FTM gender-affirming surgery: a complete guide

Gender-affirming surgery for trans men encompasses a set of different procedures, with different purposes and very different recovery pathways. This article presents all of them systematically: what they are, how they work, what risks they involve, and what the data say about satisfaction. It is not medical advice: it is an evidence-based informational guide, designed for anyone evaluating their options or simply seeking to understand. For an overview that also includes procedures for trans women, we refer to the article on gender-affirming surgery. For specific results of genital surgery, there is the in-depth article on phalloplasty and metoidioplasty.

There is no single pathway

First and foremost: there is no mandatory or standard surgical pathway for trans men. Each person has their own relationship with their body, their own priorities, and their own limits. Some trans men desire all available procedures. Many desire only mastectomy. Others want no surgical intervention at all. All of these choices are valid.

The data confirm this variability. A 2024 JAMA study found that top surgery is the most desired and most performed gender-affirming procedure among transmasculine individuals [10]. Genital surgery, on the other hand, is chosen by a minority. This does not mean it is less important: it means the need is individual.

The typical sequence, when multiple procedures are chosen, is generally as follows:

1. Mastectomy (top surgery): often the first procedure, sometimes the only one
2. Hysterectomy and oophorectomy: if desired, generally after at least one year of hormone therapy
3. Genital surgery (metoidioplasty or phalloplasty): if desired, generally the last step

This sequence is not rigid. Some choose top surgery without hormone therapy. Others proceed with hysterectomy before top surgery. The pathway is built together with healthcare professionals based on individual needs.

Prerequisites: what is needed to access surgery

The international reference guidelines are the Standards of Care Version 8 (SOC-8) from the World Professional Association for Transgender Health (WPATH), published in 2022 [1]. Requirements vary depending on the procedure.

For mastectomy

• Documented diagnosis of gender incongruence
• Assessment by a mental health professional
• One letter of recommendation
• Testosterone therapy is not a mandatory requirement for mastectomy, although many patients begin it beforehand [1]

For genital surgery (metoidioplasty or phalloplasty)

• Documented diagnosis of gender incongruence
• At least 12 months of testosterone therapy (for metoidioplasty, this is strongly recommended since clitoral growth is essential for the result) [1]
• One letter of recommendation from a mental health professional
• Minimum age of 18
• Capacity for informed consent

Mastectomy (top surgery)

Gender-affirming mastectomy — often called “chest masculinization” — is the most requested and most commonly performed procedure among trans men [10]. It involves the removal of breast tissue and reshaping of the chest to achieve a flat, masculine appearance.

Surgical techniques

There are three main techniques. The choice depends on breast size, skin elasticity, and patient preferences.

Double incision with free nipple graft: the most common technique, used for medium to large breasts (C cup and above). The surgeon makes two horizontal incisions below the pectoral muscles, removes breast tissue and excess skin, and repositions the areola and nipple as free grafts in the anatomically male position. It produces the most visible scars (two horizontal lines below the pectorals) but offers the greatest control over the aesthetic result. The nipple temporarily loses sensitivity, which partially recovers over time.

Periareolar (or circumareolar): indicated for small breasts (A-B cup) with good skin elasticity. The incision is made around the areola, through which breast tissue is removed. Scarring is minimal and barely visible. The nipple generally retains better sensitivity than with the double incision technique. The limitation is that it works only with small breasts: if there is too much tissue to remove, the result may be irregular or require revisions.

Keyhole: reserved for very small breasts (A cup or smaller). A small incision is made along the lower edge of the areola, and breast tissue is removed via liposuction or direct excision. The scars are virtually invisible. It does not involve nipple repositioning since there is no excess skin to remove. It is the least invasive technique but applicable only to a minority of patients.

Candidate suitability for each technique

Technique	Breast size	Skin elasticity	Scars
Double incision	Medium-large (C+)	Any	Visible, horizontal
Periareolar	Small (A-B)	Good	Minimal, around the areola
Keyhole	Very small (A-)	Excellent	Nearly invisible

The final assessment is made by the surgeon, who also considers factors such as tissue distribution, chest wall shape, and patient expectations.

