The Definitive Guide to FTM Bottom Surgery

Medically reviewed by Jennifer Richman on July 2, 2025.

What is FTM Bottom Surgery?

Female-to-male (FTM) bottom surgery refers to procedures that alter the external and internal reproductive organs. “Masculinizing” bottom surgery procedures for trans and non-binary individuals include metoidioplasty, phalloplasty, and others such as vaginectomy, mons resection, scrotoplasty, hysterectomy, and more.

While the term “FTM” is generally considered to be outdated, we use it out of recognition that trans men and transmasculine non-binary folks search for this term for information on surgical transition.
Regardless of your identity, if you are interested in any of the bottom surgery procedures listed below, you can request a free, in-person consultation with Dr. Ley (she/her/they) today.

Frequently Asked Questions (FAQ)

Will I be able to achieve erections and experience sexual pleasure after FTM bottom surgery?

While the ability to achieve erections and experience sexual pleasure can vary from individual to individual, many patients report positive outcomes in terms of sexual function and satisfaction after metoidioplasty or phalloplasty. For metoidioplasty patients, the new phallus can maintain its ability for erections and sexual stimulation as the natal erectile tissue is preserved.
For phalloplasty patients, nerve innervation surgery (e.g., in an RFF phalloplasty) connects the penis to the clitoral nerve, giving it the possibility of heightened sensation. Phalloplasty patients can use silicone erectile sleeves or have an erectile device surgically implanted into their phallus to facilitate penetrative sex.

How long is the recovery period after FTM bottom surgery?

The recovery period after masculinizing bottom surgery can be extensive, especially if you undergo multiple stages of surgery. The specific timeline depends on the type of surgery performed (metoidioplasty or phalloplasty).

Will I be able to urinate standing up after FTM bottom surgery?

For both metoidioplasty and phalloplasty patients, the ability to urinate standing up is achieved through primary urethral lengthening (PUL) or reconstruction. By extending the urethra so it ends at the tip of the penis, patients are able to more easily urinate while standing, experience greater gender euphoria, and often feel safer using the men’s restroom. To prevent urinary complications, if you request to undergo a PUL with the GCC, you will need to undergo a simultaneous vaginectomy or removal of the vaginal canal.

What if I have to travel for surgery or have few people to care for me during recovery?

Having a strong support network is essential when recovering from bottom surgery. Patients will likely need help with household chores, preparing meals, bathing themselves and more. The amount of time patients spend bed-bound, in pain and dealing with inflammation can be very emotionally taxing.

For those who are traveling into the San Francisco Bay Area, we recommend that you consult our free travel guide for tips on saving money and finding trans-friendly resources, like the Quest House recovery center for transmasculine bottom surgery patients.

Types of FTM Bottom Surgery

What is commonly referred to as masculinizing or “FTM” bottom surgery can be categorized into two types. Extirpative procedures involve the removal of reproductive organs (i.e., hysterectomy, oophorectomy, vaginectomy). Reconstructive procedures (i.e., metoidioplasty, phalloplasty) have functional and aesthetic purposes: they can enlarge the penis and/or help with functions like standing to urinate or facilitate penetrative sex.

There is no prescribed surgical path that trans and non-binary patients must follow to live as their gender. Rather, patients choose which procedures to undergo based on their unique needs (such as reducing gender dysphoria), embodiment goals, and whether or not they meet the candidacy requirements.

Removal of Reproductive Organs

Hysterectomy and Oophorectomy

Please note that the GCC does not offer either of these procedures at this time. You can find a gender-competent gynecological surgeon for these procedures here. For patients who are interested in undergoing a vaginectomy with Dr. Ley, we recommend that you undergo a hysterectomy with a board-certified gynecological surgeon at least 8-12 weeks prior.

What are these procedures?

