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Masculinizing Procedures

Masculinizing gender-affirming procedures span the chest, genitalia, reproductive organs, and (rarely) face / voice, each with distinct techniques, outcomes, and considerations. For overview principles see GAS Overview; for revisions see Revision & Salvage GAS.

Chest Masculinization (Top Surgery)​

Top surgery is the most commonly performed and most frequently prioritized masculinizing procedure, with 95.9% of transgender men who have undergone any GAS having had chest surgery.1 It consists of subcutaneous mastectomy, reduction and repositioning of the nipple-areola complex, and chest contouring with liposuction when needed.2

Surgical Techniques​

  • Double incision with free nipple grafting (DIFNG) — the most common technique (~67–89% of cases), used for larger breasts. Bilateral inframammary incisions, removal of breast parenchyma, and free nipple-areola grafting to a masculinized position.34
  • Periareolar / semicircular technique (PAT) — used for smaller breasts with good skin elasticity. Preserves the nipple on a pedicle, resulting in less visible scarring but higher revision rates.4
  • Pedicled nipple techniques (PNT) — intermediate option preserving nipple vascularity and sensation on a pedicle.4

A systematic review of 3,055 patients found that DIFNG had the lowest complication rates, followed by PNT, then PAT. However, PAT yielded significantly higher patient-satisfaction scores than DIFNG, reflecting the trade-off between complication risk and aesthetic outcome.4

Outcomes​

  • Complication rates are low — 2.7% major-complication rate in one institutional series, with a 5.4% revision rate. Concomitant liposuction significantly reduced the need for revision surgery.3
  • In the NSQIP database (755 cases), overall complication rates were 4.7% for mastectomy and 3.7% for reduction, with no significant difference between techniques.5
  • Satisfaction and mental health — 86% reported improvement in gender-dysphoria-related mental health conditions; quality of life and sexual confidence improved significantly (p < 0.001).6
  • A prospective matched study in adolescents and young adults demonstrated significant improvement in chest dysphoria, gender congruence, and body-image satisfaction at 3 months postoperatively, with minimal complications comparable to adults.7

Eligibility — WPATH SOC 8 does not require prior hormone therapy for chest surgery, unlike most other GAS procedures. There is no predetermined minimum age; patients are assessed individually for readiness.78

Metoidioplasty​

Metoidioplasty involves construction of a microphallus from the hormonally hypertrophied clitoris, offering a simpler one-stage option for patients who do not require penetrative sexual function.910

Surgical steps include clitoral release and lengthening, urethral lengthening (if standing micturition is desired), vaginectomy, and scrotoplasty with testicular prosthesis implantation.1011

Outcomes (largest series, 938 patients)10​

  • Mean neophallus length 4–10 cm (mean 5.6 cm).
  • Standing micturition achieved in 99% of cases.
  • Full erogenous sensitivity preserved in all patients; erogenous sensation rated 4.8/5 (vs 3.4/5 for phalloplasty).12
  • Penetrative intercourse generally not possible due to small neophallus size.
  • 12.5% of patients subsequently requested phalloplasty.

Complications​

  • In the largest series (813 patients), urethroplasty was complication-free in 89.5% of cases; urethral fistula occurred in 8.85% and stricture in 1.7%.13
  • However, a Belgian cohort reported urethral complications in 56.8% of patients, with additional urethral lengthening (AUL) being a significant predictor (OR 15.5 for all urethral complications). Smoking was an independent risk factor for fistula (OR 6.54).14
  • Testicular implant rejection occurred in 2% and displacement in 3.2%.13

Satisfaction — 79% totally satisfied and 20% mainly satisfied (99% combined).13

Phalloplasty​

Phalloplasty is the most complete genital transformation, aiming to create a sensate, aesthetic neophallus capable of standing micturition and, with a penile prosthesis, penetrative intercourse.29

