What is Bottom Surgery for Transgender Men (FTM)? A Complete Expert Guide

Bottom surgery refers to a variety of surgical procedures that alter the physical appearance and function of existing genital structures to align more closely with a transgender person‘s gender identity. For transgender men, or female-to-male (FTM) individuals, bottom surgery transforms female genital characteristics into male ones.

This in-depth expert guide will answer:

• What are the different types of FTM bottom surgery procedures?

• What surgical techniques are involved and what results can be expected?

• What factors should go into deciding if bottom surgery is right for you?

• Is undergoing bottom surgery ultimately worth it for transgender men?

Let‘s explore the world of FTM bottom surgeries in more detail.

Overview: Bottom Surgery Options for Transgender Men

There are three main categories of bottom surgery available to transgender men seeking to transition anatomically from female to male:

• Metoidioplasty – Uses the hormones-enlarged clitoris to construct a small neophallus, often combined with scrotoplasty and testicular implants. This creates male external genitalia, albeit smaller in size than phalloplasty.

• Phalloplasty – Creates a large neophallus (penis) using a skin graft from a donor site on the body, such as the forearm, thigh, or abdomen. Allows for urination while standing.

• Scrotoplasty – Uses labia majora tissue to construct a masculine scrotum. Testicular implants are commonly inserted to contribute to a natural male anatomy.

These procedures are done in tandem with a hysterectomy to remove female internal reproductive organs and a vaginectomy to close off the vagina. Some transgender men opt solely for the hysterectomy/vaginectomy without bottom surgery. Others may start with metoidioplasty, then later opt for phalloplasty for a larger phallus.

Surgery is customized to each patient‘s unique goals. The sections below explore common FTM bottom surgery procedures and considerations in more detail.

Metoidioplasty: Using the Enlarged Clitoris

In metoidioplasty surgery, the clitoris enlarged by testosterone hormone therapy is used to form a small neophallus, typically 2 to 4 inches in length when erect. The clitoral nerves, erectile tissues, and blood vessels are preserved in order to maintain sensation and enable capability for erection and orgasm.

The procedure has two main components:

• Clitoral release – The suspensory ligament anchoring the clitoris is severed, allowing the clitoris to extend further. Excess skin may be excised.

• Urethral lengthening – The urethra is elongated using surrounding vaginal tissues so the neophallus can be used to urinate while standing. A urethral opening is created at the tip of the neophallus.

Metoidioplasty is often combined with:

• Scrotoplasty – The labia majora are used to construct a masculine scrotum.

• Testicular implants – Silicone testicular prosthetics are inserted into the neoscrotum if desired.

Advantages of metoidioplasty include:

• Shorter, simpler procedure than phalloplasty – takes 2-3 hours

• Safer surgical technique with lower risk of complications

• Preserves erogenous sensation in the clitoris

• Allows ability to urinate while standing

• Capable of erection and orgasm

• Appears natural, since using one‘s own tissue

Disadvantages include:

• Results in a smaller phallus – average 2-4 inches when erect

• Cannot achieve penetration for penetrative sex

• Visible scars in genital region, though minimally

According to data from the United States Transgender Survey, metoidioplasty has a 96% satisfaction rate among transgender men surveyed. Given the less complex surgery and lower risk, metoidioplasty may be a preferable first stage before potentially undergoing phalloplasty later.

Phalloplasty: Creating a Large Neophallus

Phalloplasty aims to create a large, functional neophallus for transgender men who desire a larger penis than metoidioplasty allows. This complex surgery uses a large graft of skin and soft tissue from a donor site on the body. Common donor sites include:

• Forearm – Provides a large graft with sufficient tissue bulk and sensory nerves. Leaves a highly visible scar.

• Thigh – Less conspicuous donor site, but lower quantity/quality of tissue.

• Abdomen – Scar can be hidden by clothing, but less erogenous sensation.

