FTM Bottom Surgery - How do they make a penis?

It's one of the most asked questions concerning transgender surgeries — how do you make a penis? Taking away something — as is the case with male-to-female gender confirmation surgery — is much easier to imagine than creating something out of nothing. This article will give you a detailed description of the whole process of a phalloplasty, female-to-male bottom surgery process. We'll discuss metoidioplasty in the following article. 

Phalloplasty is a bottom surgery that revolves around (re)constructing a penis. Cismen often do this in case of trauma, disease, or congenital defects. Nowadays, it's also a surgery often considered by transgenders and some non-binary people. In that case, it's often referred to as phalloplasty. Regardless of the starting point, the goal is the same; (re-)create an adequate sized penis that can feel sensations and can be used to pee. As you can imagine, this is a complicated surgery, but luckily the techniques are evolving very rapidly.

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The FTM Bottom Surgery Timeline

In this article, we'll walk you through the bottom surgery timeline of creating an FTM penis. Remember that every journey is personal, and the order of the steps varies, and many times not all steps are included. Some choose to combine all or several surgeries, while others decide to spread them out over the years. It all depends on your personal goals and preferences. Usually, the whole process requires surgeons from three specialties: gynecology, urology, and plastic surgery.

The decision

First and foremost, it's imperative to note that FTM bottom surgery is a very invasive and expensive process. Therefore, it's understandable that not everybody feels a desire to undergo it if it's not completely necessary. In the end, whether you have a penis or not doesn't make someone more or less of a man! It has to be something that someone truly desires and has thought about very thoroughly.

Overall, the reasons people decide to get bottom surgery vary. However, for many, the main reason for wanting a (neo)phalloplasty is to pee standing. Other reasons are to be able to achieve penetration and/or to decrease gender dysphoria. 

Research

As stated before, there are numerous ways the bottom surgery procedure can be done, but it usually involves multiple surgeries. And because the procedures require surgeons from three specialties to work together, it's advisable to find an established team. With the help of the internet, you can find teams in your country and often view the results of their previous surgeries.

Additionally, it's advisable to talk to fellow FTM transgender people and ask them about their experiences. Together with the surgical team's expertise, their stories can help you make an informed decision. It's essential to understand and formulate your ultimate goal for the procedure and consider fertility preservation and sexual functioning. From there, you decide where, when, how, and by whom you would like the procedure(s) to be bone. 

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Removal of uterus and ovaries

For many, the first step in the FTM bottom surgery involves removing the uterus (hysterectomy) and the ovaries (oophorectomy). There are many reasons for getting this surgery; for medical reasons, to reduce abdominal pain (caused by the "T"), to avoid pregnancy, to maximize the effects of the "T," to change the gender on official documents, or to reduce dysphoria. For some, this will be the only procedure they get done, but if you have already decided you want other procedures, it's often combined.

Removal of the vagina

The removal of the vagina is called a vaginectomy and usually involves two procedures. First, the vulva lining is removed, and second, the vagina walls are fused, whereafter, the vagina opening is closed. There are many reasons to perform a vaginectomy, but for many, the main reasons are to reduce complications during the urethra's creation in the next procedure. Read more about a vaginectomy here

Creation of the FTM penis

Here we arrive at the central part of the FTM bottom surgery — the creation of the penis. During a phalloplasty, doctors take a flap of skin from a body's donor area to create a new phallus. First, they use the skin flap to create a new urethra and attach it to the existing urethra to lengthen it. This part is necessary if you want to pee standing.

The other part of the skin flap is used to create the penis' shaft, and it's rolled around the new urethra, building a tube-with-a-tube construction. During the procedure, the blood vessels and nerves are preserved and microsurgically reattached to the body, allowing blood flow and sensation in the FTM penis.

The most common practice for this kind of surgery is a radial forearm free-flap (RFF) phalloplasty, in which the doctor takes a flap of skin from the forearm. This because it's supposed to create the highest results of (erotic) sensitivity. Another practice is an anterior lateral thigh (ALT) pedicled flap phalloplasty. The phallus and the urethra are created in the same way as with RFF, but they take skin flap from the thigh. This way is not the preferred choice for many surgeons because it often results in less sensitivity and leaves significant scares, although in a more discreet place. Other common donor locations include the lower abdomen, groin, and torso. Check here if you want to see the results of other people.

