SRS FtM surgery
At Timeless Chirurgia Plastyczna, we perform complex microsurgical procedures using free, vascularized and innervated tissue flaps.
Phalloplasty
Phalloplasty (penile reconstruction) is a complex medical term and, in practice, refers not only to creating a penis but also to a series of preparatory and finalizing surgical stages
Phalloplasty is the most complex and demanding transformation of the genital region, so patients need to be thoroughly informed about the planned procedures, and the operations should be performed by experienced surgeons to support a successful outcome—living fully as a man.
Phalloplasty—also called penile reconstruction—is most often performed for transgender people as part of transition. It is also used to reconstruct the penis after trauma, following cancer treatment, or to correct congenital or acquired genital conditions. The surgeon’s goals are to create an aesthetically pleasing penis of sufficient size, capable of conveying sexual sensation and enabling standing urination. Penile reconstruction is a staged process that often requires more than one operation to achieve the desired result.
Phalloplasty techniques evolve alongside advances in medicine—especially plastic surgery and urology. In practice, two principal approaches to penile reconstruction are distinguished: phalloplasty (the penis is created from tissues harvested from other body sites) and metoidioplasty (existing genital tissues are used to construct a penis).
Preoperative assessment and eligibility
Phalloplasty is a complex, staged procedure, so every candidate requires careful preparation. Patients are referred to the surgeon after diagnosis, with mental-health evaluation completed and hormone therapy underway.
From a practical standpoint, legal gender/ID change is often optimal, but the transition process may begin once a diagnosis has been established and hormone therapy initiated. It is important that care follows the WPATH Standards of Care for trans, transgender, and gender-diverse people (World Professional Association for Transgender Health).
Hormone therapy helps alleviate gender dysphoria and physically prepares tissues for phalloplasty. Testosterone induces favorable hypertrophy of the clitoris and labia—tissues needed for reconstruction.
Preoperative surgical consultation
An in-person surgical consultation is required before the operation. During this visit, we review the surgical options and stages, as well as the postoperative course. The discussion covers the advantages and drawbacks of each technique and the potential risks of surgery. The surgeon seeks to understand the patient’s goals and clarifies the inherent limitations of surgical treatment. People with unrealistic expectations risk dissatisfaction with the final outcome. Overall health is very important—especially obesity and smoking—which can adversely affect reconstructive results and should be addressed before surgery. A body mass index (BMI) over 35 may increase the risk of complications and lead to suboptimal aesthetic and functional outcomes. Patients with obesity are encouraged to lose weight prior to surgery.
Patients with a history of urinary-tract problems (e.g., kidney stones) should undergo ultrasound imaging, as these issues are easier and safer to treat before reconstructive surgery. Patients with hematologic disorders may have an increased risk of reconstruction failure—for example, operative-site bleeding or thrombosis.
Tobacco or cannabis smoking can delay healing and increase the risk of graft/flap necrosis. We recommend stopping smoking at least 6 weeks before phalloplasty. Cessation can be verified with a urine cotinine test; if the result is positive, surgery is postponed based on the test outcome.
Preparation for surgery
Włosy w okolicy pobrania płata
Fine, dark hair on the forearm or thigh can look unesthetic on the penile shaft and may sometimes promote infections or urethral stone formation. Many patients concerned about the future appearance of the penis choose to remove forearm hair with electrolysis or laser before surgery.
Obecność tkanki tłuszczowej(otyłość)
Most patients in Western populations have more subcutaneous fat and hair on the forearms and thighs than, for example, patients from Asia. Because of possible increases in subcutaneous tissue, the flap width must often be greater than initially expected—sometimes requiring nearly the entire forearm circumference. In people with higher body mass, there may be technical difficulty with the tube-within-a-tube configuration; morbid obesity can contraindicate certain flaps. Obesity is also associated with diabetes and hypertension. Weight normalization or management of comorbid conditions is necessary before surgery.
Palenie tytoniu, marihuany stosowanie innych środków pobudzających.
Completing the full course of treatment—and each of its stages—requires complete cessation of smoking tobacco or cannabis and of using other psychoactive substances. Concealing such use may endanger the patient’s life and lead to serious complications, including tissue necrosis and a more difficult recovery.
