Female to male gender affirming surgery (GAS) can be extraordinarily complex and carries with it a breathtaking number and depth of potential complications. Phalloplasty, specifically, is the “Mount Everest” of all flap surgeries. It requires much larger free and pedicled flaps (21 cm x 16 cm at minimum) than are generally done for other complicated reconstructive surgeries and is usually done together with multiple OTHER significant surgeries. It is notable that these microvascular techniques were experimental as late as the 1970s, and only widely performed recently i.e. in this century. Much work needs to be done to optimize surgical outcomes. In all, a one-stage phalloplasty (including vaginoplasty, urethral lengthening and scrotoplasty) represents 200 relative value units (RVU’s) of surgery. (A craniotomy for removal of a glioblastoma multiforme brain tumor is 85 RVU’s.) Generally, the surgical team is made up of an experienced “mid-career” team, often with an experienced reconstructive urologist and a plastic surgeon that is especially well-versed in microsurgery.