Recovery

Recovery from mastectomy follows a relatively predictable timeline:

• First week: rest, compression bandage or post-operative vest, drains (removed after 5-7 days), pain manageable with analgesics
• Weeks 2-4: gradual resumption of light daily activities, no lifting weights or raising arms above the head
• Weeks 4-6: possible return to work for non-physical activities, removal of the compression vest
• Months 3-6: full resumption of physical activities, scar maturation

Full recovery, meaning aesthetic stabilization of scars and recovery of sensitivity, takes 6-12 months.

Satisfaction rates

The data on satisfaction after mastectomy are among the highest in all of elective surgery. A 2023 single-center study reported overall satisfaction of 97% [2]. A study published in JAMA Surgery in 2023 confirmed that long-term regret is extremely rare, with 97% of patients saying they would make the same choice again [3]. The impact on quality of life is documented as significant: reduced dysphoria, improved self-confidence, and greater ease in living socially in the affirmed gender [2][3].

Hysterectomy and oophorectomy

Hysterectomy (removal of the uterus) and oophorectomy or bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes) are procedures that some trans men choose for various reasons: reduction of dysphoria related to internal reproductive organs, elimination of residual menstruation (which in some cases persists even with testosterone), reduction of the testosterone dose needed (since the ovaries no longer produce estrogen), or as preparation for genital surgery.

Technique

The most common approach is laparoscopic or robot-assisted: through 3-4 small abdominal incisions (5-12 mm each), the surgeon visualizes and operates with miniaturized instruments. Compared to traditional abdominal hysterectomy (with a large incision), the laparoscopic approach involves less pain, a shorter hospital stay, and faster recovery [14].

Hysterectomy can be total (removal of uterus and cervix) or subtotal (preservation of the cervix). The choice depends on medical considerations and patient preferences. For trans men who plan future genital surgery, total hysterectomy with cervix removal is generally recommended, as it simplifies subsequent stages [15].

A 2022 systematic review of hysterectomies as gender-affirming surgery found an overall complication rate of 5-10%, the majority of which were mild (urinary infections, minor bleeding) [14]. Serious complications are rare.

Implications for hormone therapy

After removal of the ovaries, the body no longer produces estrogen in significant quantities. This means:

• Testosterone therapy becomes essential for life (or for as long as one wishes to maintain hormonal levels)
• The dosage may be reduced, since there is no longer ovarian estrogen production to counteract
• Regular endocrinological monitoring for bone health is essential, as the absence of sex hormones increases the risk of osteoporosis

For more on the effects and implications of long-term hormone therapy, we refer to the articles on physical changes from medical transition and on lifelong hormone therapy.

Recovery

• Hospital stay: 1-2 days for the laparoscopic approach
• Resumption of light activities: 1-2 weeks
• Full recovery: 4-6 weeks
• No heavy lifting: 6 weeks

Fertility

Hysterectomy with oophorectomy results in irreversible loss of fertility. Anyone who wishes to preserve the possibility of having biological children in the future must discuss and plan oocyte cryopreservation before the procedure. For more on this topic, we refer to the article on fertility and transgender people.

Metoidioplasty

Metoidioplasty is a genital surgery procedure that uses the clitoris — enlarged by testosterone therapy — to create a microphallus. It is a less invasive alternative to phalloplasty, with a shorter surgical pathway and reduced recovery times.

