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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 associated DIFNG with fewer complications and PAT with higher reported satisfaction. Technique selection depends on anatomy, and heterogeneous outcome reporting limits causal comparisons.4

Outcomes​

  • Complication rates are low — a 73-patient / 146-breast series reported 2.7% major complications and 5.4% revisions using its procedural denominator. Concomitant liposuction was associated with fewer revisions in that retrospective series, without proving a preventive effect.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 — among 58 of 81 invitees responding to a postoperative survey, 86% reported improvement in gender-dysphoria-related mental health conditions; quality of life and sexual confidence improved significantly (p < 0.001).6
  • A nonrandomized adolescent / young-adult cohort had 36 surgical and 34 control participants completing three-month outcomes. Chest dysphoria and body-image measures improved in the surgical group, but residual baseline differences and short follow-up limit causal inference.7

Adult eligibility — prior hormone therapy is not universally required for chest surgery. Use the individualized SOC8 assessment framework; adolescent assessment has separate criteria and cannot be inferred from the adult pathway.789

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.1011

Procedure components may include clitoral release, urethral lengthening when voiding from the tip is desired, vaginal closure / excision, and scrotoplasty with or without testicular implants. These components are selected around the patient's goals rather than required as a fixed package.1112

Outcomes in a 938-patient specialist series11​

  • Neophallus length ranged from 4–10 cm. An earlier 813-patient series reported a mean of 5.6 cm.13
  • Standing micturition achieved in 99% of cases.
  • Preservation of erogenous sensation is a principal goal. A separate community survey of 129 postoperative patients reported mean erogenous sensation of 4.8/5 after metoidioplasty versus 3.4/5 after phalloplasty; this was not a randomized comparison.14
  • Penetrative intercourse generally not possible due to small neophallus size.
  • 12.5% of patients subsequently requested phalloplasty.

Complications​

  • In the earlier 813-patient series, 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).15
  • Testicular implant rejection occurred in 2% and displacement in 3.2%.13

Satisfaction — among 655 questionnaire respondents in the 813-patient series, 79% were totally and 20% mainly satisfied.13

Phalloplasty​

Phalloplasty creates a neophallus using a tissue flap. Goals may include appearance, sensation, voiding from the tip after urethral lengthening, and rigidity for penetration; the desired combination varies by patient.210

Flap Options​

Flap TypeKey AdvantagesKey DisadvantagesFlap Failure Rate
Radial forearm free flap (RFFF)Thin, pliable flap that can accommodate a tube-in-tube urethraVisible forearm donor site; urethral complications; requires microsurgery~1.9%
Anterolateral thigh (ALT) pedicledConcealed donor site; pedicled transfer can avoid microsurgical anastomosisBulkier flap; may require thinning~0.6%
Musculocutaneous latissimus dorsi (MLD)Can provide substantial length / girth; donor-site function requires counselingTechnically complex; requires microsurgery—
Pedicled abdominal flapNo microsurgical transfer; concealed donor siteSensation, urethral reconstruction, and contour depend on the design—
Fibula osteocutaneousBone can provide intrinsic rigiditySignificant donor-site morbidity—

Sources: 216171819

A 2025 systematic review of 769 patients (614 RFFF, 155 pALT) found no statistically significant difference in flap failure or satisfaction. Evidence was rated low certainty with serious selection bias; the table's pooled flap-loss estimates are not individualized predictions or proof of equivalence. Its abstract reports an internally inconsistent operative-time comparison, so that comparison is omitted.16

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."20

  • 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%.1421
  • The Big Ben method had a 27% urologic complication rate in a 73-patient retrospective series, with 96% achieving standing urination. Among survey respondents (67% response rate), 96% would undergo it again. These results do not demonstrate superiority to other staging approaches.22
  • A 57-patient retrospective study reported fistula rates of 48% with RFFF, 20% with ALT, and 9.1% with abdominal flaps. These must not be confused with its 60% overall urologic-complication rate for RFFF; small, selected groups and procedural differences limit comparisons.17
  • The meta-analysis pooled standing micturition at 91.5% and tactile or erogenous sensation at 88%, with heterogeneous techniques and outcome definitions.21

Survey-reported dimensions — mean erect length was 14.1 cm after phalloplasty versus 5.5 cm after metoidioplasty in the community survey, subject to recall and selection bias.14