Flap Options​

Flap TypeKey AdvantagesKey DisadvantagesFlap Failure Rate
Radial forearm free flap (RFFF)Gold standard; single-stage phallus + neourethra; best aestheticsForearm scarring; highest urologic complication rate (60%); requires microsurgery~1.9%
Anterolateral thigh (ALT) pedicledLess operative time (290 vs 516 min); concealed donor siteBulkier flap; may require thinning~0.6%
Musculocutaneous latissimus dorsi (MLD)Adequate length / girth; minimal donor-site morbidityTechnically complex; requires microsurgery—
Pedicled abdominal flapLowest overall complication rate (40.9%); no microsurgeryLess aesthetic; limited sensation—
Fibula osteocutaneousIntrinsic rigidity; no prosthesis neededSignificant donor-site morbidity—

Sources: 215161718

A 2025 systematic review of 769 patients (614 RFFF, 155 pALT) found comparable flap survival and patient satisfaction (~78% vs 76%) between RFFF and pALT, though ALT required significantly less operative time.15

Urethral Reconstruction — The Most Challenging Aspect​

Three main staging strategies exist: (1) single-stage phalloplasty with full-length urethroplasty, (2) metoidioplasty-first two-stage approach, and (3) phalloplasty-first "Big Ben method."19

  • Overall urethral complication rates are high — a meta-analysis of 1,566 patients found a pooled fistula / stenosis rate of 48.9% across all techniques. A multicenter patient-reported survey found urethrocutaneous fistula in 40% and urethral stricture in 32%.1220
  • The Big Ben method (two-stage, phalloplasty-first) demonstrated a lower total urologic complication rate of 27%, with 96% achieving standing urination and 96% expressing willingness to undergo the procedure again.21
  • A 2026 study found that RFFF had the highest urologic complication rate (60%) compared with ALT (20%) and pedicled abdominal flaps (9.1%), though RFFF is preferred for aesthetic outcomes.16
  • After treating complications, 91.5% of patients achieve standing micturition and 88% report tactile or erogenous sensation.20

Neophallus dimensions — mean erect length of 14.1 cm after phalloplasty vs 5.5 cm after metoidioplasty.12

Penile Prosthesis Implantation​

A penile prosthesis is required for erectile function and penetrative intercourse after phalloplasty, as the neophallus lacks the corpus cavernosum. This is typically placed as a staged procedure months after phalloplasty.2

Types and Outcomes​

  • Inflatable prostheses — overall complication rate 38%; most common complications infection (14.5%), dysfunction (12.9%), dislocation (5.7%), and leakage (5.4%). Explantation rate 19%.22
  • Malleable (semirigid) prostheses — overall complication rate 37%; most common complications dislocation (14.9%), infection (11.2%), dysfunction (9.1%), and extrusion (7.6%). Explantation rate 13%.22
  • No significant difference in complication or explantation rates between inflatable and malleable types.22
  • Five-year retention rates range from 42–78%, lower than in cisgender men, though satisfaction rates are similarly high.23
  • A 2025 Dutch cohort study of ZSI FTM-specific prostheses reported a 3-year explantation-free survival of only 39% (hydraulic) and 31% (malleable), with secondary implantations carrying 3.5× higher complication risk.24
  • Surgical experience matters — infection probability decreased significantly with increasing case number at one center.25

Hysterectomy and Bilateral Salpingo-Oophorectomy (HBSO)​

Hysterectomy with or without BSO is considered medically necessary for patients with gender dysphoria who desire it, per ACOG.26 Approximately 0.3% of hysterectomies in the U.S. are performed for transgender men.27

Key Considerations​

  • Route — laparoscopic approach is used in ~96.5% of cases. Vaginal hysterectomy is possible but may be technically difficult due to lack of uterine descent and severe vaginal atrophy from testosterone.2628
  • Oophorectomy decision — should be individualized based on fertility desires, long-term hormone plans, and patient preference. In cisgender women, oophorectomy is associated with increased cardiovascular events and all-cause mortality due to estrogen loss; whether this applies to transgender men on testosterone is unknown.29
  • Combined surgery — HBSO can be safely combined with chest surgery in a single session. In a cohort of 142 patients, the combined approach had a 10.5% complication rate (thoracic hematoma most common at 7.6%), with satisfaction scores of 9.9/10.28
  • Fertility preservation — clinicians should counsel about definitive infertility and discuss oocyte or embryo cryopreservation before surgery. In practice, very few transgender men carry a pregnancy or use their oocytes after gender-affirming treatment.30
  • Bone health — testosterone may have an anabolic effect on cortical bone; if provided in adequate doses, it will prevent bone demineralization after oophorectomy.26

