Female-to-male (FTM) gender-affirming surgeries, often referred to as “bottom surgeries,” involve altering female genitalia to create male-typical genitalia. The two main procedures for FTM individuals are metoidioplasty and phalloplasty. Here’s a breakdown of how these surgeries are performed:

1. Metoidioplasty:
   • Principle: The principle behind metoidioplasty is to use the clitoral tissue that has been enlarged by testosterone hormone therapy.
   • Procedure:
     • The enlarged clitoris is released from its ligamentous attachments to increase its prominence. This gives the appearance of a small phallus or penis.
     • Urethral lengthening may also be performed, which involves extending the urethra to allow for standing urination. Tissue from the labia minora, vagina, or other areas can be used for this purpose.
     • A vaginectomy (removal of the vaginal tissue) might be performed.
     • Scrotoplasty: The labia majora can be fused together to create a scrotal sac. Testicular implants can later be inserted to give the appearance of testes.
2. Phalloplasty:
   • Principle: Phalloplasty involves constructing a neophallus (new penis) that is larger than what can be achieved with metoidioplasty.
   • Procedure:
     • Skin is typically grafted from another area of the body (commonly the forearm, thigh, or back) to create the phallus.
     • A tubular structure is made from the graft, and it’s attached to the pubic region. The nerves are connected to provide sensation.
     • Urethral lengthening is often more complex in phalloplasty than in metoidioplasty. A longer urethra is constructed using tissue from the mouth, labia, or other areas, allowing for standing urination.
     • Vaginectomy is typically performed.
     • Scrotoplasty: Similar to metoidioplasty, the labia majora can be fused and later filled with testicular implants.

Additional procedures can be done, such as glansplasty (creation of a glans or head of the penis) to enhance the appearance of the neophallus.

It’s important to note:

• Multiple Surgeries: Both metoidioplasty and phalloplasty often require multiple surgeries to achieve the desired result.
• Complications: These surgeries carry risks, including potential complications like fistulas (abnormal connections between the urethra and skin), strictures (narrowing of the urethra), and issues related to grafts or implants.
• Sensation: While efforts are made to maintain and enhance sensation, it can vary depending on the specific techniques used and individual healing factors.

If someone is considering FTM gender-affirming surgery, thorough consultation with experienced professionals is crucial to understand the procedures, potential risks, and expected outcomes.