Bottom surgery for trans men (also called gender-affirming genital surgery) refers to surgical procedures that construct male genitalia. The two main options are metoidioplasty and phalloplasty, and they differ significantly in size, complexity, recovery, and what they can achieve. Most trans men also have the option of combining either procedure with additional steps like scrotoplasty, urethral lengthening, or vaginectomy depending on their goals.
Metoidioplasty vs. Phalloplasty
These are the two primary surgical paths, and the choice between them comes down to personal priorities. Metoidioplasty works with existing tissue. Testosterone therapy causes the clitoris to grow over time, and metoidioplasty releases this tissue from the surrounding structures to create a small phallus, typically 4 to 7 centimeters. Phalloplasty constructs a full-sized phallus using tissue transplanted from another part of the body, usually the forearm or thigh.
Phalloplasty produces genitalia that look more typically male in size and proportion. But satisfaction surveys show something worth noting: there is no significant difference in overall satisfaction with appearance between the two procedures. Many people who choose metoidioplasty value its shorter recovery, fewer complications, preserved erogenous sensation, and the ability to become erect naturally without an implant. Phalloplasty offers the possibility of penetrative sex (with an implant) and a more conventional appearance, but it’s a longer, multi-stage process with higher complication rates.
Types of Metoidioplasty
Metoidioplasty isn’t a single procedure. It comes in several variations that differ mainly in whether the urethra is extended to the tip of the new phallus.
A simple metoidioplasty releases the enlarged clitoris and repositions it without extending the urethra. This means you’ll continue to sit to urinate. It’s the least complex version with the fewest risks, and urethral lengthening can be added later if desired.
More advanced techniques, sometimes called ring metoidioplasty or Belgrade metoidioplasty, include urethral lengthening so urine exits from the tip of the phallus, allowing you to stand to urinate. The Belgrade approach uses a combination of tissue from inside the cheek (oral mucosa grafts) and genital skin flaps to build the new urethra. It can also include creating a scrotum with silicone testicular implants in the same operation, producing a complete male genital appearance in a single stage.
How Phalloplasty Works
Phalloplasty is one of the most complex reconstructive surgeries in medicine. A surgeon harvests a flap of skin, fat, and blood vessels from a donor site on your body and uses it to construct a phallus. The most common donor site is the forearm, known as the radial forearm free flap. Other options include the outer thigh (anterolateral thigh flap) and lower abdomen.
The forearm flap is popular because it provides thin, pliable tissue and contains nerves that can be connected to the clitoral nerves, giving the new phallus the potential for both tactile and erogenous sensation. The trade-off is a visible scar on the forearm. The scar can be significant, and because it’s on an exposed part of the body, some people find it draws unwanted attention or questions. Surgeons have developed improved closure techniques using skin grafts and tissue matrices to minimize scarring, but a noticeable mark remains. Many trans men consider this an acceptable trade-off for the surgical result.
The thigh flap leaves a scar that’s easier to conceal under clothing, though the nerve sensation results may differ from the forearm option.
Urethral Lengthening
If you want to urinate standing up after phalloplasty, the urethra needs to be extended from its original position all the way through the new phallus. This is one of the most technically challenging parts of the surgery and the most common source of complications. The new urethra is built in two segments: one connecting the original urethral opening to the base of the phallus, and another running through the shaft to the tip.
Undergoing a vaginectomy (removal of the vaginal canal) alongside urethral lengthening substantially reduces complication risk. In one study of 224 patients, urethral complications occurred in 27% of those who had a vaginectomy compared to 67% of those who preserved the vaginal canal. The vaginectomy provides extra vascularized tissue that can be used to reinforce the new urethra, reducing the likelihood of fistulas and strictures.
Scrotoplasty
Scrotoplasty uses the labia majora to create a scrotum. Silicone testicular implants are placed inside, either during the same operation or at a later stage. This step is available with both metoidioplasty and phalloplasty.
