FtM Bottom Surgery (Metoidioplasty and Phalloplasty) in Thailand
FtM bottom surgery in Thailand: metoidioplasty or phalloplasty, staged, with urethral lengthening as a separate decision. Four to six weeks per stage. Honest complication rates, plan and price in writing first.
Anaesthesia
General anaesthesia
Operation time
3–5 hours for metoidioplasty; 6–10 hours or longer for phalloplasty, often across staged operations
Hospital / hotel
7 nights / 21 nights
Stay in Thailand
4–6 weeks in Thailand per stage, and most plans have more than one stage
Back to work
Desk work commonly 6–8 weeks after a stage; physical work considerably longer, and longer again after a forearm or thigh flap
Price
Price on request
What FtM Bottom Surgery involves
There are two different operations here and the choice between them is the single biggest decision in this field. Metoidioplasty releases and lengthens the clitoral tissue that testosterone has already grown, giving a small phallus with its own erogenous sensation and its own blood supply. Phalloplasty builds a larger phallus from a skin flap taken from the forearm, the thigh or the back, with nerves connected so that sensation can return over a year or more.
Neither is a smaller or larger version of the same thing. Metoidioplasty is shorter surgery, markedly lower risk, no donor-site scar, spontaneous erection — and a phallus usually too small for penetrative sex and sometimes too small to stand to urinate reliably. Phalloplasty gives size and, with an implant at a later stage, the possibility of penetrative sex — at the cost of a major flap operation, a permanent donor scar, several stages and the highest complication rate of anything on this site.
Urethral lengthening is a separate decision from either operation, and it is where most complications in this field come from. It is what allows you to urinate standing, and fistula and stricture rates after it are high enough that they are discussed as expected possibilities rather than as rare events. Choosing bottom surgery without urethral lengthening is a legitimate, deliberately simpler path, and anyone presenting standing urination as automatic is not describing the surgery accurately.
Scars: Metoidioplasty leaves scars confined to the genital area. Phalloplasty leaves a permanent donor-site scar: the full circumference of the forearm, or the outer thigh, or the back, depending on the flap — this is usually skin-grafted and it is a visible, lifelong scar that should weigh in the choice of donor site
Who it suits — and who it does not
Good candidates
- ✓Adults with a documented diagnosis of gender dysphoria and the assessment letters your plan requires, confirmed in writing before you book
- ✓On stable testosterone therapy, which is what provides the growth metoidioplasty relies on
- ✓Able to be away for four to six weeks per stage, and to come back for later stages — this is a multi-year plan, not a trip
- ✓Permanent hair removal of the urethral donor skin completed where the plan calls for it, because hair inside a urethra causes stones and blockage
- ✓Non-smokers without exception for flap surgery. A flap depends on microvascular blood supply and nicotine is a direct cause of flap failure
- ✓Someone who has read the complication rates and accepts that more than one operation is likely
- ✓Realistic about the goal they are choosing: sensation and simplicity, or size and penetrative capacity. Both are legitimate; wanting all of it from one operation is not available
Usually advised against
- –Anyone who has not made the fertility decision. Hysterectomy ends fertility permanently and egg freezing is a decision with a deadline
- –Smokers and vapers who will not stop. For phalloplasty this is a contraindication, not advice
- –Uncontrolled diabetes, a clotting disorder, significant cardiac or respiratory disease, or a BMI the surgical team judges unsafe for long surgery
- –Expecting one operation and a finished result in six weeks
- –Unable to accept a permanent, visible donor-site scar — in which case metoidioplasty, or bottom surgery without a flap, is the honest route
- –Documentation not in order, or relying on paperwork being accepted without confirming it first
- –No support at home and no flexibility in work or travel dates across a plan that spans a year or more
Techniques and options
Metoidioplasty
The ligaments around the testosterone-enlarged clitoris are released and the surrounding tissue reshaped to free it as a phallus. Because it is your own tissue on its own nerves and blood supply, erogenous sensation is kept and erection is spontaneous. Surgery is shorter, there is no donor site and the complication rate is far lower than phalloplasty. The limitation is size: commonly around 4–6 cm, not sufficient for penetrative sex, and standing urination is possible with urethral lengthening but less reliable than after phalloplasty. Many people choose it precisely because the trade is sensation and safety for size.