Vaginectomy​

Vaginectomy (colpocleisis) is typically performed at the time of phalloplasty or metoidioplasty if standing micturition is desired, as the vaginal tissue may be used for urethral lengthening.231 A persistent vaginal cavity / remnant occurred in 9.6% of metoidioplasty cases and is a recognized long-term complication requiring surveillance.1332

Voice and Facial Surgery​

Unlike transfeminine patients, transmasculine individuals rarely require voice or facial surgery.9 Testosterone therapy alone effectively deepens the voice and masculinizes facial features (facial-hair growth, fat redistribution, jawline changes). Voice deepening from testosterone is generally permanent.

Perioperative Testosterone Management​

Evidence supports continuation of testosterone perioperatively. See also the Gender-Affirming Hormone Therapy hub.

  • In a study of 490 patients undergoing top surgery, there was no difference in rates of hematoma (2.9% vs 2.8%), seroma, VTE, or overall complications between those who continued vs discontinued testosterone.33
  • A systematic review in JAMA Surgery concluded that exogenous testosterone was not associated with increased VTE risk or other surgical complications, and routine discontinuation is not supported by evidence.34

Long-Term Satisfaction and Regret​

Across all masculinizing procedures, outcomes are durable with very low regret:

  • Regret rate — pooled prevalence of 0.8% for transmasculine patients (vs 4.0% for transfeminine), significantly lower than regret after breast reconstruction (0–47%), prostatectomy (30%), or bariatric surgery (up to 19.5%).3536
  • Satisfaction — 82% of all GAS patients reported high surgical satisfaction, with reproductive surgeries rated most satisfactory (mean 4.6/5). Younger transmasculine patients had higher odds of high satisfaction.1
  • 40-year follow-up — body-congruency scores for chest, body hair, and voice ranged from 84.2 to 96.2. Improved mental health outcomes persisted with significantly reduced suicidal ideation and no reported patient regret.37
  • Genital self-image — postoperative scores improved significantly (20.29 vs 13.04 preoperatively, p < 0.001).12

Eligibility and Timing Summary​

ProcedureHormone Therapy Before SurgeryMental Health LettersMinimum Age
Chest surgery (top surgery)Not required (WPATH SOC 8)1Case-by-case
Metoidioplasty≥ 12 months testosterone218
Phalloplasty≥ 12 months testosterone218
Hysterectomy / BSO≥ 12 months testosterone1–218
Penile prosthesisAfter phalloplasty healing (~6–12 months)—18

Sources: 28263839

Lifelong Follow-Up Considerations​

Patients who have undergone masculinizing genital surgery require ongoing urologic follow-up, particularly after phalloplasty, given the high rate of delayed urethral complications. Symptoms of urinary retention, postvoid dribbling, pelvic pain, or recurrent UTIs should prompt urgent urology referral. Donor-site complications (nerve injury, decreased strength / sensation) may benefit from occupational therapy. Patients with metoidioplasty without vaginectomy who have receptive vaginal sex should continue STI screening with vaginal swabs.31

Footnotes​

  1. Pletta DR, Quint M, Radix AE, et al. "Gender-Affirming Surgical History, Satisfaction, and Unmet Needs Among Transgender Adults." JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494 ↩ ↩2

  2. Berli JU, Knudson G, Fraser L, et al. "What Surgeons Need to Know About Gender Confirmation Surgery When Providing Care for Transgender Individuals: A Review." JAMA Surg. 2017;152(4):394–400. doi:10.1001/jamasurg.2016.5549 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  3. Kuruoglu D, Alsayed AS, Melson VA, et al. "Masculinizing Chest Wall Gender-Affirming Surgery: Clinical Outcomes of 73 Subcutaneous Mastectomies Using the Double-Incision and Semicircular Incision Techniques." J Plast Reconstr Aesthet Surg. 2023;85:515–522. doi:10.1016/j.bjps.2023.02.020 ↩ ↩2

