FTM bottom surgery produces results that vary significantly depending on the procedure chosen. The two main options, metoidioplasty and phalloplasty, differ in size, appearance, scarring, and function. Understanding what each looks like after healing can help you set realistic expectations and decide which approach aligns with your goals.
Metoidioplasty: Size and Appearance
Metoidioplasty works with tissue you already have. After testosterone therapy enlarges the clitoris over time, a surgeon releases it from the surrounding ligaments and repositions it to resemble a small penis. The result is typically 4 to 6 centimeters long (up to about 2⅓ inches). The tissue looks and feels natural because it’s your own erectile tissue, and it can become erect on its own without any implant.
The trade-off is size. A metoidioplasty does not create a visible contour or bulge in underwear or close-fitting pants. For some people, this is perfectly fine, especially if the priority is a natural look and preserved sensation. For others, the smaller size is a dealbreaker, and phalloplasty becomes the better fit.
Phalloplasty: How the Phallus Looks
Phalloplasty builds a full-sized penis using tissue transplanted from another part of your body, most commonly the forearm or the outer thigh. The resulting phallus is typically constructed to approximate an average adult penis in both length and girth, and it creates a visible profile in clothing.
The forearm flap (radial forearm free flap) generally produces a phallus with thinner, more pliable skin that tends to look smoother. The thigh flap (anterolateral thigh, or ALT) can sometimes produce a bulkier result, though surgical technique plays a large role in the final shape. Neither version looks identical to a natal penis right after surgery. Over the months and years that follow, as swelling resolves and the tissue settles, the appearance continues to improve.
The tip of the phallus is shaped through a separate step called glansplasty, which sculpts a coronal ridge to mimic the head of a penis. This can be done during the initial surgery (common with forearm flaps) or as a later revision (more common with thigh flaps). The ridge adds definition, though the result is subtle compared to natal anatomy. Some people also opt for medical tattooing afterward to add color variation to the glans, which further improves the visual realism.
Donor Site Scarring
One of the most visible long-term effects of phalloplasty isn’t on the genitals at all. It’s at the donor site where skin was harvested. This is something many people don’t anticipate, and it’s worth understanding before choosing a flap type.
A forearm flap leaves a rectangular area on the inner forearm that’s covered with a skin graft. The graft heals flatter than the surrounding skin and differs in color and texture, making it noticeable. The scar is difficult to conceal in short sleeves. Some surgical teams have raised concerns that forearm donor scars can be mistaken for self-harm scarring, which has led to techniques designed to minimize the pattern of visible lines across the wrist and forearm.
A thigh flap leaves scarring on the outer thigh, which is easier to cover with clothing. The donor site typically heals as a depressed, hairless patch from the skin graft, and it’s quite apparent when unclothed. However, because it sits on the leg rather than the arm, many people find this location more manageable in daily life.
Scrotoplasty and Testicular Implants
Both metoidioplasty and phalloplasty can include scrotoplasty, which reshapes the labia majora into a scrotum. The most common approach uses what’s called a V-Y advancement, where the labial tissue is repositioned and sutured to create a pouch. Early results often look like a “bifid” scrotum, meaning the two sides remain somewhat separated in the middle rather than forming a single unified sac. Newer techniques rotate the labial tissue to position the scrotum more forward and create a more natural-looking result.
Testicular implants are placed in a separate, later surgery, usually about 12 months after the initial procedure. Modern implants are designed to approximate the size and weight of biological testicles. Complications do occur: the most common issues are erosion (the implant pushing through the skin) and migration (the implant shifting out of position), with about 10% of patients experiencing implant relocation. These sometimes require removal and replacement.
Sensation After Surgery
Sensation is one of the biggest concerns people have, and the results are generally encouraging. During phalloplasty, surgeons connect nerves from the donor tissue to nerves in the genital area. This reinnervation process takes months, but most people do regain feeling.
For forearm flap phalloplasty, studies report that virtually all patients regain tactile sensation (the ability to feel touch and pressure) within a year. About 71% report the return of erogenous sensation, meaning pleasurable sexual feeling. Thigh flap results are somewhat lower, with about 75% reporting tactile sensation and 60% reporting erogenous sensation. Across all flap types, between 83% and 100% of patients report at least some tactile sensation in the long term.
Metoidioplasty preserves the original clitoral nerve supply, so erogenous sensation is generally maintained from the start. This is one of its major advantages.
Erections and Erectile Devices
A metoidioplasty phallus can become erect naturally because it’s made of erectile tissue. The erection is small but functional for some types of penetration.
A phalloplasty phallus cannot become erect on its own because the transplanted skin and fat don’t contain erectile tissue. To achieve rigidity, an erectile prosthesis is implanted in a later surgery. The two main types are semi-rigid rods, which keep the phallus firm at all times (you position it up or down manually), and inflatable pumps, which allow you to shift between a flaccid and erect state by squeezing a small pump hidden in the scrotum. Inflatable devices produce a more natural-looking cycle between soft and firm, but they have more mechanical parts that can fail over time.
Urethral Lengthening and Complications
If you want to urinate standing up, both procedures can include urethral lengthening, which extends the urethra through the new phallus to the tip. This is the part of surgery most prone to complications. The new urethral channel is constructed from grafted tissue, and because urine passes through it constantly, healing can be unpredictable.
A 2024 study covering several years of surgical data found that about 12% of metoidioplasty patients and 19% of forearm flap phalloplasty patients needed surgical repair for urethral problems. The most common issues are fistulas (small holes where urine leaks through the skin) and strictures (narrowing that makes urination difficult). These are treatable but require additional surgery, and some people go through multiple revisions before the urethra functions reliably. Choosing not to have urethral lengthening eliminates this category of risk entirely, though it means continuing to sit to urinate.
The Multi-Stage Timeline
Bottom surgery is rarely a single operation. Metoidioplasty is sometimes completed in one stage, but phalloplasty almost always requires multiple surgeries spread over a year or more. A typical sequence includes the initial flap transfer and phallus construction, followed by urethral hookup (sometimes done simultaneously, sometimes separately), then glansplasty, scrotoplasty with testicular implants, and finally an erectile prosthesis. Each stage requires its own recovery period of several weeks. From first surgery to final result, the full process commonly spans 18 months to 2 years or longer, with the appearance improving at each stage.
The final cosmetic result after all stages and full healing looks substantially different from the appearance at any single point during the process. Swelling, bruising, and suture lines that are prominent in early recovery gradually fade. Many people report that they’re most satisfied with the appearance at the one- to two-year mark after their last procedure, once all the tissue has softened and settled into its final shape.