Phalloplasty — radial forearm flap
Skin, fat and nerves are taken from the forearm as a free flap and the blood vessels are joined microsurgically in the groin. It gives thin, pliable tissue that suits urethral construction and reliable nerve connection, which is why sensation outcomes are generally good. The cost is the donor site: the scar is the circumference of the forearm, skin-grafted, permanent and visible in short sleeves for life. Some people accept that readily and some will not, and it is worth looking at photographs of healed forearms before deciding.
Phalloplasty — anterolateral thigh (ALT) or latissimus dorsi flap
The flap is taken from the outer thigh, as a pedicled or free flap, or from the back. The donor scar is concealed by clothing, which is the main reason people choose it. The trade-off is bulk: thigh tissue is thicker, which can make urethral construction and later implant placement harder, and may need debulking in a later stage. Thigh and back flaps are also generally less favourable for sensation than the forearm.
Urethral lengthening
The urethra is extended through the new phallus using vaginal lining, buccal (inner cheek) mucosa, labial skin or a combination. It is what allows urination standing, and it is the source of most complications in this field: fistula — a leak along the new urethra — and stricture, a narrowing that obstructs flow. Rates reported in the literature are high, which is why plans are staged, why the first stage often builds the urethra separately, and why revision is treated as an expected part of the pathway rather than a failure. Choosing to skip it is a valid decision that substantially lowers the risk of the whole plan.
Vaginectomy, scrotoplasty and the implant stage
Vaginectomy — removal of the vaginal lining — is usually required where that lining is used for the urethra, and is a separate decision with its own recovery. Scrotoplasty creates a scrotum from labial tissue, with testicular implants placed at a later stage once healing is complete. An erectile device, when it is part of the plan at all, is implanted a year or more after the flap, because the phallus has to have healed and regained protective sensation first — an implant in a numb phallus erodes.
What happens on surgery day
- 1
A staged plan is agreed before anything is booked. Most plans involve two or three operations spread over a year or more, and the plan states what happens in each stage and what it costs.
- 2
Arrival a week or so before the first operation for consultation, examination, blood tests, imaging where needed and anaesthetic review. For flap surgery the donor site is assessed specifically, including a test of the hand's blood supply before a forearm flap is accepted.
- 3
Hysterectomy and vaginectomy are performed in the same stage as the genital surgery in some plans and separately in others, depending on your health and the surgical teams involved.
- 4
Metoidioplasty: release and reshaping, with urethral lengthening if that is part of the plan, commonly three to five hours. Phalloplasty: flap harvest, microvascular anastomosis, urethral construction and shaping, commonly six to ten hours or longer.
- 5
A urinary catheter — often suprapubic, through the lower abdomen — stays in for weeks, not days, where a urethra has been constructed. You go home with it and it is removed after a test that shows the new urethra is watertight.
- 6
Several days to a week in hospital, with flap monitoring hourly at first after phalloplasty. The first 72 hours are when flap problems declare themselves, which is why this stay is not shortened.
- 7
Discharge to a hotel nearby for the rest of the four to six weeks, with scheduled wound and flap checks and donor-site dressing changes.
- 8
Clearance to fly from the surgical team only — long-haul flying with a healing flap and a catheter is a medical decision, not a booking decision.
Recovery timeline
Days 1–7
Hospital. Flap monitored closely after phalloplasty, bed rest then assisted walking, catheter in place, pain managed with regular medication. Donor site dressed and immobilised after a forearm flap.
Weeks 2–4
In Thailand. Wound and flap checks, donor-site dressing changes, catheter care taught. Swelling substantial. Walking short distances; no sitting astride anything, no cycling, no lifting.
Weeks 4–6
Urethral testing where applicable and catheter removal on the surgical team's schedule. Clearance to fly once wounds are stable. Many people fly home still cautious rather than comfortable.
Months 2–3
Desk work usually possible from around week 6–8. Donor-site graft maturing and often itchy and fragile. Hand physiotherapy after a forearm flap.
Months 3–12
Sensation returns gradually in a phalloplasty flap, from the base outwards, over 12–24 months. Urethral problems, when they occur, typically declare themselves in this window and are treated as they arise.
Months 12–24
Later stages — testicular implants, debulking, glansplasty, erectile device — are planned once healing and sensation allow. Scars mature. This is when the result becomes the result.
Long term
Urological follow-up for life where a urethra has been constructed: flow, infections and stones are things to watch rather than assume away.
