It is a lot. Honestly, when people start looking into bottom surgery for a trans man, the sheer volume of medical jargon is enough to make anyone’s head spin. You’ve got "phalloplasty," "metoidioplasty," "scrotoplasty," and a dozen other "-oplasties" that sound more like a textbook than a life-changing decision. But at its core, this isn't just about a surgical procedure. It is about alignment. It’s about the moment a person finally feels like their physical body isn't a source of constant, grating friction with their internal sense of self.
For many, the path to lower surgery is the final piece of the transition puzzle. Others don't want it at all, and that’s fine too. Transitioning isn't a linear race with a trophy at the end. But for those who do choose this route, the options are complex, the recovery is grueling, and the results are—thankfully—more advanced than they were even a decade ago.
The Two Main Paths: Phallo vs. Metoidioplasty
You basically have two main "forks in the road" when you look at bottom surgery for a trans man.
First, there is Metoidioplasty.
Think of this as working with what you already have. After a trans man has been on testosterone for a while, the clitoris naturally grows—a process often called "bottom growth." A metoidioplasty takes that growth and releases the surrounding ligaments to give it more length and a more prominent position. It’s a shorter surgery. The recovery is usually easier. You get to keep full natural sensation because, well, it’s the same tissue you started with. The trade-off? Size. You aren't going to end up with a six-inch phallus this way. Most guys find it’s enough to "stand to pee" (STP) if they also get a urethral lengthening, but it depends heavily on their anatomy.
Then there is Phalloplasty.
This is the "big" one. It’s a multi-stage process that involves taking a skin graft from another part of the body—usually the forearm (Radial Forearm Flap or RFF) or the thigh (Anterolateral Thigh or ALT)—to create a phallus. This is how you get a penis that is average adult size. It’s a massive undertaking. We are talking microsurgery, connecting tiny nerves and blood vessels under a microscope. It’s intense. But for many, the ability to have a phallus that looks and feels "standard" in a locker room or a bedroom is worth every second of the pain.
Deciding Which Version of Bottom Surgery for a Trans Man Is Right
There is no "best" surgery. There is only what works for your life.
If your main goal is to have a phallus that is capable of penetrative sex without a prosthetic, phalloplasty is usually the answer. But phalloplasty doesn't get "hard" on its own; you eventually need an erectile implant, which is another surgery down the line. If you’re terrified of big scars on your arms or legs, or if you really value having natural "reflexive" erections, metoidioplasty might be your speed.
Wait, let's talk about the "plumbing" for a second.
Urethral lengthening (UL) is the part of the surgery that allows you to urinate through the neophallus. It is also the part most likely to have complications. We’re talking fistulas (leaks) or strictures (blockages). It’s common. Surgeons like Dr. Curtis Crane or the team at Mount Sinai’s Center for Transgender Medicine and Surgery will tell you straight up: be prepared for a "touch-up" surgery. It’s almost a rite of passage in the community.
The Role of the Vaginectomy
Not everyone wants a vaginectomy—the surgical closing of the vaginal opening. However, if you want urethral lengthening, most surgeons will strongly insist on it. Why? Because the risk of complications like fistulas sky-rockets if you try to reroute the urethra without closing that area. It’s a hard choice for some. Some guys want to keep their original equipment for various reasons while still having a phallus. This is called "salvaging" or "non-binary" bottom surgery. It’s possible, but you have to find a surgeon who is specialized and willing to work with the higher complication risks.
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The Reality of the Recovery Room
Recovery is a beast.
With phalloplasty, you aren't just healing one site; you’re healing your crotch and your arm (or thigh). Your arm might be in a splint for weeks. You might have a suprapubic catheter—a tube coming out of your abdomen—for a month or more. It’s messy. It’s emotional. Post-operative depression is a real thing that hits around week three when the adrenaline wears off and you’re just tired of being in pain.
According to research published in The Journal of Sexual Medicine, patient satisfaction rates for these surgeries are remarkably high—often over 90%. That’s a staggering number when you consider how difficult the process is. It suggests that despite the scars and the drains and the catheters, the relief of gender dysphoria is profound.
What About the Scrotum?
Scrotoplasty is usually part of the deal. The surgeon takes the labia majora and reshapes them into a scrotum. Later, once everything is healed, they can pop in silicone testicular implants. It’s a small detail that makes a huge difference in how a person feels in their own skin.
- Stage 1: Phallus creation, urethral lengthening, and maybe the vaginectomy.
- Stage 2: Glansplasty (creating the "head" of the penis) and scrotoplasty.
- Stage 3: Testicular implants and the erectile device.
This timeline can take two years or more. You have to be patient. You have to be resilient.
Financial and Logistical Hurdles
Let’s be real: this is expensive. In the U.S., a full phalloplasty can cost upwards of $100,000 without insurance. Even with insurance, you’re looking at deductibles, travel costs (since there are only a handful of elite surgeons), and months of missed work. Many guys spend years "saving up" their sick leave or running GoFundMe campaigns just to afford the stay at a medical hotel.
Organizations like Jim Collins Foundation or Point of Pride offer grants, but the demand is way higher than the supply.
Then there is the hair removal. If you’re getting a phalloplasty using your arm, that skin needs to be hairless. That means a year of electrolysis or laser hair removal before you even step foot in the OR. If you don't do it, you could end up with hair growing inside your urethra. Yeah. Do the hair removal.
The Question of Sensation
This is what everyone asks about. "Will I feel anything?"
The answer is almost always yes, but it’s a journey. In a phalloplasty, surgeons perform a "nerve hookup." They take a sensory nerve from the graft and stitch it to one of your existing nerves. It takes months for those nerves to regrow—about an inch a month. At first, the phallus is numb. Then it tingles. Eventually, most people develop tactile and even erotic sensation. In metoidioplasty, sensation is usually unchanged or even enhanced because the clitoral head is more exposed.
Actionable Steps for the Path Ahead
If you are seriously considering bottom surgery for a trans man, don't just jump at the first surgeon you see on Instagram. This is a life-altering medical marathon.
Start with your primary care provider. You will need letters of support from mental health professionals—usually two—to meet WPATH (World Professional Association for Transgender Health) standards for insurance coverage. Get those started early because therapists often have waitlists.
Research surgeons specifically. Look for "high volume" surgeons. You want someone who does this every single week, not once a month. Look into the "London Team" in the UK, or surgeons like Dr. Chen in San Francisco or Dr. Berli in Oregon. Join private groups on platforms like Reddit (r/phallo or r/metoidioplasty) to see real, uncensored healing photos and read "post-op diaries."
Physical prep is key. If you smoke, quit. Now. Most surgeons won't even look at you if you smoke because it kills the tiny blood vessels needed for a successful graft. Start a skin routine on your donor site. Moisturize. Keep it healthy.
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Build a support system. You cannot do this alone. You need someone to help you out of bed, to manage your meds, and to just sit with you when the recovery gets dark. If you don't have family or friends who can help, look into "recovery houses" near the surgical centers. They are designed for this exact purpose.
Consult with a pelvic floor physical therapist. This is a hidden gem of advice. Strengthening those muscles before surgery—and rehabilitating them after—can significantly lower your risk of urinary issues and help with sexual function later on.
This is a long road. It’s expensive, it’s painful, and it’s complicated. But for the thousands of men who have walked it, the destination is a body that finally, mercifully, feels like home.