How it works

Testosterone, taken for at least 1-2 years, causes significant clitoral growth: the average length increases from about 1 cm to 3-5 cm, with individual variability [5]. The surgeon intervenes in several ways:

1. Release of suspensory ligaments: the clitoris is freed from the ligaments that keep it attached to the pubic bone, maximizing its visible length
2. Straightening: any curvatures are corrected
3. Urethral lengthening (optional): the urethra is extended through the microphallus to allow standing urination. This component increases the risk of urethral complications
4. Scrotoplasty (optional): the labia majora are joined along the midline to create a scrotum, with possible insertion of testicular prostheses
5. Vaginectomy (optional): closure of the vaginal canal

Metoidioplasty can be performed as a “simple” procedure (release of the clitoris only) or “complete” (with urethral lengthening, scrotoplasty, and vaginectomy). The choice depends on the patient’s goals [5].

Results

The largest available study, conducted by Prof. Djordjevic on 813 patients, reported [5]:

• Microphallus size: 5-9 cm
• Standing urination: 74-90% of cases (with urethral lengthening)
• Erogenous sensitivity: 100% (the tissue is biologically native)
• Natural erection: present, since the clitoral tissue retains its erectile capacity
• Overall satisfaction: 79% fully satisfied, 20% mostly satisfied
• Urethral complications: approximately 25%

Advantages and limitations

Advantages of metoidioplasty over phalloplasty:

• 100% erogenous sensitivity [5]
• Natural erection without prostheses
• No scars at donor sites (forearm, thigh)
• Shorter surgical pathway (1-2 procedures vs. 3-4)
• Faster recovery
• Lower complication rates [6]
• Lower costs

Limitations:

• Limited dimensions (5-9 cm): in most cases, this does not allow sexual penetration
• The result depends on the individual response to testosterone (clitoral growth varies)
• Some trans men desire a standard-sized phallus, and metoidioplasty cannot provide this

The choice between metoidioplasty and phalloplasty is strictly personal. There is no hierarchy: they are two options with different profiles of advantages and limitations. Some trans men choose metoidioplasty and are completely satisfied with it. Others begin with metoidioplasty and later opt for phalloplasty. No pathway is wrong.

Recovery

• Hospital stay: 3-5 days
• Urinary catheter: 2-3 weeks (if urethral lengthening was performed)
• Resumption of light activities: 2-3 weeks
• Full recovery: 6-8 weeks
• Resumption of sexual activity: after 6-8 weeks

Phalloplasty

Phalloplasty constructs a standard-sized neophallus (12-16 cm) using tissue harvested from another part of the body. It is the most complex gender-affirming surgical procedure and requires a multi-stage pathway spanning 12-24 months [4]. For detailed results, we refer to the dedicated article on phalloplasty and metoidioplasty.

Techniques: donor sites

Radial forearm flap (RFF — Radial Forearm Free Flap): considered the gold standard by most centers [6]. The forearm tissue is thin, flexible, and well-vascularized, producing a neophallus with good aesthetics and good sensory potential. The surgeon harvests a flap of skin and subcutaneous tissue from the non-dominant forearm, shapes it into a phallus using the “tube-within-a-tube” technique (an inner tube for the urethra, an outer tube for the shaft), and microsurgically connects it to the blood vessels and nerves in the pubic area. The main disadvantage is the visible scar on the forearm, which is covered with a skin graft from the thigh.

Anterolateral thigh flap (ALT — Anterolateral Thigh Flap): an alternative that avoids the forearm scar. Thigh tissue is thicker, which may require subsequent debulking (volume reduction) procedures. A comparative study of 413 cases showed that the ALT flap has higher rates of secondary revisions (45% vs 15% for the radial flap), but the donor site scar is less visible and concealed by clothing [7]. Long-term functional results are comparable.

Musculocutaneous latissimus dorsi flap (MLD): uses tissue from the back. It is less common than the previous options but is chosen in specific cases when other sites are not available or preferred. The scar is well hidden on the back.

The choice of donor site depends on the patient’s body type, the quantity and quality of available tissue, aesthetic preferences, and the surgeon’s experience.

The multi-stage pathway

Phalloplasty is not a single procedure: it is a pathway of 2-4 separate surgical operations, each followed by a recovery period [4].