Results — and their limits
What metoidioplasty reliably delivers: a phallus of your own tissue with erogenous sensation and spontaneous erection, with a far lower complication rate than phalloplasty and no donor scar. What it does not deliver: size sufficient for penetrative sex.
What phalloplasty reliably delivers: size and appearance. What it delivers over time: sensation, returning from the base outwards over one to two years, usually protective and often erogenous, but variable and not guaranteed.
Standing urination is the goal of urethral lengthening and it is achieved in most cases — after a pathway that commonly includes at least one complication and at least one corrective procedure. Presenting it as a routine outcome of a single operation is misleading.
Penetrative sex requires an erectile device, implanted in a later stage, and implants have their own failure and erosion rates and a limited lifespan — they are replaced, not permanent.
The donor scar after phalloplasty is permanent and in forearm cases visible. Grafts mature over a year or more and stay a different colour and texture from the surrounding skin.
More than one operation is the norm. A plan presented as a single definitive surgery with no revision stage is not a realistic plan.
When it is final: Allow 12–24 months and more than one operation. Erectile device implantation, when it is part of the plan, comes a year or more after the flap has healed and sensation has returned
Risks and how they are managed
Every operation carries risk. These are the ones that matter for this procedure, and what is done to reduce, spot or treat each.
Urethral fistula — a leak along the new urethra
One of the two commonest complications of urethral lengthening, and common enough to be discussed as likely rather than rare. Many close on their own with the catheter left in longer; the rest are repaired surgically, usually after the tissue has settled for some months rather than immediately.
Urethral stricture — narrowing that obstructs flow
The other common complication. Watched for with flow testing and symptoms, treated with dilation, internal incision or a staged reconstruction depending on where and how long it is. This is the main reason urological follow-up is lifelong.
Partial or total flap failure (phalloplasty)
The catastrophic one, and the reason the first 72 hours are spent in hospital with hourly flap checks. Prevented by microsurgical technique, by absolute avoidance of nicotine, and by assessing the donor vessels before accepting the flap. Partial loss is debrided and reconstructed; total loss means starting again from a different donor site.
Donor-site problems
Graft loss, delayed healing, stiffness, altered sensation and permanent scarring at the forearm, thigh or back. Managed with immobilisation, dressings and physiotherapy; the scar itself is permanent and belongs in the donor-site decision rather than in the consent form.
Hair inside the urethra, causing stones and blockage
Prevented, not treated: permanent hair removal of the skin used for urethral construction has to be completed before surgery. This is a preparation step with a months-long lead time.
Wound infection, haematoma and delayed healing
Antibiotic cover, drains where indicated, and scheduled checks for the whole four to six weeks rather than a single post-operative visit.
Erectile device erosion, infection or mechanical failure
The reason implantation waits a year or more until protective sensation has returned — a numb phallus cannot warn you that an implant is pressing through. Devices have a finite lifespan and are revised or replaced over the years.
Loss or alteration of sensation
Nerves are connected deliberately in phalloplasty and sensation returns slowly and variably. Metoidioplasty keeps native sensation, which is one of its strongest arguments.
Clots, chest infection and the general risks of very long general anaesthesia
Anaesthetic fitness assessed before travel, compression and early mobilisation, and staging the plan rather than combining everything into one marathon operation.
Permanent loss of fertility after hysterectomy
Not a complication but a certainty. Egg or embryo freezing is arranged at home before surgery, and it is a decision with a deadline.
Need for further surgery
Expected rather than possible. Your plan states the stages, what each costs and what happens if a complication needs correcting — before you book, not after.
Package and cost
Price on request
Priced per case and per stage, not from a list, because this is the most variable operation we arrange. What moves the figure: metoidioplasty or phalloplasty, which donor site, whether urethral lengthening is included, whether hysterectomy and vaginectomy are part of the plan, how many stages your plan needs and how long each stay is. Send your history and your letters and you get the staged plan, the stays, the inclusions and the price for each stage in writing — with the hospital and surgeon suited to your case named in that plan — before you commit to anything.