  4. Zhu J, Wang E, Liu S, et al. "Impact of Surgical Technique on Outcome Measures in Chest Masculinization: A Systematic Review and Meta-Analysis." J Plast Reconstr Aesthet Surg. 2023;87:109–116. doi:10.1016/j.bjps.2023.09.002 ↩ ↩2 ↩3 ↩4

  5. Cuccolo NG, Kang CO, Boskey ER, et al. "Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes." Aesthetic Plast Surg. 2019;43(6):1575–1585. doi:10.1007/s00266-019-01479-2 ↩

  6. Poudrier G, Nolan IT, Cook TE, et al. "Assessing Quality of Life and Patient-Reported Satisfaction With Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study." Plast Reconstr Surg. 2019;143(1):272–279. doi:10.1097/PRS.0000000000005113 ↩

  7. Ascha M, Sasson DC, Sood R, et al. "Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults." JAMA Pediatr. 2022;176(11):1115–1122. doi:10.1001/jamapediatrics.2022.3424 ↩ ↩2

  8. Dakkak M, Kriegel DL II, Tauches K. "Caring for Transgender and Gender-Diverse People: Guidelines From WPATH." Am Fam Physician. 2023;108(6):626–629. ↩ ↩2

  9. Wylie K, Knudson G, Khan SI, et al. "Serving Transgender People: Clinical Care Considerations and Service Delivery Models in Transgender Health." Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6 ↩ ↩2 ↩3

  10. Stojanovic B, Djordjevic ML. "Updates on Metoidioplasty." Neurourol Urodyn. 2023;42(5):956–962. doi:10.1002/nau.25102 ↩ ↩2 ↩3

  11. Kocjancic E, Acar O, Talamini S, Schechter L. "Masculinizing Genital Gender-Affirming Surgery: Metoidioplasty and Urethral Lengthening." Int J Impot Res. 2022;34(2):120–127. doi:10.1038/s41443-020-0259-z ↩

  12. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. "Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients." J Sex Med. 2021;18(4):800–811. doi:10.1016/j.jsxm.2021.01.183 ↩ ↩2 ↩3 ↩4

  13. Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. "Metoidioplasty: Surgical Options and Outcomes in 813 Cases." Front Endocrinol. 2021;12:760284. doi:10.3389/fendo.2021.760284 ↩ ↩2 ↩3 ↩4

  14. Waterschoot M, Hoebeke P, Verla W, et al. "Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery." J Sex Med. 2021;18(7):1271–1279. doi:10.1016/j.jsxm.2020.06.023 ↩

  15. Netshiongolwe T, Mitchell S, Kathiravelupillai S, et al. "Pedicled Flaps Versus Free Radial Forearm Flap for Phalloplasty in Female to Male Gender-Confirming Surgery: A Systematic Review." Ann Plast Surg. 2025. doi:10.1097/SAP.0000000000004502 ↩ ↩2

  16. Wang E, Cleff B, Basta A, et al. "Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates." Microsurgery. 2026;46(1):e70154. doi:10.1002/micr.70154 ↩ ↩2

  17. Robinson I, Chao BW, Blasdel G, et al. "Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes." Urology. 2023;177:204–212. doi:10.1016/j.urology.2023.03.038 ↩

  18. Valada A, Purohit RS, Djordjevic ML. "Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips." Urology. 2024;183:e323–e324. doi:10.1016/j.urology.2023.10.010 ↩

  19. Berli JU, Monstrey S, Safa B, Chen M. "Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging." Plast Reconstr Surg. 2021;147(5):801e–811e. doi:10.1097/PRS.0000000000007898 ↩

  20. Hu CH, Chang CJ, Wang SW, Chang KV. "A Systematic Review and Meta-Analysis of Urethral Complications and Outcomes in Transgender Men." J Plast Reconstr Aesthet Surg. 2022;75(1):10–24. doi:10.1016/j.bjps.2021.08.006 ↩ ↩2

  21. Berli JU, Ferrin PC, Buuck C, et al. "Long-Term Urologic Outcomes Using the Big Ben Method for Phalloplasty." Plast Reconstr Surg. 2025. doi:10.1097/PRS.0000000000012010 ↩

  22. Fraiman E, Nandwana D, Loria M, et al. "Complication and Explantation Rates of Penile Prostheses in Transmasculine Patients: A Meta-Analysis." Urology. 2024;194:260–268. doi:10.1016/j.urology.2024.08.022 ↩ ↩2 ↩3