Ogólny stan zdrowia
Good overall health is very important, as it lowers operative risk and reduces the frequency of complications. For this reason, patients must undergo preoperative testing. Those with chronic conditions should receive specialist care; when planning treatment, we remain in close contact with the patient’s physicians. Chronic diseases are not a contraindication to surgery, but they require regular medication under specialist supervision. Testosterone therapy is adjusted perioperatively: injectable testosterone is switched to transdermal gels/creams, which allows better control of serum levels and may reduce thromboembolic risk. During surgery, we implement appropriate antithrombotic prophylaxis.
Phalloplasty or metoidioplasty
Phalloplasty is the most comprehensive form of genital reconstruction. It involves complex, staged procedures, harvesting tissue from distant donor sites, and weighing risks such as complications related to urethral reconstruction and implanted devices. For these reasons, some patients choose metoidioplasty instead. The choice between metoidioplasty and phalloplasty is personal and depends on the patient’s preferences. For trans men who want to urinate standing but are not focused on penetrative intercourse, metoidioplasty clearly meets those needs. For those who desire penetrative intercourse, phalloplasty with a later stage of erectile prosthesis implantation is an excellent solution.
It is important to know that choosing metoidioplasty does not rule out phalloplasty at a later time. If a patient’s goals change, we can perform phalloplasty for individuals who previously underwent metoidioplasty.
Roadmap: stages of FTM masculinizing care at Timeless
1. Procedures required beforehand:
- Hysterectomy (complete removal of the uterus and ovaries, and the upper portion of the vagina).
2. Urethral lengthening and perineal preparation for Phalloplasty / Metoidioplasty
- Vaginectomy with perineal plasty (perineoplasty).
- Scrotoplasty — transforming the labia majora into a scrotum, with or without testicular implants.
- Urethroplasty (Stage I) — lengthening and preparing the urethra to connect to the future penis.
3. Phalloplasty — microsurgical creation of the penis using skin and tissue flaps from donor sites on the body.
- Glansplasty — sculpting the glans to match the appearance of an uncircumcised penis.
- Scrotal plasty — scrotal enlargement.
- Reconstruction of the urinary tract — Urethroplasty (Stage II).
4. Implantation of a penile erectile prosthesis with testicular implants, enabling erection and penetrative sexual activity.
5. Additional penile-sculpting procedures:
- Glansplasty
- Autologous fat augmentation
- Lengthening
- Tattoos
Techniques for performing phalloplasty
We continually refine our phalloplasty techniques. During candidacy assessment, we tailor the surgical approach to the patient’s needs—taking into account personal goals, health status, individual preferences, and anatomy.
We currently use penile-reconstruction procedures that can be divided into pedicled flaps and free flaps. Pedicled flaps transfer tissue from nearby areas—typically the thigh, groin, or abdomen—while free flaps harvest tissue from more distant sites—such as the forearm or back—and require microsurgical anastomosis of small vessels.
Falloplastyka RFFF
The current “gold standard” for phalloplasty is the free radial forearm flap (RFFF) technique. The RFFF has become the most commonly used surgical method for phalloplasty and is considered superior to many alternatives. It reliably achieves the primary goals: creating a penis with good tactile qualities and sensibility and a functional urethra that allows urination from the meatus at the glans. The concept of this flap was introduced in 1981 by Yang et al. for burn reconstruction; today RFFF is widely used for various reconstructive procedures of the head and neck as well as the genital region. An RFFF phalloplasty typically takes 5–12 hours. In a later stage, after implantation of an erectile prosthesis, many patients experience this method as enabling full participation in life as a man.
During RFFF phalloplasty, plastic surgeons harvest a skin-and-soft-tissue flap from the forearm and shape it using the “tube-within-a-tube” technique. The tissue is used to create both the urethra and the penile shaft: the outer tube wraps around the inner urethral tube. The forearm donor site leaves a sizable defect that usually requires skin grafts, most often taken from the thigh or other easily concealed areas, which are then grafted onto the forearm.
