The current domestic practice of female-to-male gender affirming surgery requires the certifications from two different psychiatrists. Since the operation is irreversible, the oocytes may be reserved. The female-to-male gender affirming surgery is composed of three stages. The uterus and ovaries removed is firstly performed by the obstetrics and gynecology department. The second stage is performed by plastic surgery and urology for urethra lengthening and phalloplasty. The third stage is the prothesis insertion. The operation involves the anastomosis of nerves, blood vessels and urethra, thus, no smoking is suggested before and after the operation.

• #1
  In the first stage, the obstetrics and gynecology department will complete the removal of the uterus and ovaries. One month after surgery, the second stage operation could be arranged.
• #2
  Before the stage II operation, the patient could consider whether standing to urinate or not. Urinating in a standing position requires both urethra extension and phalloplasty, which have high risks of urethral stricture. In consideration of surgical complications, some may choose not to urinate in a standing position. The urethra is partially extended and opened just behind the neo-scrotum. A thigh or inguinal flap could be used for neo-penis formation.
• #3
  The phalloplasty is composed of tube-in-tube structure. The inner and outer tube were designed for the urethra extension and penis appearance, respectively. If the thigh thickness is less than 1cm, a single thigh flap is adequate for tube-in-tube formation. Skin graft is required for the flap donor site coverage.
• #4
  If the thigh thickness is between 1 to 2 cm, a free forearm flap (forming an inner tube) combined with a thigh or inguinal flap (forming an outer tube to cover the urethra) might be suggested.
• #5
  If the thigh thickness is larger than 2 cm, it is difficult to form a tube-in-tube structure. It is advisable to implant the vaginal mucosa or other skin into the thigh or calf flap firstly for a stable inner channel formation. After that, the outer skin paddle surrounded the inner tube to form a neo-penis shaft. The skin or mucous membrane over the inner tube may have risks of skin contracture and subsequent urethral stricture.
• #6
  In order to avoid significant scar formation over thigh, a bilateral inguinal flap might be considered. The required length of the inguinal flap is about 25 cm. Although the scar can be hidden in the groin area, the distal perfusion of the groin flap may be inadequate.
• #7
  Different from the free forearm flap used as the inner urethra reconstruction, the single free forearm flap here needs to complete the tube-in-tube structure simultaneously. The large flap donor area requires a large area of skin grafting.
• #8
  During phalloplasty, the sensory nerve of the free flap will be anastomed to inguinal nerve. About 1 year later after anastomosis, the subcutaneous prothesis might be implanted.

Complete of stage I FtM surgery, check the residual vagina depth (routine requirement < 3 cm), elastic-garment for thigh/forearm use, hormone therapy suspended for 2 weeks.

• Locationperineal area.
• Anesthesiageneral anesthesia.
• DurationVariable.
• Targetstaged phalloplasty.

• Drainage tube remove on postoperative day 3. Constant elastic underwear for penis support.
• No smoking.

Numbness over flap donor site, flap partial loss, hypertrophy scar formation, urethra stricture or fistula, etc.