  23. Kocjancic E, Jaunarena JH, Schechter L, Acar Ö. "Inflatable Penile Prosthesis Implantation After Gender Affirming Phalloplasty With Radial Forearm Free Flap." Int J Impot Res. 2020;32(1):99–106. doi:10.1038/s41443-019-0153-8 ↩

  24. Levy M, van der Sluis WB, van Abbema EL, et al. "Hydraulic and Malleable Female-to-Male Penile Implants After Phalloplasty in Transgender Individuals: A Retrospective Cohort Analysis." BJU Int. 2025. doi:10.1111/bju.16911 ↩

  25. Briles BL, Middleton RY, Celtik KE, et al. "Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications." J Sex Med. 2022;19(4):641–649. doi:10.1016/j.jsxm.2022.01.518 ↩

  26. Cronin B, Stockdale CK. "Health Care for Transgender and Gender Diverse Individuals." American College of Obstetricians and Gynecologists, 2021. ↩ ↩2 ↩3 ↩4

  27. Lee Cruz AS, Cruz J, Behbehani S, et al. "Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations." J Minim Invasive Gynecol. 2024;31(4):265–266. doi:10.1016/j.jmig.2023.12.009 ↩

  28. Mancini I, Tarditi D, Gava G, et al. "Feasibility, Safety, and Satisfaction of Combined Hysterectomy With Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals." Int J Environ Res Public Health. 2021;18(13):7133. doi:10.3390/ijerph18137133 ↩ ↩2

  29. Reilly ZP, Fruhauf TF, Martin SJ. "Barriers to Evidence-Based Transgender Care: Knowledge Gaps in Gender-Affirming Hysterectomy and Oophorectomy." Obstet Gynecol. 2019;134(4):714–717. doi:10.1097/AOG.0000000000003472 ↩

  30. Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. "The Uterus in Transgender Men." Fertil Steril. 2021;116(4):931–935. doi:10.1016/j.fertnstert.2021.07.005 ↩

  31. Jackson Q, Yedlinsky NT, Gray M. "Lifelong Care of Patients After Gender-Affirming Surgery." Am Fam Physician. 2024;109(6):560–565. ↩ ↩2

  32. Elyaguov J, Isakov R, Nikolavsky D. "Evaluation and Management of Urologic Complications Following Transmasculine Genital Reconstructive Surgery." Neurourol Urodyn. 2023;42(5):979–989. doi:10.1002/nau.25100 ↩

  33. Robinson IS, Rifkin WJ, Kloer C, et al. "Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone Before Top Surgery Really Necessary?" Plast Reconstr Surg. 2023;151(2):421–427. doi:10.1097/PRS.0000000000009858 ↩

  34. Boskey ER, Taghinia AH, Ganor O. "Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review." JAMA Surg. 2019;154(2):159–169. doi:10.1001/jamasurg.2018.4598 ↩

  35. Ren T, Galenchik-Chan A, Erlichman Z, Krajewski A. "Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review." Ann Plast Surg. 2024;92(5):597–602. doi:10.1097/SAP.0000000000003895 ↩

  36. Thornton SM, Edalatpour A, Gast KM. "A Systematic Review of Patient Regret After Surgery — A Common Phenomenon in Many Specialties but Rare Within Gender-Affirmation Surgery." Am J Surg. 2024;234:68–73. doi:10.1016/j.amjsurg.2024.04.021 ↩

  37. Park RH, Liu YT, Samuel A, et al. "Long-Term Outcomes After Gender-Affirming Surgery: 40-Year Follow-Up Study." Ann Plast Surg. 2022;89(4):431–436. doi:10.1097/SAP.0000000000003233 ↩

  38. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. "Endocrine Treatment of Gender-Dysphoric / Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab. 2017;102(11):3869–3903. doi:10.1210/jc.2017-01658 ↩

  39. Sun HH, Isali I, Mishra K, et al. "Surgical Outcomes at a Single Institution of Infrapubic Insertion of Malleable Penile Prosthesis in Transmen." Urology. 2023;173:209–214. doi:10.1016/j.urology.2023.01.001 ↩