Included
- ✓A staged written plan before you commit: which operation, which donor site, whether urethral lengthening is included, the stages, the stays, the inclusions and the price for each stage — with the hospital and surgeon suited to your case named in it
- ✓Pre-operative consultation, examination, blood tests, donor-site assessment and anaesthetic review in Thailand
- ✓Surgeon, microsurgical team, anaesthetist and theatre fees for the stage in the plan
- ✓Hospital stay with flap monitoring, nursing care and in-hospital medication
- ✓Catheter, drains, dressings and donor-site care during the stay
- ✓Hotel accommodation for the post-discharge part of the stay
- ✓Airport, hospital and clinic transfers
- ✓Scheduled wound, flap and urethral checks, and catheter removal, until you are cleared to fly
- ✓Operative report, imaging and discharge summary, issued before you leave the country
- ✓A coordinator who holds your file between stages and is the route back to the team that treated you
Not included
- –Flights, travel insurance and visa costs
- –Later stages, which are planned and quoted separately as each becomes due
- –Permanent hair removal of the urethral donor skin, done at home over months before surgery
- –Fertility preservation — egg or embryo freezing is arranged and paid for at home, before surgery
- –Mental health assessments and the letters your plan requires
- –Testosterone therapy and your ongoing prescriptions
- –Hand or limb physiotherapy once you are home after a flap
- –Your companion's flights and meals; their room is quoted with the plan
- –Erectile and testicular devices, which belong to a later stage and are quoted then
- –Treatment of complications after you have gone home, and care from your local doctor or urologist
How to compare this with a quote at home
Ask any clinic for the same list: surgeon and anaesthetist fees, hospital nights, tests, medication, garments or splints, follow-up visits. A cheaper headline price usually excludes several of these. Then add your flights and insurance to our price for a like-for-like comparison.
How to prepare
- 1.Decide the real question first: sensation and simplicity, or size and penetrative capacity. Everything else follows from that, and no technique gives all of it.
- 2.Make the fertility decision deliberately, before any operation that includes hysterectomy.
- 3.Complete permanent hair removal of the skin that will form the urethra, where the plan calls for it. This has a months-long lead time and cannot be rushed.
- 4.Get your assessment letters, and let us confirm in writing exactly what your plan requires before you buy a flight.
- 5.Stop smoking and all nicotine completely. For flap surgery this is not advice; surgery is cancelled rather than risked.
- 6.Blood tests, imaging and donor-site assessment as instructed, including a test of the hand's blood supply before a forearm flap.
- 7.Stop anti-inflammatories, fish oil and supplements that affect bleeding on the timescale the surgical team gives.
- 8.Plan the time honestly: four to six weeks per stage, across a plan that spans a year or more. Arrange work, income and support around that before you start, not after the first stage.
- 9.Identify a doctor and, ideally, a urologist at home who will see you for post-operative issues, and tell them before you travel.
- 10.Book a changeable return flight.
Aftercare at home
- •Catheter care as taught, for weeks rather than days where a urethra has been constructed. Removal follows a test showing the urethra is watertight — not a date.
- •Attend every scheduled flap, wound and donor-site check while you are in Thailand. The first three weeks are when problems are cheap to fix.
- •No sitting astride anything, no cycling, no heavy lifting and no strenuous exercise until cleared.
- •Keep the donor site dressed, elevated and immobilised as instructed; start hand or limb physiotherapy on the schedule given after a flap.
- •Report any change in urine flow, spraying, leaking from an unexpected place, fever or increasing pain immediately rather than at the next appointment.
- •Protect scars and grafts from sun for a year; grafts stay fragile longer than they look.
- •Keep urological follow-up for life: flow, infections and stones are the long-term things to watch after urethral lengthening.
- •Contact us between stages and afterwards. We hold your plan and operative documentation and we are the route back to the surgical team for the later stages and for anything that needs them.
Frequently asked questions
Metoidioplasty or phalloplasty — how do I actually choose?
Will I be able to urinate standing?
How many operations and how long will this take?
How bad is the donor scar?
Why is there no price here?
Which hospital and surgeon?
What happens if a complication appears after I am home?
Read more on this treatment
Female-to-Male Gender-Affirming Surgery: Top Surgery, Metoidioplasty and Phalloplasty
What FtM surgery involves and which option fits
Gender-Affirming Surgery: The Questions People Actually Ask
General questions about eligibility, process, recovery and travel
Gender-Affirming Surgery Prices: What Drives the Figure, and How to Check a Quote
What it costs and whether a quote is reasonable
Often considered alongside
Free assessment
Send your details; a coordinator replies with a surgeon’s opinion and a written plan.