Female-to-Male Gender-Affirming Surgery: Top Surgery, Metoidioplasty and Phalloplasty

Chest surgery techniques by chest size, metoidioplasty versus phalloplasty with the complication rates stated honestly, how staging works, and how long the whole process really takes.

Written and kept up to date by the CureBooking medical travel team · Last updated October 2026

The short answer

Chest surgery is the operation most people have first, and it is the one with the highest satisfaction and the shortest recovery. The technique depends on chest size and skin elasticity: keyhole or periareolar for small chests, double incision with free nipple grafts for larger ones.

Bottom surgery is two very different paths. Metoidioplasty uses the tissue that testosterone has already enlarged — shorter, far fewer complications, often retaining the ability to orgasm without implants. Phalloplasty builds a larger phallus from a flap taken from the forearm or thigh, in stages over one to two years, with a visible donor scar.

The honest part most marketing leaves out: when urethral lengthening is included — the "stand to pee" part — published complication rates for fistula and stricture are high, and revision surgery is common rather than exceptional. That is not a reason not to do it; it is a reason to plan for it.

Chest surgery: the technique follows your chest, not your preference

Technique	Suits	Trade-offs
Keyhole	Small chest, good skin elasticity, small areolae	Smallest scars, nipple left attached with its own blood supply; no skin removal, so not an option for larger chests
Periareolar (circumareolar)	Small to medium chest with reasonable elasticity	Scar hidden around the areola, some skin tightening possible; higher revision rate for loose skin or contour
Double incision with free nipple grafts	Medium to large chest, or poor elasticity	The flattest, most reliable contour. Two horizontal scars across the chest and grafted nipples with reduced or absent sensation

Revision for "dog ears" at the ends of the incisions, contour irregularity or nipple position is common across all techniques and is normal rather than a failure.

Metoidioplasty versus phalloplasty

This is the decision that shapes everything else, and it is not about which is better. It is about what you want to be able to do, how much surgery you are prepared to have, and how you weigh complication risk against size.

	Metoidioplasty	Phalloplasty
What it uses	The clitoris, enlarged by testosterone, released from its ligaments	A skin and tissue flap from the forearm (radial) or thigh (anterolateral)
Typical length	Modest — commonly a few centimetres	Larger, chosen in the planning
Stages	Often one, sometimes two	Typically two to four over 12–24 months
Erection	Natural erectile tissue, usually sufficient for sensation but not for penetration	Requires an erectile implant at a later stage
Donor scar	None	Visible and permanent at the forearm or thigh
Urethral lengthening	Optional, and the main source of complications	Usually included, same complication profile
Sensation	Native erotic sensation retained	Depends on nerve coaptation; takes many months and is less predictable
Recovery burden	Lower	High: multiple operations, long immobilisation of the donor limb, catheters

Urethral lengthening: the part to understand before you choose

Lengthening the urethra so that you can urinate standing is technically the hardest part of FtM bottom surgery, because it means building a tube from tissue that was not a tube. Published series across centres report fistula — urine leaking from an unintended opening — and stricture, a narrowing that obstructs flow, at rates that make revision a normal part of the pathway rather than a rare event.

Those are figures from the surgical literature generally, not a claim about any one hospital. What they mean practically: if someone presents urethral lengthening as routine and low-risk, they are not describing the field accurately. Ask your surgeon for their own revision rate, how revisions are handled, and who pays for them.

It is also entirely legitimate to choose metoidioplasty or phalloplasty without urethral lengthening. Many people do, keep sitting to urinate, and avoid the single largest source of complications in this surgery.

Hysterectomy and the order of operations

Removal of the uterus and ovaries is a separate laparoscopic operation. Some surgeons require it before or alongside bottom surgery, particularly where vaginectomy is part of the plan; others do not. It ends menstruation and removes the need for cervical screening, and it ends fertility permanently.

If you may want biological children, egg or embryo freezing is a decision with a deadline — before hysterectomy and ideally before long-term testosterone. This is the conversation that cannot be revisited later, and it belongs at the start of planning, not at the end.

