Transmasculine gender affirming surgeries

Author: Nix. Reviewed by Moonbeam.

Bottom Surgeries

When discussing gender affirming surgical procedures, the phrase “bottom surgery” is often used to refer to operations on a patient’s genitalia. This includes both surgeries which aim to create a new genital arrangement from what a patient is born with and surgeries which stop certain undesired biological processes (e.g. hormone production or menstrual cycle).


Also frequently referred to as a “meta”, metoidioplasty is a surgery performed for AFAB individuals which aims to create a penis analogue, or “neophallus” using the clitoris. It is almost always required to be on testosterone prior to a meta operation as testosterone can enlarge the clitoris and provide more tissue to work with. Unlike a more elaborate multiple-stage phalloplasty operation, metas are often treated as outpatient procedures and are usually completed in one stage.

There are several methods that can be performed in a meta procedure:

  • Simple release/simple meta: Clitoris is freed from the surrounding tissue and allowed to grow further, increasing the length and visibility of the resulting penis. It is referred to as “simple” because the vagina and urethra are unaltered.
  • Full metoidioplasty/ring metoidioplasty: Clitoris is freed from the surrounding tissue, and tissue is grafted from either the cheek (in a full metoidioplasty) or the vaginal lining (in a ring metoidioplasty) to bring the urethra up to the penis. These methods allow for the option of a vaginectomy to remove the vagina and scrotoplasty to create a scrotum with implants.
  • Centurion metoidioplasty: The clitoris is freed from the surrounding tissue along with the round ligaments that run through the labia to the labia majora, and uses the ligaments to create extra girth in the neophallus. No skin grafting is required with this method and as a result this method can see fewer complications.

Meta procedures come with their own strengths and drawbacks compared to a phalloplasty. For example, while metas are generally more cost-effective, have easier recovery, and result in having a functioning phallus capable of achieving erection, a meta phallus will very likely be very short compared to a phalloplasty, and may not be capable of penetration or the ability to stand while urinating. When considering a metoidioplasty, it is important to weigh the benefits and drawbacks of the procedure with your surgeon ahead of the operation. [13]


Phalloplasty refers to a complex series of procedures where the aim is to construct a functioning penis. Phalloplasty is very commonly performed in multiple stages due to its complexity. Most commonly during phalloplasty, a vaginectomy is performed, a large section of skin, most commonly from the forearm, thigh, or back, is rolled and grafted to form a shaft and attached to the groin. Optionally after this is done, additional stages to create a scrotum and head of the penis (glans) can be performed. Some phalloplasty stages can be performed in addition to and alongside a metoidioplasty. Since phalloplasty cannot commonly be performed in its entirety in one stage, patients may opt to only complete some of the stages as they see necessary for their own gender dysphoria.

The first stage of a phalloplasty operation involves removal of the female genitalia, lengthening of the urethra, and creation of the shaft of the penis using grafts of skin (known as flaps) from one of three donor sites:

  • Radial Forearm Flap (RFF): The most common place to take a skin graft for phalloplasty. Uses skin from all around the forearm to construct the penis. Because this skin is thin and relatively easy to work with, the urethra-lengthening procedure can very commonly be completed in a single stage.
  • Anterolateral Thigh (ALT) Flap: The ALT donor site uses skin from the front of the thighs to construct the new penis. Depending on the thickness of the thigh skin and subcutaneous fat, this option may not be ideal for all patients. Use of the ALT may result in less immediately pleasing aesthetics in the new penis, so some revisions may be required to improve aesthetics if desired. Some surgeons are able to use this donor site in a “delayed” fashion, where prior to the grafting of the thigh skin, blood flow from everywhere other than the body’s main blood supply is cut off, and for 4-6 months the skin is able to become accustomed to the blood supply it will be receiving in the post-op phallus.
  • Latissimus Dorsi Myocutaneous Flap (LDMF): Located along the back from the rear of the ribcage to the upper buttocks, the LDMF is a section of skin used commonly for skin grafts for many reconstructive surgeries, including some phalloplasties. Despite being a versatile site, it does have the disadvantage of experiencing minimal physical sensation if used, and may require a second stage to complete the phalloplasty.

During a phalloplasty procedure, if desired, steps can be taken to give the new phallus the appearance of a circumsized penis. This can be done with either a glansplasty–where skin is grafted during construction of the penis to create the appearance of a penis crown–or a glans implant–where a silicone implant is inserted into a post-operative penis to create a naturally shaped penis crown–or both can be performed.