Because the female-type urethra is shorter than the male urethra, surgeons lengthen the urethra and connect it to the native urethra so that urine exits from the tip of the penis. The clitoris is typically preserved near the base of the penis, where it can still be stimulated. Patients who were able to have orgasms before surgery usually maintain orgasmic function after surgery.
During the preoperative consultation, we discuss the relatively common occurrence of fistulas and leakage within the reconstructed urethra. We individualize urethral reconstruction for each patient. Many patients choose not to reconstruct the urethra initially, or to have it performed at a later stage.
Phalloplastyka ALT – Płat z okolicy przednio-bocznej uda
The anterolateral thigh (ALT) flap is a reliable technique for penile reconstruction performed at Timeless Chirurgia Plastyczna. Today, the ALT flap is one of the two primary methods used by our reconstructive surgeons.
The microsurgical ALT flap was first described for phalloplasty in transgender men in 2006. Since then, it has become a realistic option for patients who prefer not to have a visible forearm scar. Some patients find a forearm scar recognizable and worry it may be hard to conceal under clothing. Advantages of the ALT flap include a discreet donor site on the thigh, flexibility in penile length, and the ability to achieve sensory innervation of the penis.
The technical limitations of the ALT flap relate to flap thickness and variability in vascular anatomy. In most patients, ALT phalloplasty requires several stages—urethral reconstruction, debulking to reduce penile thickness so the diameter is appropriate for penetrative intercourse, etc. Suitable candidates include patients with slender thighs who understand and accept the need for multiple surgical stages and who prefer no visible forearm scar. The ALT flap is also a good alternative when a forearm flap cannot be used—for example, after complications with an RFFF, when the forearm donor site has already been used, when there are anatomic variants of the palmar arch, or when forearm scarring from prior procedures is present. In a subset of appropriately selected patients, a pedicled ALT variant can be performed without microsurgical vessel anastomosis.
Phalloplastyka LD – płat z okolicy pleców, grzbietu
The back (latissimus dorsi, LD) flap is another option for microsurgical penile reconstruction. Tissue is harvested from the posterolateral back; the scar runs from the axilla downward—similar to a shirt’s side seam—and is relatively easy to conceal. This technique allows creation of a long, substantial penis, and inclusion of a muscle component can produce a paradoxical “erection-like” tensing with contraction. In some patients, the inherent bulk and firmness permit penetrative intercourse even before implantation of a prosthesis. The main advantage of the back flap is the ability to construct a relatively long (several to many centimeters) penis with increased girth. With this technique, urethral reconstruction is performed after several months. Sensory recovery comparable to other techniques is generally limited.
Płaty rurowate z podbrzusza
Historic techniques using tubed adipocutaneous flaps from the lower abdomen were employed in the last century. These flaps are transferred in stages—rolled into a cylinder—from distant body areas to the perineum. Care must be taken to maintain an approximate length-to-base-width ratio of 3:1, which also limits reconstructive possibilities. During serial transfers, the flap tends to shrink at each stage, with portions eventually regressing after final inset and healing at the defect site. Planning the flap along the course of vessels (most often epigastric or inguinal) can improve arterial inflow and venous outflow, allowing a more favorable length-to-pedicle-width ratio. If a long flap is needed that would exceed safe proportions, a multistage delay/elevation technique can be used—though this prolongs the process. Today, this method is reserved for patients who are not candidates for pedicled or microsurgical free flaps. Transferred flaps typically require secondary shaping/sculpting procedures. Urethral reconstruction is performed at the final stage. A penis reconstructed in this way lacks sensibility and may contract significantly with weight loss. Implantation of an erectile prosthesis is only feasible if sufficient penile girth is achieved.
Postoperative care
The viability of the reconstructed penile flap is assessed clinically by temperature, skin color, turgor, and capillary refill. Frequent pulse checks and Doppler assessments of blood flow are performed, with continuous monitoring using specialized devices.
Perioperative antibiotics, subcutaneous heparin, and low-dose aspirin are used in all cases. IV antibiotics are discontinued on postoperative day 2, and oral antibiotics are continued until the bladder catheters are removed.
After surgery, urine is diverted through a suprapubic catheter, allowing the urethral catheter to remain closed. This reduces tension on the sphincter and the penis. In postoperative week 3–4, a urethral leak test is performed by inserting a small catheter alongside the indwelling catheter and instilling dye. The urethral catheter can be removed when there is no evidence of fistula. The suprapubic catheter (cystostomy) is then removed 1–2 days after normal voiding is established.
