What phalloplasty is

Phalloplasty is surgical construction of a phallus for trans-identified females (usually after years of testosterone). It is the most complex procedure in the entire transition surgical catalogue — typically multiple stages over one to several years, with a permanent donor-site scar on the arm, thigh, or abdomen.

It is not one operation. A full course usually includes: the phallus itself, urethral lengthening (so urination can be done standing), scrotoplasty (building a scrotum) and testicular implants, an erectile device, glansplasty (shaping the head of the penis), and often medical tattooing. Each stage carries its own complication risk, and revisions are common.

Two things distinguish phalloplasty from every other transition surgery: the complication rate is far higher than any other procedure, and the donor-site scar is large, permanent, and visible.

Methods compared

The phallus is built from a flap — a section of skin, fat, and sometimes bone and muscle lifted from one part of the body and moved to the groin, with its blood supply reconnected under a microscope (free flap) or left attached (pedicled flap). The choice of donor site determines the trade-off between appearance, sensation, urethral function, and donor-site damage.

Urethral lengthening is the stage that drives most complications. It requires joining the native urethra to a new tube built inside the phallus, and the junction point (anastomosis) is where fistulas and strictures concentrate. Some patients choose phalloplasty without urethral lengthening to avoid this — accepting urination while sitting in exchange for a much lower complication rate.

What the research shows

The most-cited pooled figures come from a 2022 meta-analysis of 39 studies covering 1,731 patients:

A separate systematic review of urethral outcomes broke results down by flap. For radial forearm flaps, wound complications averaged 8%, strictures 32%, and fistulas 36%. For anterolateral thigh flaps, strictures averaged 28% and fistulas 22%. Flap necrosis (tissue death) averaged about 10% across both. A 2025 single-centre cohort of 57 patients found an overall complication rate of 61.4%, with RFF at 80% and pedicled abdominal flaps at 40.9%.

Regret and satisfaction

Published satisfaction figures are high and regret figures are low — but the same methodological caveats that apply across gender-medicine research apply here with particular force.

Two structural problems sit underneath all of these. First, loss to follow-up: patients with bad outcomes are the ones most likely to stop attending the clinic that harmed them, so they vanish from the denominator. Second, follow-up length: observed times to regret in the literature run from about 3 to 130 months, with medians around 7.5–8 years in some cohorts — longer than most studies follow anyone. As Cohn (2023) argues, the widely quoted 0.3–0.6% regret figures come from studies that fail on follow-up time, loss to follow-up, measurement, or sample relevance, and the honest conclusion is that the rate is unknown.

There is also a distinction worth holding onto: satisfaction with a surgical result is not the same as no regret about having transitioned. A person can be glad the phallus looks right and still regret the road that led there. Surveys that ask only the first question will miss the second.

Detrans perspectives

Accounts from /r/detrans cluster around three themes: complications that were under-discussed beforehand, the gap between what surgery was sold as and what it delivered, and the permanence of the donor-site change. (Several commenters use "SRS", sex reassignment surgery, as a general term for genital surgery.)

I have such a bitterness towards some of the biggest trans youtubers. Convinced me that if i transitioned my gender dysphoria would go away, I'd be happier... They don't speak about the horrors of srs and if they do they brush it off "yeah they fucked up my phalloplasty and I have a fistula, my first graft developed necrosis so another spot had to be selected, I have arm hair growing on my shaft, I can't empty my bladder properly, the pump in my fake balls stopped working, I have little sensation, and they're currently taking a graft from the inside of my cheek to build a urethra that may or may not fail, and I have no idea how any of this will age down the line but i have zero regrets and my audience of 13 year old girls should strive for this too"

—Lurkersquid, detrans female.

As someone who had Phalloplasty and 8 other surgeries to fix complications... I am super open that it is NOwhere close to being a biological penis. Granted, I knew this going in logically, but it was also explained to me by my surgeon and soooo many other trans men that it has all of functionality-minus the ability to produce sperm obviously. That couldn't be further from the truth... I can guarantee if it wasn't advertised or claimed to be basically the same or similar, myself and I'm sure others would never get it.

—struggletobecome, questioning own gender transition.

At one point my "penis" was half rotting off and he just kept saying it'll be fine. I had to push to get him to do surgery to fix it. It was a nightmare. Yeah I don't think many of us post phallo are open about it. I'd love to connect with anyone who has had any bottom surgery... how to cope with the loss of something sacred... Knowing there's no way to ever fully get it back.

—Rockerboy86, post-phalloplasty detransitioner.

From the bottom of my heart, thank you for sharing this. I was so close to pulling the trigger on going through with this... Any time I ask about complications, less than satisfactory outcomes, followup surgeries, long term quality of life, trans people (especially guys post-phallo, or guys interested in phallo) shut me down, to the point where I feel like finding honest conversation about SRS is impossible.