What the trip looks like

Chest surgery: typically a short hospital stay and around 7 to 10 days in the country, with drains removed before you fly. Desk work in one to two weeks; no upper-body exercise for about six weeks.
Metoidioplasty: longer — plan on two to three weeks, with a catheter for part of it.
Phalloplasty stage one: the longest stay of anything we arrange. Several weeks in Thailand, with the donor limb immobilised and a catheter in place, then further stages on later trips.
For any bottom surgery, travel with a companion and book a changeable return flight. The schedule is set by healing, not by your calendar.

Risks, stated plainly

Chest surgery: haematoma, seroma, partial or complete loss of a nipple graft, reduced or absent nipple sensation, scar widening or keloid, contour irregularity, and revision — commonly needed and usually minor.
Metoidioplasty: urethral fistula and stricture, wound breakdown, and limited length, which is a known outcome rather than a complication.
Phalloplasty: the above plus flap complications up to partial or total flap loss, donor-site problems including tendon exposure and limited wrist function with a forearm flap, implant infection or erosion at the later stage, and a long process in which each stage carries its own risk.
All of it: clots, infection, anaesthetic risk, and the simple attritional cost of multiple operations across one or two years.
Permanent loss of fertility once the ovaries or uterus are removed.

What has to be ready before you fly

Mental health assessment letters confirming a diagnosis of gender dysphoria. Requirements for the number of letters and who may write them have varied between clinics and over time; we confirm exactly what your plan needs in writing before you book.
Testosterone history. For metoidioplasty the growth testosterone has already produced is literally the raw material, so time on hormones matters surgically, not just administratively.
Fertility preservation decided, not postponed.
Smoking and nicotine stopped. For flap surgery this is not advice, it is a requirement — nicotine kills flaps.
For phalloplasty, hair removal on the donor site, and a frank conversation about the forearm scar if that is the flap you choose.
A plan for the time off work and the help at home. Phalloplasty in particular is not something to do with no support.

How we work on this

We proceed with the partner hospital suited to your case in Thailand, and the hospital and surgeon are named in your written plan before you commit to anything. Which one it is depends on the operation: the teams that do high volumes of chest surgery are not necessarily the teams you want for staged phalloplasty, and that choice is part of what we are for.

Prices are set per case, because the variables are real: which path, how many stages, whether urethral lengthening is included, and whether an implant stage is planned. The plan states the stages, the stay, what is included and the figure, in writing, before you pay anything.

If your expectations and what surgery can deliver do not match — and with phalloplasty that is a real risk — you will hear it from us before you book a flight, not afterwards.

Questions people ask

Which bottom surgery should I choose?

Start from what matters most to you: native sensation and fewer complications point towards metoidioplasty; size and penetrative capacity point towards phalloplasty with an implant stage. Then weigh the number of operations and the donor scar. There is no medically superior option, only a better fit.

Can I have chest and bottom surgery on the same trip?

Chest surgery with hysterectomy is sometimes combined. Chest surgery with phalloplasty stage one is a great deal of surgery in one anaesthetic and is usually a poor idea. The surgeon decides based on your health, and a team that agrees to anything you ask is a warning, not a service.

How long before the result looks final?

Chest: contour settles over three to six months, scars continue to fade for a year or more. Metoidioplasty: a few months. Phalloplasty: one to two years across stages, with sensation developing slowly over that period.

Will I be able to urinate standing?

Only with urethral lengthening, and that is the part with the highest complication and revision rates. Many people deliberately choose not to have it. Ask your surgeon for their own fistula and stricture rate and how revisions are handled before deciding.

Is testosterone enough on its own for some people?

For some, yes — hormonal changes plus chest surgery is a complete plan, and the proportion of trans men who choose no bottom surgery at all is substantial. Nobody needs to justify stopping where they are comfortable.

What does it cost?

We quote per case, because the paths differ so much. Published third-party ranges for Thailand are set out on our pricing page with their sources, so you can sanity-check any quote you receive, ours included.