Initially, the penis lacks protective sensation, so care must be taken to avoid accidental injury or pressure from clothing until sensation returns. Most patients regain tactile sensation within 4–6 months. When this occurs, penile implant placement can be considered to reduce the risk of implant erosion or extrusion. By 6–9 months, many patients are typically able to masturbate to orgasm.
Physiotherapy begins immediately after surgery. Intermittent compression sleeves massage the calves to improve circulation, and antithrombotic exercises start the next day; patients are mobilized on postoperative day 1. Forearm and hand rehabilitation begins after initial dressings are removed on postoperative day 5. The forearm is supported in a removable wrist splint for 2 weeks. Custom compression garments are fitted after healing and worn for 3–6 months.
Risks associated with phalloplasty
In surgery, we always consider general risks that vary with procedure complexity—such as serious infection, bleeding, injury to surrounding tissues, postoperative pain, and cardiopulmonary complications.
Specific to phalloplasty in trans men (and AFAB non-binary people) is the risk of flap necrosis of the tissue used to reconstruct the penis. Medical literature also notes complications at the reconstruction site related to the urethra (fistula/stricture), wound dehiscence, bleeding, or pelvic pain. Other risks include bladder or rectal injury, reduced sensation, prolonged need for dressings, or the need for additional corrective procedures.
Donor-site risks include a visible scar, reduced range of motion, hematoma, pain, and diminished sensation.
Early complications (within one month)
Wound infection is uncommon, typically appearing in the first few weeks post-op and may present as cellulitis.
Important: We recommend frequent follow-ups to ensure dressings are performed correctly. Antiseptic creams and antibiotics are usually sufficient.
Wound dehiscence is associated with postoperative swelling and usually occurs where multiple suture lines meet (e.g., the perineum–scrotum junction and the base of the phallus).
Important: Most wound-healing problems can be avoided with professional local wound care. Some defects may require thorough debridement; a minority may need skin grafting or further surgery for closure.
Catheter-related discomfort, e.g., a blocked catheter or bladder spasms; urinary tract infections.
Important: Most catheter issues can be avoided with professional catheter care, catheter irrigation, and antispasmodic medications. If infection is suspected, a urinalysis and antibiotic therapy are required.
Flap loss/necrosis is rare and usually results from a hematoma compressing the phallus’s small vessels, kinking or suturing of vessels, or pressure on the vascular pedicle from a bent leg or side-sleeping. Warning signs typically appear within the first 72 hours; if detected early (within hours), urgent surgery can correct the problem.
Important: Most necrosis-related problems can be avoided with expert postoperative care. In urgent cases, immediate OR readiness and an experienced surgical team help ensure safety and restore flow in compressed vessels.
Rectal injury is an uncommon but serious complication of vaginectomy. One technically challenging step is separating the plane between the posterior vaginal wall and the anterior rectal wall; inadvertent rectal injury can occur. When suspected, it is recognized immediately and precisely repaired. In some cases, diagnosis is delayed and a fistula develops. Treatment may include a temporary diverting colostomy to protect the fistula from stool contamination and allow the wound to close.
Important: Most fistula-related problems can be avoided through meticulous vaginectomy technique or by performing it as a preparatory operation. In urgent cases, OR readiness and an experienced surgical team ensure safety and restore circulation in compressed vessels.
Late complications
Urethral strictures typically occur after phalloplasty in two time windows:
I. between 2–4 months;
II. between 6–12 months post-op.
Patients may report a weak urinary stream, straining, and sometimes secondary urinary fistulas. Management may involve urethral dilation with bougies or, in some cases, surgical urethroplasty.
Contracture and scarring occur whenever skin is incised, but severity varies by patient. Scars may remain thin lines, widen, become hypertrophic, or extend beyond the original borders (keloids). Hypertrophic scars can often be corrected by excision and re-closure using tension-reducing techniques to lower recurrence. Keloids are uncommon and more frequent in predisposed individuals; recurrence after simple excision and closure is high (≥70%). To improve scar quality, we offer laser therapy, injections, silicone sheeting, and compression.
