Trans bottom surgery produces genitalia that closely resemble natal anatomy, though the specific results depend on the procedure. For transfeminine patients, surgery creates a vulva with a clitoris, labia, and (optionally) a vaginal canal. For transmasculine patients, surgery constructs a penis and scrotum using tissue from the forearm, thigh, or existing genital tissue. The final appearance continues to change for up to two years as swelling resolves and scars fade.
Transfeminine Surgery: Vaginoplasty and Vulvoplasty
The most common transfeminine procedure is penile inversion vaginoplasty, which uses existing genital tissue to construct a full vulva and vaginal canal. Surgeons create labia majora (outer lips) from scrotal skin, labia minora (inner lips) from foreskin or urethral tissue, and a clitoris from the sensitive tip of the glans. The result is external anatomy that looks and functions much like a natal vulva, with structures in their expected positions.
In one study of 18 patients, over 60% rated themselves “very satisfied” with the overall appearance of their genitalia. Satisfaction was highest for the clitoris, with 72% of patients giving it the top score. The constructed vaginal canal in that study averaged about 14.6 centimeters deep, which is within or above the range considered optimal (at least 11 cm). Width is typically around four centimeters.
A vulvoplasty (sometimes called zero-depth vaginoplasty) creates the same external structures but without an internal vaginal canal. According to OHSU’s transgender health program, the outward appearance is almost identical to a full vaginoplasty, with a labia, clitoris, and shortened urethra. People who don’t want or need vaginal penetration sometimes choose this option for its shorter recovery and lower complication risk.
Scarring from vaginoplasty is minimal and mostly hidden in the natural folds between the labia and inner thighs. Most visible changes in the months after surgery come from swelling rather than scarring. Labial swelling is normal and gradually resolves over six to eight weeks, though prolonged sitting or standing can make it worse. The final cosmetic result continues improving for up to two years.
Revisions and Touch-Ups
It’s common for transfeminine patients to have a secondary procedure to refine the results. A follow-up labiaplasty can bring the labia majora closer to the midline, add clitoral hooding, and better define the labia minora. In a large study of 869 vaginoplasty patients, about 25% experienced at least one complication, and roughly half of those required a surgical correction. The most common issues were bleeding (5.8%), wound healing problems (5.7%), and urethral strictures (3.2%). These numbers are consistent with what’s reported across the broader surgical literature, and many of the corrective procedures also improve the cosmetic outcome.
Transmasculine Surgery: Phalloplasty
Phalloplasty builds a full-sized penis, most often using a large flap of skin and tissue from the forearm (called a radial forearm flap) or the thigh. The surgeon shapes this tissue into a cylindrical phallus, constructs a urethra so the patient can urinate while standing, and sculpts a glans (head of the penis) at the tip to mimic the natural coronal ridge and sulcus. Some patients later get medical tattooing to add color differentiation between the shaft and glans for a more realistic appearance.
The phallus created through phalloplasty is typically adult-sized, and its dimensions are largely determined by the amount of donor tissue available. Because the skin comes from another part of the body, the color and texture of the shaft may differ slightly from the surrounding groin skin, though this becomes less noticeable as scars mature over one to two years.
Sensation After Phalloplasty
During surgery, a nerve from the donor tissue is connected to a nerve in the groin to allow sensation to develop over time. In a study of 26 post-phalloplasty patients, 92% experienced tactile sensitivity in their new penis, and 88.5% reported erogenous sensation. Among those with sensation, about 70% said they “always” felt tactile sensitivity, and 58% said they “always” experienced erotic feeling. Pooled data from multiple studies suggest that over 90% of patients recover at least some glans sensitivity, with erogenous sensation present in more than 95%.
The Donor Site
One visible consequence of phalloplasty is the donor site scar, particularly with the forearm flap. The forearm requires a skin graft (taken from the thigh) to cover the area where tissue was harvested, leaving a rectangular patch that can show volume loss and noticeable scarring. Because the forearm is highly visible, this scar can draw attention and unwanted questions. Some patients opt for fat grafting later to restore forearm contour. Thigh-based phalloplasty hides the donor site more easily under clothing, which is one reason some patients prefer it despite other tradeoffs.
Transmasculine Surgery: Metoidioplasty
Metoidioplasty is a smaller procedure that works with the clitoral tissue that has already grown from testosterone therapy. The surgeon releases the ligament that holds the clitoris close to the body, straightens any natural curvature, and positions the tissue to project outward as a small phallus. The median length after surgery is about 6 centimeters, with a range across studies of roughly 2 to 12 centimeters depending on how much growth testosterone produced beforehand. Patients typically gain an additional 0.5 to 1 centimeter of length beyond their pre-operative stretched clitoral measurement.
The result looks like a small penis with a natural glans, since it’s made from the patient’s own erectile tissue. Unlike phalloplasty, the tissue already has full sensation from the start, and natural erections are possible without an implant. The tradeoff is size: the phallus is significantly smaller than what phalloplasty produces.
Scrotoplasty and Testicular Implants
For transmasculine patients who want a scrotum, scrotoplasty uses the labia majora to form a scrotal sac. Silicone testicular implants are then placed inside to provide volume and weight. These come in a range of sizes, from small (under 15 cc) to large (over 30 cc), and there are even weighted steel options (about 60 grams) that mimic the natural hang and movement of testes. Most patients in published studies chose medium or large implants.
The implants can be placed during the initial surgery or added later. When done as a separate procedure, the surgeon makes a small incision at the base of the phallus to create two pockets, one for each implant. Many transmasculine patients report that the implants improve not just the physical appearance but their overall sense of embodiment.
How the Final Result Develops Over Time
Immediately after any bottom surgery, the area looks swollen, bruised, and very different from the eventual outcome. For vaginoplasty, significant labial swelling persists for six to eight weeks. For phalloplasty and metoidioplasty, swelling can take even longer to fully resolve due to the complexity of tissue healing and nerve regeneration.
Scar appearance improves steadily for up to two years. Early scars tend to be red or purple and raised, then gradually flatten and lighten. For transfeminine patients, most scarring is concealed in skin folds. For transmasculine patients, the genital scars are similarly hidden, but the donor site on the forearm or thigh remains the most cosmetically significant mark. Many patients consider their results “final” somewhere around the 12 to 18 month mark, though subtle changes continue beyond that point.