• Hysterectomy is a surgical procedure that involves the removal of the uterus. Sometimes this also includes removing the cervix located at the bottom of the uterus, as well as the fallopian tubes (salpingectomy), which connect the ovaries on either side of the uterus.
• Oophorectomy entails the removal of ovaries, which can also be performed during a hysterectomy. Whether an oophorectomy should be performed simultaneously with a hysterectomy is still a matter of debate in the medical community, considering its potential negative effects on bone density. You can learn more about bone health in trans individuals here.

Why do patients undergo these procedures?  

• Reproductive considerations: Individuals who do not wish to undergo a pregnancy or have no desire to have their own genetic children may consider a hysterectomy (removal of the uterus) and/or oophorectomy (removal of one or both ovaries).
• Gender dysphoria: For some individuals, the presence of a uterus and/or ovaries is a cause of gender dysphoria.
• Gynecological concerns: While the surgery can be gender-affirming for transmasculine patients, it is also performed to address other gynecologic conditions such as pelvic pain or concerns about uterine cancer.

Vaginectomy

What is this procedure? 

A vaginectomy is the removal of the vaginal canal. A vaginectomy cannot be performed in patients with an intact uterus since it would prevent access to the cervix and inhibit cervical cancer screening. Additionally, patients who are still capable of menstruating would end up with an accumulation of blood in their uterus.

Why do patients undergo this procedure?

• Gender dysphoria: Patients who experience dysphoria from having a vaginal opening or canal may seek to have this organ removed or closed.
• Urinate standing up: Dr. Ley’s patients who would like to undergo a primary urethral lengthening (PUL) as a part of a metoidioplasty or phalloplasty must undergo a simultaneous vaginectomy. A PUL facilitates a patient’s ability to urinate standing up. This is because preserving the vaginal canal while extending the urethra results in a very high risk of surgical complications.

Genital Reconstruction Surgeries

If you are interested in a metoidioplasty, phalloplasty, or a revision procedure, you can request a free, in-person consultation with Dr. Ley (she/her/they) today. If you would like to learn more about the deciding factors between metoidioplasty and phalloplasty procedures, click here.

Metoidioplasty

What is this procedure?

Metoidioplasty, also known as “meta”, is a surgical technique used to lengthen existing genital tissue to create a phallus close to the size of a thumb. Specifically, the erectile tissue is released from surrounding ligaments, giving it a more forward, prominent position.

This procedure can be performed with or without a primary urethral lengthening (PUL). A meta with PUL involves lengthening the urethra so that urine exits the body at the tip of the penis, which makes it easier for patients to stand to urinate. Dr. Ley requires her patients who undergo a PUL to undergo a simultaneous vaginectomy (vaginal removal) to prevent urinary complications.

Why do patients undergo this procedure?

• Gender euphoria: Patients who would experience gender euphoria from having an enlarged, more prominent phallus or penis are good candidates for a metoidioplasty. Results are usually about the size of a thumb.
• Accentuate bottom growth from testosterone: While Dr. Ley does not hold this as a requirement, many surgeons suggest that patients be on testosterone hormone therapy for at least 1.5-2 years prior to undergoing a metoidioplasty to maximize “bottom growth.” This allows for a more prominent meta result, although it is not technically necessary. However, not all people who take testosterone experience noticeable growth of their erectile tissue.
• Urinate while standing: If the ability to urinate standing up is important to you, a meta can be performed with a PUL. Please note that Dr. Ley’s meta with PUL patients must undergo a simultaneous vaginectomy, meaning your vaginal canal/opening would be removed.
• Erotic sensation: Since the meta does not remove the erectile tissue from its original nerve and blood supply, there is virtually no risk of long-term loss or reduction in erotic sensation to the genitals.
• Penetrative sex: While penetration is often not as easy as it is with a phalloplasty (whose results are generally larger), some meta patients report that their length gives them penetrative capabilities.
• Lighter recovery than phalloplasty: Metoidioplasty is generally considered a less invasive procedure compared to a phalloplasty, with a shorter recovery time.
• BMI candidacy concerns: Many patients who want to undergo phalloplasty do not qualify due to BMI limitations. At the GCC, Dr. Ley requires that patients have a BMI no greater than 30 to undergo a groin flap or RFF phalloplasty to prevent serious complications (ALT phalloplasty patients must have a BMI ≤23). Patients can have a BMI of 35 or below to undergo a meta with PUL or a BMI of 40 or below to undergo a simple meta. For this reason, many patients choose to start their bottom surgery journey by undergoing a metoidioplasty. From there, once their weight puts them in the proper BMI range for a phalloplasty, they can undergo this surgery at a later time.

