Bottom surgery is a broad term covering several distinct procedures that reconstruct genital anatomy to align with a person’s gender identity. The specific technique depends on the goal: creating a vagina and vulva (vaginoplasty), constructing a penis (phalloplasty), or releasing and repositioning existing tissue into a small phallus (metoidioplasty). Each approach involves different surgical steps, recovery timelines, and tradeoffs worth understanding before pursuing any of them.
Vaginoplasty: Creating a Vaginal Canal and Vulva
The most common approach, and the one considered the gold standard for decades, is penile inversion vaginoplasty. The surgeon uses penile and scrotal skin to line a newly created vaginal canal between the bladder and rectum. The head of the penis is reshaped into a clitoris, preserving its nerve supply so that erogenous sensation remains intact. The urethra is shortened and repositioned, and the outer labia are sculpted from scrotal tissue.
A newer alternative is robotic peritoneal vaginoplasty, where the surgeon uses tissue from the peritoneum (the membrane lining the inside of the abdomen) to create the vaginal canal instead. This is done through small abdominal incisions with robotic assistance. The technique is especially useful for patients who have less genital tissue to work with, including those who used puberty blockers, because it doesn’t rely as heavily on existing skin. It also offers advantages for revision surgeries when a previous canal has narrowed. The tradeoff is that it carries the additional risks of any abdominal surgery.
Both techniques produce successful outcomes with overall low rates of major complications. Hospital stays typically run three to five days. The most demanding part of recovery is dilation: inserting a medical dilator into the new vaginal canal on a strict schedule to prevent it from narrowing or closing. For the first year, you’ll dilate multiple times a day. After that, the frequency drops to roughly once a week, though some degree of ongoing dilation is a lifelong commitment.
Phalloplasty: Building a Penis in Stages
Phalloplasty constructs a full-sized penis using a large flap of skin and tissue transferred from another part of the body. It’s one of the most complex reconstructive surgeries performed today, and it typically happens across multiple staged procedures spread over a year or more.
Choosing a Donor Site
The most common donor site is the forearm, known as a radial forearm flap. Surgeons favor it because the skin is relatively thin, pliable, and has a reliable blood supply and nerve anatomy. The tissue is rolled into a tube to form both the shaft and a new urethra, then microsurgically connected to blood vessels and nerves in the groin. The downside is a visible scar on the forearm and temporary limitations in hand function. You’ll typically begin hand therapy about two weeks after surgery and gradually rebuild range of motion in your fingers and wrist.
For people with smaller forearms or thinner skin where a forearm flap might cause functional problems, the anterolateral thigh (ALT) is an alternative donor site. This uses tissue from the outer thigh, which leaves a scar that’s easier to conceal under clothing. The choice between sites involves balancing aesthetics, function, and scarring with your surgical team.
How Sensation Is Restored
One of the most important steps in phalloplasty is the nerve hookup. Surgeons take the nerves that came with the donor tissue and microsurgically connect them to nerves in the pelvis. This allows both protective sensation (feeling touch, pressure, and temperature) and, in many cases, erogenous sensation to develop over time. The clitoris is often buried at the base of the new penis to preserve an additional source of sexual feeling. Nerve regrowth is slow, and sensation continues to improve for a year or more after surgery.
Staged Procedures and Erectile Devices
Phalloplasty is rarely completed in a single operation. The first stage constructs the phallus itself and connects blood vessels, nerves, and the urethra. Later stages may include scrotoplasty (creating a scrotum from labial tissue and inserting silicone testicular implants) and implanting an erectile device. There’s usually about six months of healing between each stage, which gives nerves time to regenerate and lowers the risk of complications like implant shifting.
Because the constructed penis doesn’t become erect on its own, an implant is needed for penetrative sex. Two main types exist. Inflatable implants use cylinders placed inside the shaft connected to a small pump in the scrotum and a fluid reservoir. Squeezing the pump moves saltwater into the cylinders to create an erection, and a release valve drains it afterward. Three-piece versions place the reservoir under the abdominal wall, while two-piece versions combine the reservoir and pump into one scrotal unit. Semirigid implants are simpler: bendable rods that keep the penis firm enough for intercourse and can be positioned downward for concealment. Implant placement is always a later-stage procedure, never done during the initial construction.
Recovery From Phalloplasty
Expect to stay in the hospital for at least five days after the primary surgery. During early recovery, you shouldn’t lift anything over five pounds with the donor arm, and bending at the waist past 90 degrees is restricted. Walking at least four times a day for ten minutes or more helps prevent blood clots. You’ll need to avoid submerging your surgical sites in water (no baths, pools, or hot tubs) until your surgeon clears you. Sexual use of the penis is off-limits until explicitly approved, which typically takes several months.
Metoidioplasty: Working With Existing Tissue
Metoidioplasty is a less invasive option that works with the growth testosterone has already produced. After months or years of hormone therapy, the clitoris enlarges significantly. A simple metoidioplasty releases this tissue by cutting the ligament that anchors it to the pelvic bone, pushing it forward into a more prominent position. The result resembles a small circumcised penis, typically one to three inches in length. Because the existing nerve supply is left intact, erogenous sensation is fully preserved, and the tissue can become erect naturally.
Additional steps can be combined with the release. Urethral lengthening extends the urethra through the new phallus so you can urinate while standing. Scrotoplasty creates a scrotum from labial tissue: during the clitoral release, the labia descend from their usual position, and tissue expanders gradually stretch the skin to make room for silicone testicular implants. Without scrotoplasty, the result has a split (bifid) appearance where the labia remain separated on either side.
Metoidioplasty has a shorter recovery and fewer stages than phalloplasty, but the smaller size means penetrative sex may not be possible for most patients. For many people, the tradeoff of preserved natural erection and sensation, a single surgery, and a simpler recovery is worth it.
Urethral Complications Are Common
Any surgery that lengthens the urethra carries a meaningful risk of complications. Across published studies, urethral narrowing (stricture) occurs in roughly 25% to 63% of cases, and fistulas, where a small opening forms along the urethra allowing urine to leak, occur in 17% to 75% of cases depending on the study and technique. These rates apply to both phalloplasty and metoidioplasty when urethral lengthening is performed. Most of these complications are correctable with additional procedures, but they’re common enough that surgeons discuss them as an expected possibility rather than a rare event.
Eligibility and Preparation
Most surgical programs follow guidelines that require at least 12 months of hormone therapy (when medically appropriate), at least 12 months of living in your affirmed gender role, and one or two letters of support from mental health professionals, depending on the procedure. You generally need to be at the age of majority in your jurisdiction, though some programs will operate on patients under 18 in specific clinical circumstances. Procedures that only remove the gonads without full genital reconstruction may have fewer requirements.
The preparation period also serves a practical purpose. For phalloplasty patients, forearm hair may need to be removed before surgery (since that skin will line the urethra). Smoking must be stopped well in advance because it impairs blood flow to the transferred tissue. Weight stability and overall fitness directly affect surgical outcomes and healing speed, so most programs set clear physical health benchmarks before scheduling.