—black_cat_7, commenter on /r/detrans.

A recurring point is that the donor-site scar and the loss of native sensation are not reversible. Reversal of the phallus itself is surgically possible in some cases, but the forearm or thigh graft, the urethral rearrangement, and any hysterectomy or oophorectomy are not.

For an F to M transition... skin is removed from the arm, to create a tube like object that is supposed to imitate a phallus... The scar that remains on the arm where a large piece of skin was taken is forever. It cannot be reversed... the ovaries are gone and cannot be replaced... You need hormone replacement for life. The surgeries can "somewhat" be reversed... but not really.

—TheDorkyDane, desisted female.

Not every /r/detrans voice is uniformly negative. One poster who had bottom surgery as "the catalyst" for their detransition reported that, from conversations with others, most phalloplasty patients are content with results "as long as they went in with managed expectations" — while also noting that many trans people decide it is not worth it for them.

I've found from my conversations with others who have been through this that most patients (at least for phalloplasty), are content with the results and happy with the surgery. At least as long as they went in with managed expectations... there's a reason lots of trans people also decide it's not worth it for them.

—Unusualthoughts070, FTM currently questioning gender.

Trans perspectives

People pursuing phalloplasty describe severe, long-standing genital dysphoria and specific functional goals — standing to urinate, penetration, a bulge in clothing, recognition in male spaces. Many are explicit that they know the risks and have decided the trade is worth it for them.

I have pretty extreme bottom dysphoria and although I'm of course not thrilled about the scars and the potential complications and pain and the amount of surgeries I'll need to get I've decided it's 100% worth it for me. I want to be able to actually have a relationship with somebody, I want to pee standing up, I want to look in the mirror and fully recognize my body as my own.

—UpperZookeepergame2, ftm.

I'm actually a month post op of phallo! I have no regrets. I had really bad bottom dysphoria and I just knew I'd get surgery eventually. I do want to say this surgery and journey is a hard and long one. I'm extremely mentally tough and can handle pain easily but this almost destroyed me.

—KatoB23, ftm.

My dick and balls may not be cis, they may not be perfect but they are as 'real' as any other. These surgeries have alleviated my dysphoria and allowed me to live freely without that weight. To walk, sit, shower, wear what I like, piss, fuck. I finally feel present and at home in my body.

—LondonMeta, ftm.

Some trans-identified people decline it. One commenter weighed the cost, the multi-year timeline, scar location, sensation loss, and the eventual replacement of an erectile device, and concluded: "it's not worth it for me where I'm at in life now, and I've grown to be pretty good with what I have overall."

Questions worth asking before any decision

• What is the surgeon's own complication rate by flap type, and how many patients have they treated — not how many operations?
• What happens if the urethral lengthening fails? What does a perineal urethrostomy (permanent diversion, sitting to urinate) mean in practice?
• How many additional operations are statistically likely, and what does recovery from each look like?
• What exactly will the donor site look and feel like in ten, twenty, thirty years? Has anyone asked a patient ten years out?
• What is the plan if regret arrives later — what is reversible, what is not?
• Is the dysphoria being treated, or is something else (trauma, depression, internalised homophobia, autism-related distress) riding along underneath it that surgery cannot touch?

The last question is not an argument against surgery for everyone. It is the question that 55% of Littman's 100 detransitioners said their clinicians had not adequately asked before transition began (Littman 2021), and that the Helsinki clinic concluded, after seeing nine detransitioners with high rates of trauma and untreated psychiatric illness, should be asked before irreversible interventions (Kettula et al. 2025).

References

• Wang et al. (2022). Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis. source.
• Esmonde et al. (2021). A systematic review and meta-analysis of urethral complications and outcomes in transgender men. source.
• Ortengren et al. (2021). Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review. source.
• Flap choice cohort (2025). Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates. PubMed 41492140.
• Urethral stricture after phalloplasty (2019). Translational Andrology and Urology. PMC6626307.
• Robertson et al. (2021). Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies. PMC8105823.
• Cohn (2023). The Detransition Rate Is Unknown. study page, source.
• Littman (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. study page, source.
• Kettula et al. (2025). Gender Dysphoria and Detransitioning in Adults: An Analysis of Nine Patients from a Gender Identity Clinic from Finland. study page, source.
• Garcia et al. Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery. source.
• Papadopulos et al. Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study. source.
• Kearney et al. (2022). Patient-reported satisfaction and quality of life after trans male gender affirming surgery. PMC8726650.
• Regret meta-analysis summary (2022). Regret after Gender Reassignment. source.
• Comparison of surgical outcomes with versus without urethral lengthening (2022). source.