Penile Prosthesis Implantation​

A soft-tissue flap lacks native corporal erectile bodies. A penile prosthesis is commonly used to provide rigidity for penetration, usually after staged healing; alternatives and the need for an implant depend on flap design and patient goals.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%.23
  • 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%.23
  • The meta-analysis found no statistically significant difference between implant types, with wide confidence intervals; this does not establish equal safety.23
  • Five-year retention rates range from 42–78%, lower than in cisgender men, though satisfaction rates are similarly high.24
  • A 2025 retrospective cohort of 50 patients and 85 ZSI implant procedures reported three-year explantation-free survival of 39% for hydraulic and 31% for malleable devices. Secondary implantation was associated with higher complication odds (OR 3.5); these estimates apply to this cohort and device family.25
  • Surgical experience matters — infection probability decreased significantly with increasing case number at one center.26

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.27 Approximately 0.3% of hysterectomies in the U.S. are performed for transgender men.28

Key Considerations​

  • Route — a laparoscopic approach was used in 137 of 142 patients (96.5%) in one series. Vaginal hysterectomy is possible but may be technically difficult due to lack of uterine descent and severe vaginal atrophy from testosterone.2729
  • 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.30
  • Combined surgery — HBSO and chest surgery can be combined in selected patients. In a 142-patient cohort, 123 underwent combined surgery, with a 10.5% complication rate (thoracic hematoma most common at 7.6%), with satisfaction scores of 9.9/10.29
  • Fertility preservation — discuss oocyte / embryo preservation before gonadectomy. Hysterectomy removes the ability to carry a pregnancy, while retained ovaries may still permit later oocyte retrieval; bilateral oophorectomy removes that source of future oocytes. Fertility counseling should not assume a lack of interest in genetic parenthood.31
  • Bone health — plan adequate sex-steroid replacement and individualized bone-health follow-up after oophorectomy. Testosterone treatment does not guarantee protection from every cause of bone loss.279

Vaginectomy​

Vaginal mucosal excision / ablation and closure, and colpocleisis techniques, are distinct approaches used with some urethral-lengthening procedures. Vaginal preservation is also a patient goal that should be discussed rather than assuming closure is mandatory.232 A persistent vaginal cavity / remnant occurred in 9.6% of metoidioplasty cases and is a recognized long-term complication requiring surveillance.1333

Voice and Facial Surgery​

Unlike transfeminine patients, transmasculine individuals rarely require voice or facial surgery.10 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 in the groups that held versus continued testosterone (175 versus 211 patients); another 104 had never received it. This retrospective mastectomy study does not establish outcomes for every genital operation.34
  • 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.35

Long-Term Satisfaction and Regret​

Reported satisfaction is often high, but outcome definitions, follow-up, and participation vary:

  • Regret rate — one systematic review estimated 0.8% in transmasculine and 4.0% in transfeminine cohorts. Cross-procedure comparisons with other operations use different populations, follow-up, and definitions and should not be interpreted as controlled comparisons.3637
  • 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 — 15 of 97 identified patients participated. Respondents reported favorable body congruency and mental health with no regret, but the substantial nonresponse prevents generalization to all surgical patients.38
  • Genital self-image — postoperative scores improved significantly (20.29 vs 13.04 preoperatively, p < 0.001).14

Eligibility and Timing Summary​

For adults, use SOC8 assessment and consent principles, ordinarily with one competent assessment opinion if documentation is required. Hormones are not universally mandatory; metoidioplasty planning depends on achieved clitoral growth, whereas phalloplasty and hysterectomy do not inherently require a fixed year of testosterone. Gonadectomy requires discussion of hormone goals and long-term endocrine care. The 2017 Endocrine Society guideline used a one-year genital-surgery interval; this should not be presented as the current universal SOC8 criterion.2827399

Prosthesis placement follows sufficient flap and urethral healing with no active infection; timing is individualized with the reconstructive team.40

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. Acute retention, systemic infection, or threatened flap / device complications require urgent assessment. Persistent dribbling, pelvic pain, and recurrent infections warrant timely reconstructive review. 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.32

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. Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." Int J Transgend Health. 2022;23(Suppl 1):S1–S259. doi:10.1080/26895269.2022.2100644 ↩ ↩2 ↩3

  10. 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

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

  12. 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 ↩

  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 ↩5

  14. 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

  15. 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 ↩

  16. 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

  17. 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

  18. 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 ↩

  19. 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 ↩

  20. 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 ↩

  21. 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

  22. 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 ↩

  23. 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

  24. 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 ↩

  25. 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 ↩

  26. 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 ↩

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

  28. 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 ↩

  29. 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

  30. 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 ↩

  31. 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 ↩

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

  33. 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 ↩

  34. 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 ↩

  35. 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 ↩

  36. 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 ↩

  37. 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 ↩

  38. 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 ↩

  39. 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 ↩

  40. 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 ↩