Complication Rates
Both procedures carry a risk of urethral complications, specifically fistulas (small holes where urine leaks through the skin) and strictures (narrowing of the urethra that blocks urine flow). These are the most common issues after any bottom surgery that includes urethral lengthening.
Phalloplasty has a particularly high complication profile because of the length and complexity of the new urethra. Across published studies, the overall urethral complication rate for phalloplasty is around 51%, though this has dropped to roughly 24% at the most experienced surgical centers using optimized techniques. Fistulas are the single most common issue, with rates reported between 10% and 64% depending on the surgical era and technique. The encouraging detail is that about two-thirds of fistulas resolve on their own without additional surgery.
Strictures at the junction between the original urethra and the new one occur in 14% to 57% of cases. Surgical technique has improved dramatically over the past two decades, and complication rates continue to fall as centers gain experience. Still, many patients need at least one revision procedure.
Sensation After Surgery
During phalloplasty, surgeons connect a nerve from the donor tissue to one of the clitoral nerves. This nerve hookup (called coaptation) gives the new phallus the potential to develop both protective touch sensation and erogenous feeling. However, nerve regrowth is slow. In a study with a median follow-up of nearly two years, tactile sensitivity in the new phallus was significantly reduced compared to the donor site, and it improved at a rate of only about 0.3 points per year on a 5-point scale.
The base of the phallus tends to be more sensitive than the tip, since it’s closer to the nerve connection point. Sensitivity continues to improve over multiple years, but the final result varies from person to person, and full recovery is not guaranteed. During metoidioplasty, the clitoral nerves are preserved in place, so erogenous sensation is generally maintained more reliably.
Erectile Function and Implants
After metoidioplasty, the phallus can become erect on its own because the underlying erectile tissue is preserved. The size is typically not sufficient for penetrative intercourse, but natural erections occur.
After phalloplasty, the constructed phallus has no erectile tissue. Penetrative sex requires an erectile implant, which is placed in a separate surgery, usually at least 9 to 12 months after the initial phalloplasty once healing is complete and sensation is developing. Two main types of implants exist: malleable (semi-rigid) rods that you bend into position when needed, and inflatable devices with a pump placed in the scrotum that fills the implant with fluid. There is also a malleable implant designed specifically for trans men, with an adjustable length ranging from 13 to 16 centimeters. Malleable implants are simpler to use and can later be exchanged for an inflatable device if desired.
Recovery After Phalloplasty
Phalloplasty requires at least a five-day hospital stay, sometimes longer. During the first days, surgical drains are in place and movement is limited. By day five, drains from the groin and scrotum are typically removed and you’ll begin walking with assistance.
A catheter drains the bladder for several weeks after surgery. One catheter runs through the new urethra and may be removed before discharge, while a suprapubic catheter (a tube placed through the skin above the pubic bone directly into the bladder) stays in place longer to protect the healing urethra.
Activity restrictions are significant. You should not lift more than five pounds with the arm that provided the skin graft. Bending at the waist or hips beyond 90 degrees is off-limits, and sitting with your thighs pressed against your chest can compress blood flow to the new phallus. Walking at least four times daily for 10 minutes each is encouraged to prevent blood clots. Sexual activity with the phallus is not permitted until the surgeon confirms healing is complete, which can take several months. For multi-stage phalloplasty, the intervals between stages are typically three to six months.
Requirements Before Surgery
Most surgical programs follow the World Professional Association for Transgender Health (WPATH) Standards of Care, which outline several prerequisites. You need a diagnosis of gender incongruence that is marked and sustained. Mental health conditions and physical health factors that could affect surgical outcomes should be assessed and addressed beforehand. You’ll need to demonstrate the capacity to consent to the specific procedure, and you should have explored your options regarding fertility, since bottom surgery affects reproductive ability.
Hormone therapy for at least six months is suggested before surgery, partly because testosterone-driven tissue changes (particularly clitoral growth for metoidioplasty) improve surgical outcomes. Longer hormone use may be recommended depending on the procedure. Hormones are not required if they are medically contraindicated or not desired, though this is uncommon for people pursuing bottom surgery.