Phalloplasty

What is this procedure?

Compared to a metoidioplasty, phalloplasty or “phallo” is a more extensive surgical procedure that involves using flaps or other tissues from the body to create a penis. Phallo results typically have more girth and length, though recovery is more intense, and patients often require multiple stages of surgery to achieve their final results.

There are several phalloplasty techniques to create the phallus: the radial forearm free (RFF) flap, the anterolateral thigh (ALT) flap, and the groin flap method. Depending on individual preferences and the amount of tissue available in the donor site, the resulting length can be between 4-6 inches. Please note that a free, in-person consultation with Dr. Ley (she/her/they), is required to determine your candidacy for the different phalloplasty procedures.

Why do patients undergo this procedure?

• Gender euphoria: For many patients, having a penis of 4-6 inches in length brings significant amounts of gender euphoria: feelings of satisfaction, alignment and being more at-home in their bodies. Patients who decide to undergo multiple stages of surgery can have a penis complete with glands, a scrotum, testicular implants and/or an erectile device.
• Penetrative sex: The length of a phalloplasty can make it easier to have penetrative sex. With your surgeon’s approval, usually about 3 months after your phalloplasty is constructed, you can start using silicone erectile sleeves if needed. Likewise, usually about a year after the phalloplasty is constructed, patients can opt to have an erectile device surgically implanted.
• Erotic sensation: Patients that undergo an RFF phalloplasty are most likely to experience heightened, erogenous sensation in their penis after surgery since the clitoral nerves are hooked up (or innervated) to the nerve graft taken from the forearm. However, there isn’t a 100% chance that RFF patients regain sensation. ALT and groin flap patients have a chance of gaining erotic sensation in their penis if they undergo a urethral lengthening that uses a graft from the forearm (wherein the sensitive forearm nerve is grafted into the penis).
• Urinate while standing: A phalloplasty can be performed with a primary urethral lengthening (PUL) so that urine exits the body at the tip of the penis. This facilitates urinating standing up. Dr. Ley requires that patients who undergo a PUL also undergo a simultaneous vaginectomy to prevent surgical complications.
• Noticeable scar: The RFF procedure leaves by far the largest, most difficult to conceal scar. While this is an issue for some, many RFF patients learn to accept it (as it often looks like a burn mark once healed). Patients that are more concerned about visible scar tissue will most often opt for a groin flap procedure or a metoidioplasty.

• Surgical staging and recovery: Patients who undergo a phalloplasty should have the proper social support and financial resources to be able to undergo and recover from multiple surgeries. Undergoing any major surgical procedure is both mentally and physically taxing. However, phalloplasty patients often have to go through multiple stages of surgery to reach their desired result. The phalloplasty recovery process is longer compared to a metoidioplasty. Each additional procedure carries its own risks for complications that may require revisions in the future. Learn more about revisions here.

Additional Procedures

Depending on your unique embodiment goals, you may want to undergo an additional procedure as a part of your metoidioplasty or phalloplasty. Please note that while some of these can be performed during the initial surgery, the majority cannot be performed until after your results have healed. Additional procedures include: scrotoplasty, testicular implants, mons resection, panniculectomy, glansplasty, and the placement of an erectile device.