You can check out pictures of the procedure on this website. Please be advised that some images might be considered disturbing by some. 

There is another way to create a penis — metoidioplasty. This procedure is significantly less intrusive but also results in a smaller penis. We'll discuss this procedure in detail in another article.

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Creation of the scrotum

After the penis is created, many want to have a scrotum as well. Scrotoplasty is an umbrella term for all (re-)constructive scrotum surgeries. Cismen often undergo this surgery to reduce excessive skin or in case of trauma. In the case of gender affirmation surgery, the labia majora is used to create the scrotum. They use the labia majora because they evolve from the same embryonic structure during development. Therefore, they have the same consistency, nerve endings, and color. The next stage involves implanting testicular implants and is usually performed 6-12 months after the first part. 

Creation of the glans

During a glansplasty (or coronoplasty), the appearance of the glans or corona of the penis is created. This procedure is often combined with the phalloplasty, and the result is a circumcised -looking phallus. The glansplasty doesn't add anymore functionally but is purely an aesthetically based decision. The procedure involves creating a "ridge" with skin from either the FTM penis itself (Munawar procedure) or from a donor area of the body (Norfolk procedure, Gottlieb design, or Horton technique). Here you can get more in-depth information about the various methods. 

Penile implantation for erection

Last but not least, is the penile implantation to make the FTM penis function as closely as possible to a cis-penis. If your goal is to penetrate with your newly acquired apparatus, this is a surgery to consider. As with many of the procedures discussed here, this procedure has been originally developed to help cismen with erectile dysfunctions. Therefore, it had time to develop and improve significantly for over 40 years now.

This procedure can only be done after a successful phalloplasty. There are basically two options; non-inflatable implants and inflatable implants. The non-inflatable implants are steel rods that are inserted into the penis that can then be bent to put the penis into an erected position. The advantages of this kind of implant are that the procedure is straightforward and less expensive. A non-inflatable implant is very easy to use, fully concealed, and very durable; it can last for more than 20 years. The obvious downside is that it leaves you with a semi-erection all the time, which can be awkward and uncomfortable.

If you wish to avoid this, inflatable implants are an option. These implants have two cylinders in the penis' shaft, a reservoir that holds saltwater and a pump. The pump is placed in the scrotum and is used to transport the saltwater into the cylinders to create an erection. If you wish to release the created erection, a valve in the scrotum is pressed, and the saltwater returns to the reservoir. The reservoir can also be placed in the belly, and thus can be larger. As a result, the erection will be harder and resemble a non-assisted erection more closely.   

Whether you decide to have a phalloplasty, a metoidioplasty, or no surgery at all, it has to be your decision! If you are considering having bottom surgery, please keep in mind that not everybody is always satisfied with the results. Additionally, as with any surgery, there are risks involved, and there can be complications.

We advise you to inform yourself well about these potential complications and listen to stories from both sides to make an informed decision about which surgery you want and the reasons behind it. In the meantime, there is always the option to pack with one of the many packing options on our website! Read more about packing here. And remember, it's on the inside that counts! 

Sources:

Author Unknown., Vaginectomy: What Trans Men Need to Know. [online] Metoidioplasty. Available at: https://www.metoidioplasty.net/procedures/ftm-vaginectomy.htm

Author Unknown., 2017. Phalloplasty: Gender Confirmation Surgery. [online] Healthline. Available at: https://www.healthline.com/health/transgender/phalloplasty

Selvaggi G., Hoebeke P., Ceulemans P., Hamdi M., Van Landuyt K., Blondeel P., De Cuypere G., Monstrey S., 2000. Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty. Plastic & Reconstructive Surgery Journal. 

Trans Health Editors., 2013. Penile Implants: The Total Guide For Transsexual Men. [online] Trans Health. Available at: http://www.trans-health.com/2013/penile-implants-guide/