Granulation tissue is common at the donor site around and within the skin graft. Its appearance reflects excessive proliferation of fibroblasts and small blood vessels. Most cases are treated with local laser therapy; only rarely is more involved treatment required.
Hydraulic implant
The next stage of reconstruction is to provide a functional erection after penile reconstruction. With appropriate surgical techniques, a hydraulic penile implant can be placed within the soft tissues of the neophallus. Owing to its design, the implant reproduces the function of the corpora cavernosa. A discreet pump mechanism positioned in the previously created scrotum allows easy inflation of the cylinders within the neophallus—producing an erection.
The prosthesis enables quick, discreet inflation and deflation of the new corporal cylinders without complex actions by the patient. Restoring sexual function of the neophallus with a corporal prosthesis—while preserving sensory perception in the reconstructed penis—provides full functional capability of the created penis.
Metoidioplasty
Metoidioplasty (from Greek, “to transform toward male genitalia”), commonly called “meta” in trans communities, leverages testosterone-induced clitoral hypertrophy—the clitoris enlarges and resembles a small penis with a downward curve. Metoidioplasty is considered a less invasive variant of phalloplasty and is the most popular surgical technique for creating male genitalia among trans men. In classic metoidioplasty, we use local tissues (labia, urethra, clitoris, vaginal mucosa) without harvesting free flaps from the forearm, thigh, or abdomen, to create a somewhat smaller phallus—approximately 3–8 cm in length with a girth similar to a thumb or index finger. Metoidioplasty can be performed as a standalone procedure or as part of a staged plan that may include hysterectomy with oophorectomy and vaginectomy, urethral lengthening, and scrotoplasty with testicular implants.
We have developed several safe techniques for metoidioplasty: simple, ring, and Timeless metoidioplasty.
- Eligibility criteria for metoidioplasty for people transitioning in a masculinizing direction (trans men and AFAB non-binary people):
1. Persistent, well-documented gender dysphoria.
2. Capacity to make a fully informed decision and provide consent.
3. Age of majority.
4. Any coexisting health conditions are properly diagnosed, controlled, and treated.
5. Non-smoking patient.
6. Twelve months of testosterone therapy, appropriate to the patient’s expected masculinizing characteristics.
7. Twelve months of living in a gender role consistent with the patient’s gender identity.
8. Patient seeks a single-stage, complete operation.
9. Patient has concerns about complex, multi-stage full phalloplasty, or prefers to consider phalloplasty at a later time.
10. Slender or average body habitus without suprapubic fat pad enlargement.
Simple metoidioplasty
Simple metoidioplasty can be performed when the clitoris has enlarged to an adequate length (≈3–5 cm) after preoperative testosterone therapy. The procedure involves a subglanular skin incision on the clitoris, followed by dissection and division of the clitoral ligaments. On the ventral side, the tethering chord (ventral chordee) is released to straighten the clitoris. The remaining clitoral skin together with tissues from the labia minora and majora is used to cover the shaft as a foreskin, giving a more substantial appearance. The crura are reshaped and sutured in a specific manner to provide better support for the enlarged phallus. In this simple technique, the urethral meatus and the vagina remain in place. Future urethral lengthening can be performed surgically if desired.
In fewer than 5% of cases, certain complications are observed. The most common are less aesthetic scarring and skin puckering of the penis. One notable drawback can be a sense of hollow spaces when sitting. Based on our observations, to achieve full patient satisfaction it may be worth considering additional stages—especially urethral lengthening. Despite its limitations, this technique offers a less burdensome form of gender-affirming surgery (GAS), with lower costs and a somewhat shorter recovery.
Ring metoidioplasty
The ring metoidioplasty technique is similar to the simple approach but differs in how the ventral chordee is released and how the suspensory ligaments are divided. All additional steps aim to lengthen and straighten the clitoris. Another key difference is ventral urethral lengthening along the penile underside. Using a specialized “ring” method, a vaginal mucosal flap is harvested to extend the urethra. This flap is attached to the undersurface of the clitoral corporal bodies and tubularized, allowing urine to pass through. Compared with simple metoidioplasty, a principal improvement is creation of the ventral penile urethra, enabling eventual completion of full urethral lengthening. The clitoral shaft is then covered with remaining labial skin to form a small penis.