Once a phalloplasty has had enough time to properly heal (around 9 months post-op), a penile implant may be added to allow for the possibility of penetrative sexual activity. The implant is typically either inflatable, or semi-rigid, and is inserted into the phallus. [14,15]


For patients seeking the ability to stand to urinate post operative, urethroplasty is available as part of both metoidioplasty and phalloplasty procedures. This is done by relocating the opening to the urethra to the perineum, then extending the opening to the urethra with either neighboring tissue for metoidioplasty, or a newly-created skin tube for phalloplasty. If urethral lengthening is performed, a suprapubic catheter will typically be left in for 2-4 weeks to allow the opening to heal, until urination through the opening is possible.

It is important to note that this is not a mandatory requirement for any bottom surgery and the urethra may be able to remain in place, but the patient will still be required to sit to urinate post-op. It is not terribly uncommon for urethral lengthening to run into complications with urination becoming difficult or urine to not all make it out through the new urethral opening. If a patient chooses to not go through the urethroplasty procedure they have much lower risk of urethral complications. [14,15]


Scrotoplasty refers to procedures which aim to create an aesthetically pleasing scrotum alongside a phalloplasty or metoidioplasty. The new scrotum is constructed primarily using labia majora tissue, but additional tissue can be grafted to create a larger scrotum if the labia majora has insufficient tissue. Once the scrotoplasty has healed completely, the option to add testicular implants is available.

Sometimes if a metoidioplasty or phalloplasty procedure with scrotoplasty included is performed, the scrotum may end up lowering too far below the legs. This can be fixed with an outpatient monsplasty procedure, which pulls the scrotum out from between the legs and raises it to a more natural location. [14,15]

Top surgeries

When discussing gender affirming surgical procedures, the phrase “top surgery” is often used to refer to operations on a patient’s chest or breasts. Most commonly, top surgery takes the form of breast removal or augmentation, and on occasion, changes to or removal of one’s nipples.

Breast Reduction

Perhaps the most common gender confirming surgery performed for transmasculine individuals is a breast reduction, or double mastectomy. Most commonly this is performed by making two incisions along the bottom of the pectoral muscles to remove unwanted breast tissue, and a smaller incision along the nipple to allow the nipples to be repositioned and reshaped.

For individuals with smaller breasts who aren’t concerned with making adjustments to the positioning or aesthetics of the nipples, this can be done with one smaller incision per breast near the nipples to remove the unwanted breast tissue. [19]

Chest Contouring/Body Masculinization

Some transmasculine patients may be eligible for and desire some chest contouring to be done as part of top surgery procedures. Generally, this is done using liposuction to relocate fat from other parts of the body (such as the buttocks and armpits) and redistributed to areas to give the torso and chest a more masculine shape. As with all liposuction, the relocation and removal of fat can be temporary as fat is burned and recreated by the body over time. [20]

Other Miscellaneous Transmasculine Surgeries

Voice Masculinization Surgery (VMS)

VMS refers to a number of different procedures which can be performed to decrease the pitch and deepen the voice of an individual. While testosterone hormone replacement does deepen the voice over time, some transmasculine individuals may not be completely satisfied with the results of voice deepening that comes with HRT and seek out a VMS procedure. Surgically, the voice is able to be deepened by enlarging the vocal folds or decreasing the tension of the vocal folds.

Enlarging the vocal folds is done most commonly with injection (sometimes called “injection augmentation”). It is performed by injecting a substance, like fat tissue, collagen, or a hyaluronic acid filler (used frequently in facial cosmetic surgeries) directly into the vocal folds to deepen the voice. This option is typically cheaper, carries lower risks, and has easier recovery than decreasing the vocal folds tension. However, it is difficult to know exactly how much the voice will deepen post-op, and over time, some injections may gradually be absorbed into the body, which may result in some pitch increasing.

Reducing the tension of the vocal folds is done with surgery called “Relaxation Laryngoplasty” or “Type 3 Thyroplasty”. Both names refer to the same general procedures. The specific methods may vary from surgeon to surgeon, but most versions of this procedure involve relocation and/or removal of cartilage in the vocal folds.

VMS may not be necessary for all transmasculine individuals by way of the voice changes that come with HRT, or with the help of speech therapy. This should be considered prior to seeking out VMS procedures. [16]