Preparing for FTM Bottom Surgery

Preparing for FTM bottom surgery is a multifaceted process that requires careful consideration and planning. Here are some key steps:

1. Fertility Preservation: Consult with reproductive/fertility specialists to consider fertility preservation options.
2. Surgical Consultations: For bottom surgery procedures, consultations must be in-person to determine surgical candidacy and make a surgical plan. Dr. Ley (she/her/they) is a former patient and one of the only trans surgeons of color who offers these procedures. You can request a free consultation with her to have any of your questions about bottom surgery answered.
3. Hair Removal Preparation: Patients that would like to undergo an RFF phalloplasty or have a urethral graft taken from the forearm must undergo hair removal to this area prior to surgery.

Please note that permanent hair removal is only required for the section of the forearm (highlighted in orange on the illustrations) that will be used as a graft to extend the urethra out to the tip of the penis. This is due to the fact that hair growth inside of the urethra can cause a variety of complications. For more information, click here

4. BMI Requirements: Unlike other surgeries offered at the GCC, there are strict BMI requirements for many bottom surgery procedures due to the high risk of complications and surgical failure, especially in the case of phalloplasty. You can read about Dr. Ley’s BMI candidacy requirements here.
5. Support letter: Bottom surgery patients, especially when seeking out insurance approval, often need to present one or more support letters from a licensed mental health professional. For more information on the requirements for the procedure you are interested in, you can request a consultation and our team can get back to you.
6. Lifestyle Adjustments: Quit smoking for at least 4 weeks prior to surgery and make any necessary lifestyle changes to optimize your overall health and reduce complications during recovery. Please note that before undergoing microsurgery (e.g., nerve innervation for an RFF phallo), patients who have a smoking history may need to take a nicotine and cotinine exam, as any tobacco use can cause surgical failure.
7. Support System: Regardless of whether or not you will be spending time in the hospital after surgery, bottom surgery recovery is known to be very physically and emotionally taxing. Having a strong support network of family, friends, support groups and/or a mental health professional is crucial. Organizations like Quest House in San Francisco offer bottom surgery patients a safe place to stay while they recover.
8. Leave Planning: Consider your options for medical leave. Prior to your operation, your surgeon’s office will let you know how much time you will need to take off from work and provide you with the proper documentation to solicit leave.
9. Financial Planning: Explore insurance coverage and plan for the costs associated with the surgery, potential follow-up procedures or revisions, and taking time off from work. Please note that the GCC only offers phalloplasty for patients with insurance coverage at this time due to hospital restrictions.

Recovery and Aftercare

The recovery process after masculinizing or “FTM” bottom surgery can be lengthy and challenging. You can find more specific recovery instructions for metoidioplasty here and phalloplasty here. It is important to be patient and allow your body the necessary time to heal and adjust to the physical changes of bottom surgery. Adhering to your surgeon’s instructions and seeking support when needed can help ensure a successful recovery and long-term satisfaction with your results.

1. Initial Hospital Stay: Some procedures (i.e., simple metoidioplasty) can be performed as an outpatient procedure, meaning you will be released home the same day as your surgery. With most bottom surgery procedures, patients can expect to remain in the hospital for at least 1-2 days after surgery for close monitoring and initial recovery.
2. Medications: Your surgeon will prescribe pain medication to help manage any pain and discomfort that are common in the initial weeks following surgery. Antibiotics may also be prescribed in order to prevent infections.
3. Wound Care: Proper wound care, including application of ointments, dressing changes, and hygiene, is crucial to prevent infections and promote healing. You and your support person will receive detailed instructions after your surgery.
4. Catheterization: Depending on the procedure performed, a catheter may be in place for days or weeks after to allow for proper urethral healing and function.
5. Activity Restrictions: Strenuous activities, heavy lifting, and sexual activity will be restricted for several weeks or months to allow for adequate healing.
6. Follow-up Appointments: Follow-up appointments with your surgeon are essential to monitor healing progress, address any complications, and discuss potential revisions or additional procedures.
7. Psychological Support: Seeking counseling or support groups can help manage the emotional and psychological aspects of the recovery process. As patients navigate pain, discomfort, being bed-bound, activity restrictions, and more, they may experience temporary feelings of depression or even regret during recovery. Once patients heal, they express overwhelming amounts of joy and satisfaction.