The graft is detached on a vascular pedicle containing the blood supply, then sculpted into a phallus shape and relocated to the genital region. The urethra is elongated within the neophallus either using surrounding vaginal tissue or directly connecting the native urethra within the graft.

In a separate subsequent procedure, an erectile prosthesis like a penile implant is inserted to enable erection capability. Many patients also undergo scrotoplasty and testicular implants for aesthetic appearance.

Key features of phalloplasty:

• Creates neophallus of 5-7 inches, larger than metoidioplasty

• Allows urinating while standing with urethral extension

• Erectile prosthesis enables erection and penetrative sex

• Gives natural, anatomically male aesthetic appearance

• Multi-stage procedure – initial surgery 8-10 hours, multiple follow-ups

• Higher risk of complications – flap failure, strictures, fistulas

According to data, approximately 80-85% of phalloplasty patients report satisfaction with aesthetic appearance and function. However, complication rates are also higher compared to metoidioplasty. Proper aftercare and commitment to follow-up procedures are essential.

Scrotoplasty and Testicular Implants

Scrotoplasty and testicular implants are often incorporated with either metoidioplasty or phalloplasty procedures to complete the masculine genital anatomy:

• Scrotoplasty – The labia majora are used to create the scrotal sac. The edges are sutured together in the midline raphe. Loose wrinkled skin results in a natural scrotum appearance.

• Testicular implants – Silicone testicle-shaped implants approximately 40-50cc in volume are inserted into the neoscrotum. This provides the look and feel of anatomical testes.

Together, scrotoplasty and testicular implants contribute greatly to the male aesthetic outcome transgender men seek from bottom surgery. The additional procedures add 1-2 hours of operating time.

Hysterectomy and Vaginectomy

A hysterectomy to remove internal female reproductive organs and a vaginectomy to close off the vagina are also commonly done in conjunction with FTM bottom surgery.

• Hysterectomy – The uterus and sometimes ovaries are removed via incisions in the abdomen or vaginally. This eliminates any possibility of pregnancy.

• Vaginectomy – The vaginal canal is surgically removed and the vaginal opening sewn closed. This eliminates vaginal lubrication and discharge.

For many transgender men, excising these residual female structures provides further relief of gender dysphoria. The procedures add 2-3 hours to the total surgery time.

What Factors Should Go Into the Decision for Surgery?

Deciding whether to undergo FTM bottom surgery is a highly individual determination. Some key factors transgender men commonly consider include:

• Cost – Bottom surgeries range from $10,000 – $50,000+, with metoidioplasty less expensive than phalloplasty. Many procedures may not be covered by insurance.

• Appearance – Those who desire a larger phallus may opt for phalloplasty, while others are satisfied with metoidioplasty results.

• Function – Priorities include standing urination, erogenous sensation, erection/orgasm capabilities, depth for penetrative sex.

• Risks – Complication rate around 15-20%. Main risks include tissue death, strictures, fistulas, prosthesis failure over time.

• Recovery – Initial healing takes 4-6 weeks, complete healing up to 1 year. Multiple procedures usually required.

Some key questions to consider:

• How distressing is your current anatomy? Will surgery significantly relieve gender dysphoria?

• Are there nonsurgical alternatives that could meet your needs?

• Do you have social/community support during your transition?

• Are you willing and able to commit to an extensive recovery process?

• Does your surgeon have specialized expertise performing this procedure with good outcomes?

Thorough counseling to address expectations and weigh your priorities is recommended. Many find connecting with others who have undergone surgery to be helpful when making this decision.

Perspectives: Is FTM Bottom Surgery Ultimately Worth It?

The decision of whether bottom surgery is “worth it” depends heavily on the individual and their goals. Here are some perspectives from transgender men who have undergone bottom surgery:

• “This surgery was life-saving for me. I suffered extreme discomfort with my female anatomy to the point of being unable to function. Having anatomy that matches who I am as a man has given me my life back.”

• “While recovering from a phalloplasty is no picnic, finally feeling comfortable being intimate with my partner makes all the challenges worthwhile. My only regret is not getting it sooner.”

