Medically reviewed by Ellie Zara Ley, MD on June 20, 2025.
Phalloplasty is a type of gender-affirming bottom surgery that creates a penis over multiple stages of surgery using the existing genital tissue and tissue from another part of the body: often the forearm, thigh or groin. Some forms of phalloplasty can graft nerves into the phallus to allow for the possibility of heightened, erogenous sensitivity in the new penis. Here we present information about the different phalloplasty options we offer, their results, and why patients opt for them. Some of the topics we cover are phalloplasty scarring, urinating while standing, sensation, orgasms, penis size, penetrative sex (erections) and the possible stages of phalloplasty.
A phalloplasty involves taking a skin flap from the body to create a phallus. At the Gender Confirmation Center (GCC), there are three donor sites we use to construct a phallus for a patient:
There are multiple stages in a phalloplasty surgery. The number of stages depends on the patient’s goals, which will be determined by you and the surgeon during your consultation. Here is a brief summary of the stages we offer:
Patients who choose a groin flap phalloplasty often do so because:
Patients who choose a forearm (RFF) or thigh (ALT) phalloplasty often do so because:
If you have questions about whether your anatomy qualifies you for RFF or ALT phalloplasty, you can request a free, in-person consultation with Dr. Zara Ley here.
The first step to any surgical journey is scheduling a consultation with a board-certified surgeon who specializes in phalloplasty. Dr. Ley (she/her/they) is the only transgender woman of color to offer a full-spectrum specialization in gender-affirming surgery: top surgery, bottom surgery, facial surgery, and body contouring.
For phalloplasty procedures, Dr. Ley requires that patients come in person to her San Francisco office to conduct an examination to verify which type of surgery the patient qualifies for. You can request a free consultation with her here.
Dr. Ley will not perform microsurgery (e.g., nerve reinnervation) on patients who smoke or vape, as tobacco and nicotine use significantly increase surgical risks and impair healing. If you are a current smoker, you may be required to obtain medical clearance from another healthcare provider confirming that you have been smoke-free for a designated period before surgery can be scheduled. Other positive lifestyle habits, like eating a balanced, healthy diet and exercising regularly, can help prevent surgical complications.
Patients who would like to undergo an RFF or ALT phalloplasty or have a urethral graft taken from the forearm or thigh must undergo electrolysis hair removal to this area prior to surgery.
Please note that permanent hair removal is only required for the section of the forearm or thigh (highlighted in orange on the illustrations) that will be used as a graft for the urethra. Complete and permanent hair removal (electrolysis) is required because hair growth inside of the urethra can cause a variety of complications. Patients may undergo hair removal of the other areas of their forearms if they wish to prevent hair growth on the phallus portion. For more information, click here.
The visibility of phalloplasty scars depends on the procedure type. Patients who get a groin flap phalloplasty will have the most concealable scars.
Patients who get a forearm (RFF) or thigh (ALT) phalloplasty will have a large rectangular swath of scar tissue visible on either their forearm or thigh. This swath of scar tissue will be depressed and discolored compared to the surrounding skin, making it look similar to a burn. It can be concealed with shorts or a long-sleeved shirt. The area can be repigmented by an experienced medical tattoo artist a year after it has healed (at least 12 months post-op).
During the initial construction of the phalloplasty, a urethra can be built inside of the penis to allow for a patient to eventually urinate while standing up. However, to let the phalloplasty heal, the natal urethra and the urethra in the penis are not connected until 6-9 months after the initial procedure. This means a patient will not be able to urinate out of the tip of their penis until 6-9 months later. Catheters will be used during the recovery process of each of these procedures.
The size and girth of a patient’s phalloplasty results from the unique plan you make with your surgeon during a free in-person consultation. An in-person consultation is required to determine candidacy for a phalloplasty operation. Generally speaking, the size of the patient’s body (specifically the skin flap donor site) can limit the size of the phallus.
Nerve regeneration can start as early as three weeks after surgery, but it is different for every patient. As nerves regenerate, patients may experience tingling sensations in the site until they heal after a few months. Some patients experience no nerve regeneration at all.
Whether sensation is tactile or erogenous (heightened), it will generally be felt equally along the entire penis. The radial forearm flap (RFF) and anterolateral thigh flap (ALT) phalloplasty can give patients a heightened, erogenous sensation in their penis since the nerves used in the donor site (the forearm or the outer thigh) allow for more sensation.
The groin flap phalloplasty allows for tactile sensation as opposed to erogenous sensation. That said, if a patient opts for a urethral lengthening using a smaller skin graft from the forearm, erogenous sensation can be established through nerve innervation microsurgery.
If your phalloplasty involves preserving erogenous sensation, orgasms are possible through stimulating the penis. Patients should wait 3-4 months (or until incisions are fully healed with approval from your surgeon) before masturbating or engaging in other kinds of sexual activity with the new penis. With a completed urethral lengthening, some patients report being able to ejaculate clear fluid when they orgasm.
3-4 months after an RFF or ALT phalloplasty is constructed (or when incisions have fully healed), a patient can begin engaging in sexual activity with their new penis, alone or with partners. For a groin flap phalloplasty, this is about 6+ months after the first surgery.
To have penetrative sex with a phalloplasty, a patient can use the assistance of a silicone erectile sleeve and/or a penis pump after they have fully healed and have received clearance from their surgeon. 12 months after the phalloplasty is constructed, a patient can have an erectile device inserted: a malleable rod or a saline pump system. You can read more about these options here.
The following medical illustrations represent the construction of the new penis in an RFF phalloplasty:
Metoidioplasty is a much simpler procedure than a phalloplasty. It requires fewer surgeries, has faster recovery times, and minimal scarring.
Due to different BMI requirements, some patients who are interested in getting a phalloplasty first undergo a metoidioplasty while they lose weight.
To read more about how patients make the decision between these two bottom surgery procedures, click here.
For more detailed instructions about phalloplasty recovery, click here.
All virtual and in-person consultations with our board-certified surgeons are free. Once you fill out this form, our patient care team will reach out and guide you through every step to get to surgery.