Stage 1 — Creation of the neophallus (duration: 8-12 hours): harvesting of the flap, shaping into a phallus, microsurgical connection of blood vessels and nerves. This is among the longest and most complex operations in reconstructive surgery. Hospital stay is 7-10 days. The neophallus is carefully monitored for the first 72 hours to verify vascular viability.

Stage 2 — Urethral lengthening and scrotoplasty (approximately 5-6 months later): the urethra is extended through the neophallus to allow standing urination. The labia majora are joined to create the scrotum. This is the stage with the highest complication rate (urethral fistulas and strictures) [9].

Stage 3 — Testicular prostheses and erectile device (at least 12 months after Stage 2): insertion of testicular prostheses into the scrotum and, if desired, an erectile prosthesis into the neophallus [8]. Glanuloplasty (reshaping the tip to simulate the glans) is often performed during this stage.

Potential revisions: corrective procedures to optimize aesthetics, manage urethral complications, or replace malfunctioning prostheses.

Complications: necessary transparency

Phalloplasty has significant complication rates. This is not a reason not to choose it — it is a reason to choose it with full awareness.

Urethral complications (the main challenge) [9]:

• Urethrocutaneous fistulas: 17-40% of cases. Up to two-thirds resolve spontaneously
• Urethral strictures: 21-51% of cases. These require endoscopic or surgical treatment

The most experienced centers report urethral complication rates of 24%, significantly lower than the average [9].

Donor site complications: problematic scarring, temporary functional limitation of the forearm (for the radial flap), need for physical therapy [7].

Prosthetic complications: among patients with an erectile prosthesis, 53% require at least one reoperation. The main causes are mechanical malfunction (40%), infection (6%), malpositioning (5%) [8].

Partial or total flap loss: rare (1-5% of cases) but the most feared complication [4]. It occurs when the vascular connection does not function adequately.

Functional results

Despite the complexity, the results are significant [4]:

• Standing urination: 75-91% of cases
• Tactile sensitivity: 88% of patients develop tactile sensitivity in the neophallus
• Erogenous sensitivity: 69% (the clitoris is preserved at the base of the neophallus)
• Penetration capability with erectile prosthesis: 77%
• Ability to reach orgasm: approximately 50-61%

Satisfaction

Overall satisfaction is high, considering the complexity of the procedure [4]:

• Satisfaction with masculinizing effect: 82%
• Satisfaction with appearance: 66%
• Satisfaction with overall life: 75%
• Regret is below 1% [11]

The lowest score is satisfaction with sexual function (34%), related to the complexity of sensory recovery and prosthetic complications [4]. This does not mean that the majority of patients are dissatisfied with their choice: it means that sexual function is the area with the most room for improvement.

Recovery: a realistic timeline

The complete phalloplasty pathway extends over 18-24 months [15]:

• After Stage 1: 2-3 weeks of hospitalization, 6-8 weeks of rest, 3-6 months before resuming normal activities. Physical therapy for the donor site
• After Stage 2: 1-2 weeks of hospitalization, urinary catheter for 3-4 weeks, 4-6 weeks of rest
• After Stage 3: 1 week of hospitalization, 4-6 weeks of rest, 3-6 months before resuming sexual activity

Each stage requires healing time before proceeding to the next. The post-operative period can be emotionally complex: it is not unusual to experience moments of anxiety, frustration, or doubt, even when one is deeply convinced of one’s choice. This is normal after any major surgical procedure and even more so after such a prolonged pathway.

Scrotoplasty and testicular prostheses

Scrotoplasty can be performed as part of metoidioplasty or phalloplasty, or as a standalone procedure. It involves creating the scrotum from the labia majora, which are joined along the midline.

Testicular prostheses made of silicone are generally inserted at a later stage, at least 6 months after creation of the scrotum. They are available in various sizes and are selected based on the patient’s body type. The explantation (removal) rate is 20.8%, with the main causes including infection, extrusion, and discomfort [8]. Rates have improved over time with the evolution of techniques and materials.

