Female to Male & Non-Binary

Top and Bottom Procedures Offered

The following is a list of Female to Male Gender Affirmation Surgery procedures that we currently offer with a brief description to help you make an educated decision on which might be the best fit for you. With each procedure description there is also an option to view photos and the associated WPATH requirements based on procedure.

Top Surgery Procedures Offered

Double incision mastectomy with free nipple graft

In this procedure the skin on the chest is opened along two horizontal incision at the bottom of the pectoral muscle, the muscle itself is not disturbed. The nipples are re-moved, the excess skin and tissue are removed and the top is pulled down to meet the incision at the bottom of the chest. Liposuction is sometimes done to contour and masculinize the chest. Nipples are then resized and reshaped and placed in the appropriate place on the chest. This is the most common procedure for top surgery.

Procedure Photos

Keyhole mastectomy

Keyhole can only be performed on someone with a small chest (A-cup and smaller for reference). A small incision is made at the bottom of each areola of the nipple and the tissue is removed via liposuction. The nipples are not removed or resized in this procedure.

Procedure Photos

Nipple – free top surgery

We have had several individuals ask for their nipple grafts not to be replaced during their top surgery, we are happy to accommodate that if that is part of your desired outcome! This procedure would follow the standard double incision or keyhole procedure, with the difference being the nipples not being placed back on the chest and instead closed.

Revision surgery

If you have previously had top surgery and are unhappy with your results, have severe or painful scarring or would like for something to be changed, we are happy to consult with you and Dr. Gallagher can offer possible solutions on a case-by-case basis.

WPATH Requirements for FTM and Non-binary Top Surgery

Details and Requirements for FTM and Non-binary Top Surgery

Female to Male Bottom Surgery Procedures Offered

Factors to consider when choosing a bottom surgery procedure are availability for downtime, sexual practices, and medical readiness for a major operation as well as social and lifestyle factors. The following is a a description of the two procedures offered, phalloplasty and metoidioplasty. FTM gender affirmation bottom surgery procedures are more extensive and therefore more involved.


Phalloplasty means creation of a penis.

The goal is to use “spare tissue” from other parts off the body in order to create a penis through which a trans-man can urinate and have sex with. This is a long complex surgery that requires over a week in hospital to recover from.

In addition the patient also requires 2-3 or even more trips to the operating room.

Before undergoing this procedure the patient must be on a full year of hormone therapy. The patient must be healthy enough to undergo this major surgery and be a healthy weight. Prior to the full phalloplasty a patient will require a hysterectomy – but it is possible this can be done as part of the first surgery with our team.

The patient will need to urinate through a tube for at least the first 3 weeks after phalloplasty surgery. 6 weeks off work is usually necessary.

The clitoris, labia and vagina are modified in order to help lengthen the urethra and prepare the groin for the new penis. There are 3 ways to create the penis: Radial Forearm Free Flap, Anteriolateral Thigh Flap, and Latissimus Dorsi Flap.

Radial Forearm Free Flap

The most common way to create a new penis is by using the tissue on the forearm. This is known as a Radial forearm free flap. The skin and underlying tissue on the forearm is removed and rolled into an inner tube to create a new urethra (through which the patient can urinate). The rest of the skin forms the outer layer or skin of the penis. A tube within a tube. Nerves supplying this skin can be attached to nerves in the patients groin allowing sensation in the new penis when everything is healed (this often takes up to a year). The vein and artery to that new penis need to be attached to the groin vessels under a microscope. Taking this large amount of skin from the forearm leaves behind a visible scar – a skin graft from elsewhere on the body is required to heal it – most commonly the thigh skin is used for this.

Anteriolateral Thigh Flap

This is usually only an option for thinner patients. The thigh tissue is rolled into a tube. (it is too thick to be rolled into a tube within a tube). Like the forearm flap nerves can be connected to allow sensation in the penis.

Another surgery is required later to create a tube through which a patient can urinate (neo-urethra).

A skin graft will be needed from the opposite thigh in order to heal the area where the flap comes from.

Latissimus Dosi

This is a muscle on the upper back, which can be taken with overlying skin and rolled into a tube. Patients have other back muscles, which can take over this muscle’s job so usually only very athletic patients will notice it gone.

This option gives the best scar, which is located on the back and often doesn’t require a skin graft. This flap however does not have a nerve that can be attached to allow sensation in the new penis. Sexual pleasure is from the clitoris which is usually left behind at the base of the new penis. A reconstruction to lengthen the urethra would be carried out at a later stage.


Metoidioplasty is a procedure in which the genitals are masculinized.

It is a less complex surgery than phalloplasty in which tissue is used from elsewhere on the body (usually the forearm leaving behind a scar).

The goal of this surgery is to give a masculine appearance to the genitals and allow the patient to urinate standing up. The penis created however is usually not big enough for penetrative sex.

This is done with one or 2 surgeries and usually requires 2 years on testosterone allowing time for the clitoris to enlarge.

The enlarged clitoris is made into a small penis.

Other parts of the genitals such as the vagina and labia minora are used to lengthen the urethra (the tube through which the patient urinates) with the goal to allow the patient to stand to urinate.

The labia majora can be formed into the scrotum and later testicular implants can be placed.

Most patients take at least a month off work for this procedure. Hospital stay is 2-3 days and catheters (tube for urination) stay in for at least 3 weeks after surgery.

A patient can always choose to convert their metoidioplasty to phalloplasty later if desired.

Hysterectomy can be done at the time of metoidioplasty or before hand.

WPATH Requirements for Phalloplasty and Metoidioplasty