Complications mainly include urethral fistulas (10–26%) and strictures (3–5%). In nearly 30% of patients, urethra-related issues affect urination and are the primary postoperative challenge. Because of this, scrotoplasty with testicular implants is always performed as a separate operation, with good outcomes in most patients.
Timeless metoidioplasty technique
We specialize in techniques that reconstruct and straighten the penis, maximize length, and place the urethra within the penis so that the patient can urinate comfortably in a standing position. The penis elevates with erection, and preserved sensation allows for intense orgasms. In our method, urethral lengthening and reconstruction use a buccal mucosa graft (from the inner cheek). This approach can add several additional centimeters of length.
- 1. Metoidioplasty begins with transperineal removal of the vaginal tissue (vaginectomy).
The space left after vaginectomy is approximated and closed with internal absorbable sutures, followed by perineal skin plasty to create a masculine appearance.
- 2. Sculpting the penis involves lengthening the clitoris and shaping it to enable standing urination while preserving sensation and the ability to experience orgasm.
For an appropriate appearance, penile lengthening is necessary. This includes planned steps such as dividing the clitoral suspensory ligaments and suturing the crura to provide additional support (straightening and stiffness). The ventral clitoral plate adjacent to the urethra is contoured and split in the midline to gain extra length. The next stage is urethral reconstruction (urethroplasty). It is crucial to cover the reconstructed penis with well-vascularized tissue—using skin flaps from the labia and mucosal grafts—to reduce the risk of postoperative fistula and to achieve an appropriate appearance and mobility of the foreskin.
- 3. Advanced urethroplasty (urethral reconstruction) creates a urethra within the penis to enable standing urination.
This surgical procedure uses oral (buccal) mucosa grafts (donor sites are inside the mouth and not visible) together with delicate, well-vascularized genital skin flaps (clitoral hood, labia minora). These tissues are shaped and tubularized over a catheter. Subsequent urethral healing occurs around the catheter, which helps the lumen form correctly from the inside. The advantage of this technique is the use of these specific flaps and grafts, which significantly reduces the risk of urinary fistula and strictures. For additional protection of urinary outflow, a second catheter is placed suprapubically (cystostomy).
- 4. Scrotoplasty — the scrotum is created from the labia majora.
Carefully planned incisions are made around the labia to form a scrotal pouch of adequate size to comfortably accommodate testicular implants.
- 5. Additional procedures
a) Penile implant (erectile prosthesis)
After metoidioplasty with our technique, patients experience erections—the penis becomes firm and elevates—and many report intense orgasms. Sometimes, however, rigidity may be insufficient for penetration. In selected cases, a specialized erectile implant can be placed to provide adequate stiffness. This is usually performed ~6 months after metoidioplasty, or—in specific situations and if intraoperative assessment permits—during the metoidioplasty itself.
b) Testicular implants
Scrotoplasty is tailored to accommodate testicular implants. At our clinic, we select implants from leading manufacturers so that their consistency and feel resemble natural testes as closely as possible. Implant size is chosen based on the patient’s goals and the surgeon’s assessment of the achievable scrotal volume. Implants may be placed during metoidioplasty or about 6 months later, once scars have fully healed.
c) Penis enlargement
The size of the penis after metoidioplasty depends on genetic factors, individual response to testosterone, and the duration of hormone therapy. Many patients are initially satisfied with shape and size, but expectations regarding length and girth may increase over time. For these patients, we offer several safe enlargement and firming options. These include mechanical traction/strengthening protocols to condition the penis for subsequent augmentation and lengthening, e.g., autologous fat grafting or hyaluronic acid fillers.
Please note that, due to procedure-specific risks, post-metoidioplasty augmentation is considerably more complex than traditional methods and should be performed by a surgeon with direct experience in metoidioplasty.
Timeless Chirurgia Plastyczna
- ul. Gen. Abrahama 18/322
03-982 Warszawa - pon-pt: 9:00-19:00
- tel. (+48) 508 713 484
- klinika@timeless.com.pl