The procedure is relatively straightforward compared to other genital procedures:

• Duration: 1-2 hours
• Hospital stay: 1-2 days or outpatient
• Recovery: 2-4 weeks

Body contouring

Body contouring includes body reshaping procedures that some trans men choose to harmonize their silhouette. Testosterone therapy redistributes body fat toward an android pattern (more abdominal, less on hips and thighs), but not always enough to completely eliminate the gynoid distribution.

The most commonly requested procedures are:

• Liposuction of hips and thighs: removes fat deposits resistant to hormonal redistribution
• Abdominal liposuction: to define the abdominal area
• Fat transfer (lipofilling): transfer of fat harvested from one area to another to masculinize body contours

Overall satisfaction and regret rates

The data on satisfaction after gender-affirming surgery are among the most robust in the surgical literature:

• Top surgery: satisfaction of 95-97%, regret below 3% [2][3]
• Hysterectomy: satisfaction above 90% [14]
• Metoidioplasty: satisfaction of 79% (full) + 20% (partial) = 99% overall [5]
• Phalloplasty: overall life satisfaction at 75%, masculinizing effect satisfaction at 82% [4]

The overall regret rate for gender-affirming surgery, according to the most comprehensive available meta-analysis (2021), is below 1% [11]. For comparison, knee replacement surgery has dissatisfaction rates between 6% and 30%. A 2024 JAMA study confirmed that 99.7% of trans people who had access to surgery report satisfaction with their decision [10].

In the rare cases of regret, the associated factors do not relate to gender identity but rather to post-operative complications, unsatisfactory aesthetic results, or poor social support [11].

Realistic expectations: what to know before deciding

Gender-affirming surgery is not a magic wand and it is not a horror. It is a set of medical procedures with solid evidence and known limitations. Here is what it is reasonable to expect:

Top surgery is an established procedure with excellent results. The vast majority of patients describe it as transformative [2][3]. Scars are present, especially with the double incision, but for most trans men they represent a more than acceptable tradeoff.

Hysterectomy is a routine procedure in gynecological settings, with contained risks and rapid recovery [14]. The decision to remove the ovaries has long-term implications for hormone therapy that should be discussed with an endocrinologist.

Metoidioplasty offers excellent results in terms of sensitivity and natural erectile function, with the limitation of size [5]. Anyone expecting a standard-sized phallus will be disappointed. Anyone who prioritizes sensitivity and a less invasive pathway will likely be very satisfied.

Phalloplasty is a long and demanding pathway. Complications are frequent, reoperations likely, and recovery is measured in months [4]. But for many trans men, it is a life-changing procedure. The key is to approach it with realistic expectations: the neophallus is not identical to a cisgender penis, but that is not its goal either. The goal is to create a functional organ that reduces dysphoria and allows a life more congruent with one’s identity.

The surgical center matters. Results vary significantly based on the experience of the team [1]. WPATH guidelines recommend choosing surgeons with a high case volume and specific training. Seeking information, asking for case histories, and speaking with other patients is both a right and a form of self-advocacy.

The overall picture

Gender-affirming surgery for trans men offers diversified options, from mastectomy — a relatively straightforward procedure with excellent results — to phalloplasty, among the most complex procedures in reconstructive surgery. Not all procedures are necessary for everyone. Not all trans men want or need genital surgery. Top surgery alone is sufficient for many, and this is not a compromise: it is a legitimate choice.

For those who desire genital surgery, the options exist and results continue to improve. Techniques are being refined, complication rates are decreasing, and recovery protocols are becoming more effective. No procedure is perfect, but the data show that the vast majority of people who choose this pathway are satisfied with their decision [10][11].

The decision to have surgery is personal. It belongs to the person who lives it, with the support of competent professionals and accurate information. What we can do is ensure that the available information is complete, honest, and respectful of each person’s autonomy. For those also researching other aspects of transition, we refer to the articles on physical changes from hormone therapy and on sexuality of trans people.