doesn’t become erect on its own, a penile implant is placed in a later-stage surgery, typically the final procedure in the sequence. There are two main types.
- Semi-rigid rods keep the phallus firm at all times. You bend it upward for sexual activity and downward for daily life. These have fewer mechanical parts and a low malfunction rate, but they can be harder to conceal under clothing and put constant pressure on internal tissue.
- Inflatable implants are the more common choice. A three-piece system includes cylinders inside the phallus, a small pump in the scrotum, and a fluid reservoir under the abdominal wall. Squeezing the pump moves saline into the cylinders to create an erection; a release valve drains the fluid back. This produces the most natural cycle of firmness and softness, though the more parts involved, the higher the chance of eventual mechanical failure.
Complication Rates for Bottom Surgery
Phalloplasty with urethral lengthening carries the highest complication risk of any gender-affirming procedure, and it’s important to understand what that looks like in practice. The urethra is being constructed from scratch through grafted tissue, and that new channel is prone to two main problems: strictures (narrowing that blocks urine flow) and fistulas (small holes where urine leaks through the skin).
Published rates for urethral stricture have historically ranged from 40% to over 80%, which sounds alarming. In practice, surgical centers with high volume and newer techniques report much lower numbers. One study documented a 14% stricture rate and a 22% fistula rate, with nearly half of the fistulas healing on their own without additional surgery. Newer post-operative wound care protocols have driven those numbers down further at some centers. Revision surgeries to address these complications are common and considered a normal part of the phalloplasty process rather than a failure.
Metoidioplasty has significantly lower complication rates, largely because the anatomy being modified is smaller and the urethral lengthening (if chosen) is shorter.
Hysterectomy
Some transmasculine people choose to have the uterus and sometimes the ovaries removed. This is typically done laparoscopically, through a few small incisions in the abdomen, each less than a centimeter. Most people go home within one to two days. The external scarring is minimal, just a few small dots that fade quickly. Robotic-assisted versions of the same procedure exist but haven’t shown meaningful advantages over standard laparoscopic surgery in terms of outcomes.
Hysterectomy is sometimes performed as a standalone procedure and sometimes as a prerequisite for certain bottom surgery techniques that require access to internal tissue for urethral construction.
Requirements Before Surgery
Under the current WPATH Standards of Care (version 8), candidates for gender-affirming surgery need a documented diagnosis of gender incongruence and an assessment of any mental or physical health conditions that could affect surgical outcomes. For procedures that involve hormonally changed tissue, like bottom surgery, at least six months of stable hormone therapy is typically expected, though some surgeries (like top surgery) may proceed on a different timeline. The specifics vary by surgeon, insurance provider, and country.
What the Full Timeline Looks Like
If someone pursues multiple procedures, the process stretches over years rather than months. A common sequence might look like this: top surgery first, since it requires the least recovery time and has the biggest impact on daily comfort for many people, followed by hysterectomy if desired, then bottom surgery in its staged sequence. Each phalloplasty stage requires its own recovery period of several weeks to months before the next can be scheduled.
Scar appearance evolves throughout this entire timeline. Fresh surgical scars are raised, red or purple, and firm. Over 12 months they flatten, soften, and fade to a color closer to the surrounding skin. Silicone scar sheets, sun protection, and massage can improve the final result, but genetics play the largest role in how scars ultimately look. The forearm donor site from phalloplasty tends to be the most visually noticeable long-term scar, which is one reason some people opt for a thigh donor site instead.