• “Opting not to get bottom surgery does not make me any less of a man. I’ve come to terms with my body over time and prefer to avoid a major surgery.”

• “I thought phalloplasty was the only way to truly relieve my dysphoria. But after complications, loss of erotic sensation, and years of repairs, I wish I’d given more thought to metoidioplasty or non-surgical options which may have been sufficient for me.”

In surveys, 87-97% of transgender men report being satisfied with their surgical results, with high improvements to gender dysphoria, sexual function, and quality of life. While bottom surgery carries risks, those whose suffering around their anatomy is severe often find the benefits outweigh the costs when chosen thoughtfully.

Finding a Surgeon and Planning Your Procedure

Choosing an experienced bottom surgery surgeon who specializes in FTM procedures is critical to achieving optimal aesthetic, functional, and psychosocial outcomes. Here are some tips:

• Look for a board-certified plastic surgeon or urologist with years of focused training in transgender surgeries.

• Ask to see before/after photos and speak with former patients about their results.

• Have in-depth consultations to discuss technique, approach to preserving erotic sensation, expected results, and aftercare.

• Confirm your surgeon has had no major disciplinary actions or malpractice claims against them.

• Undergo a full medical evaluation to identify any risk factors needing optimization before surgery.

• Discuss the staging – some complete procedures in a single stage, while others use a multiple stage approach.

With an experienced surgeon you trust fully briefed on your goals and anatomy, you can develop a customized treatment plan to fulfill your vision.

Recovering from FTM Bottom Surgery

Recovering properly after bottom surgery is vital to outcomes. Here‘s what to expect:

• Initial hospitalization – 1-2 days inpatient to monitor for complications like bleeding.

• Early healing phase – 4-6 weeks of limited mobility to allow incisions to close. Swelling and bruising is common.

• Later healing – Return to non-strenuous work by 6 weeks. No sexual activity for minimum 3 months.

• Long-term healing – Complete remodeling of tissues occurs over 6-12 months. Maximum results are seen by 1 year.

• Impact to urination – Catheterization for 3-6 weeks until swelling subsides and urethral hookup heals.

• Pain – Significant discomfort managed with medication for 2-4 weeks, tapering subsequently.

• Aftercare – Regular follow-up appointments for at least 1 year to monitor for complications.

Adhering closely to your surgeon‘s postoperative instructions is crucial to proper healing. Have a strong support network to assist you during recovery.

Insurance Coverage for FTM Bottom Surgery

Due to costs ranging $10,000-$50,000+, insurance coverage is an important consideration for those seeking FTM bottom surgery. Currently:

• Medicare – Covers gender-affirming surgeries including bottom surgery based on recent policy changes. Requires detailed documentation of medical necessity.

• Medicaid – Varies by state. Around half of US states explicitly cover transition-related surgeries through Medicaid programs.

• Private insurers – Many now offer transgender-inclusive health benefits, but confirm coverage specifics in your state. Get pre-authorization.

Out-of-pocket, bottom surgeries typically cost:

• Metoidioplasty – $10,000 – $15,000

• Phalloplasty – $20,000 – $50,000

• Scrotoplasty with implants – $2,000 – $10,000

Talk to your insurer early about requirements like letters from mental health providers documenting gender dysphoria to understand coverage. Seek financial assistance resources if needed.

Closing Thoughts

Pursuing bottom surgery is a deeply personal choice for transgender individuals seeking congruence between their gender identity and anatomy. For transgender men greatly impacted by gender dysphoria, undergoing procedures like metoidioplasty, phalloplasty and scrotoplasty enables them to fully inhabit their male identities.

While not without risks, FTM bottom surgery techniques allow for standing urination, natural aesthetic appearance, sexual function, and immense relief of dysphoria when aligned with the patient‘s goals and performed by a skilled surgeon. With thorough self-reflection and education on the options, transgender men can make the most informed choice about whether undergoing bottom surgery is ultimately the right decision for their journeys.