FTM surgery refers to a range of gender-affirming surgical procedures that align the body with a masculine identity. There is no single “FTM surgery.” Instead, it’s an umbrella term covering several distinct operations, from chest reconstruction to genital surgery to removal of internal reproductive organs. Most people pursue these procedures individually over time, choosing only the ones that match their goals.
Chest Reconstruction (Top Surgery)
Top surgery is the most common FTM surgical procedure. It removes breast tissue and reshapes the chest to create a masculine contour. Several techniques exist, and the right one depends almost entirely on your anatomy, specifically how much chest tissue you have and how elastic your skin is.
The two most widely discussed approaches are double incision and keyhole. Double incision involves larger cuts along the chest, removal of tissue, and repositioning of the nipples as free grafts. It works for a wide range of body types. Keyhole surgery uses a small incision along the edge of the areola to remove tissue from inside, leaving minimal visible scarring. Because no excess skin is removed, only about 5% of candidates have the right combination of minimal tissue and elastic skin to qualify for it.
Other techniques fill the gap between these two. Periareolar surgery uses a circular incision around the areola and works for people with small to moderate chests. Buttonhole, fishmouth, lollipop, and inverted-T approaches each handle different combinations of tissue volume and skin laxity. Your surgeon will recommend a method based on your chest size, skin quality, and the results you want.
Top Surgery Recovery
Recovery from top surgery follows a fairly predictable path. For the first two to four weeks, you should avoid lifting anything heavier than a few pounds and limit arm movements for the first three weeks. Driving is typically off the table for at least the first week, and you’ll need to sleep on your back for a minimum of six weeks. Most people return to desk work within two to three weeks, though physically demanding jobs take longer.
Healing checkpoints continue well beyond the initial recovery. At one and three months, your surgeon will assess how incisions and nipples are healing. A general wound healing check happens around six months, with a final evaluation of results at one year. Scars continue to fade and flatten for up to two years.
Genital Reconstruction (Bottom Surgery)
Bottom surgery for transmasculine patients involves two fundamentally different approaches: metoidioplasty and phalloplasty. They differ in size, complexity, recovery time, and functional outcomes, and neither is objectively “better.” The choice is deeply personal.
Metoidioplasty
Metoidioplasty works with tissue you already have. Testosterone use over time enlarges the clitoris, and this procedure releases the surrounding ligaments to create a small phallus, typically one to three inches long and roughly the width of a thumb. Because it uses your own genital tissue, natural erections are possible without an implant. Erogenous sensation is preserved since the nerve supply stays intact.
You can optionally have the urethra lengthened and routed through the new phallus to allow standing urination, though not everyone chooses this. The surgery is shorter, recovery is faster, and scarring is minimal compared to phalloplasty. The tradeoff is size: the result is not large enough for penetrative sex without assistance, and standing urination requires the optional urethral lengthening, which carries its own risks.
Phalloplasty
Phalloplasty constructs a full-sized penis using tissue borrowed from another part of the body. The donor skin is shaped into a tube-like structure and grafted to the groin area. This is a complex, multi-stage process that typically requires two to four separate surgeries spread over a year or more.
The two most common donor sites are the forearm and the outer thigh. The forearm flap (radial forearm free flap) uses thin, pliable skin that’s ideal for creating both the outer shaft and an inner urethral channel in a “tube within a tube” design. The downside is a noticeable scar on the forearm, and some patients experience hand swelling. In people with a very lean build, the forearm may not provide enough tissue for adequate girth.
The thigh flap (anterolateral thigh) leaves a less conspicuous donor scar with minimal functional impact at the harvest site. However, thigh tissue can be quite thick. Surgeons generally prefer a tissue thickness under 1.5 centimeters to successfully create the inner urethral tube, which limits candidacy for some people. Total flap loss is uncommon at around 3%, and rates are similar between both donor sites.
Standing urination is possible with phalloplasty if urethral lengthening is performed, using tissue from the cheek lining or vaginal lining to construct the new urinary channel. Erections require a penile implant, which is placed roughly nine months after the initial surgery to allow full healing first.
Sensation After Phalloplasty
One of the biggest concerns people have about phalloplasty is whether they’ll be able to feel anything. The short answer: most patients regain meaningful sensation, though the type and timeline vary.
During surgery, nerves in the donor tissue are connected to nerves in the groin. Protective sensation, the ability to feel touch, temperature, and pressure, typically returns over 9 to 12 months. Studies of forearm flap phalloplasty report that 98% of patients regain tactile sensation, and in one large study, 100% of patients recovered tactile sensitivity within a year. For thigh flap procedures, about 75% report tactile sensation.
Erogenous sensation is more variable but still common. Roughly 71% of forearm flap patients and 60% of thigh flap patients report the return of erogenous feeling. Multiple studies have found that 100% of forearm flap patients were able to reach orgasm after surgery, with patients reporting they could achieve orgasm through stimulation of the new phallus alone. Across all flap types, 83% to 100% of patients report some form of sensation.
Urological Complications
Urethral lengthening, whether performed as part of metoidioplasty or phalloplasty, carries a significant risk of complications. This is one of the most important things to understand before choosing a procedure that includes it.
Strictures (narrowing of the new urinary channel) occur in about 63% of cases for both phalloplasty and metoidioplasty when urethral lengthening is performed. They typically appear around three months after surgery. Fistulas (abnormal openings where urine leaks through the skin) develop in roughly 27% of phalloplasty cases and up to 50% of metoidioplasty cases, usually around two and a half months post-surgery.
Overall, about 73% of patients who undergo urethral lengthening need at least one revision surgery to address fistulas or strictures. These complications are well-known in the field, and revision procedures are considered a normal part of the process rather than a failure. Many surgeons discuss this upfront so patients can plan for the possibility of additional procedures.
Hysterectomy and Ovary Removal
Some transmasculine people choose to have the uterus, and sometimes the ovaries and fallopian tubes, removed. This can be a standalone decision or part of preparation for certain bottom surgeries.
Three surgical approaches exist: abdominal (through a cut in the belly), laparoscopic (through small incisions using a camera), and vaginal (through the vaginal canal with no external incisions). For transmasculine patients, the vaginal approach has specific advantages: fewest complications, least blood loss, fastest recovery, and no abdominal scars. Laparoscopic hysterectomy is the next least invasive option and also has strong outcomes.
Whether to keep or remove the ovaries is a separate decision. Retaining them preserves a natural hormone source, which matters if you ever need to stop taking testosterone, and keeps fertility options open for those who may want biological children in the future. Removing them eliminates the ovaries as a concern entirely but commits you to lifelong hormone replacement. The choice depends on your plans for hormones, fertility, and any existing conditions like endometriosis that might benefit from removal.
How These Procedures Fit Together
There is no required sequence or checklist. Some people pursue only top surgery and feel complete. Others want bottom surgery but not a hysterectomy. Some want everything available. Each procedure is an independent decision, and surgeons generally tailor a surgical plan around individual goals rather than following a fixed protocol.
When multiple procedures are planned, top surgery is typically done first because it’s a single operation with a relatively straightforward recovery. Bottom surgery, especially phalloplasty, involves the longest timeline: multiple staged surgeries, months of healing between stages, and a total process that can stretch over one to two years. Insurance coverage, time off work, and access to experienced surgeons all factor into how and when people move through these steps.