Bottom surgery is a broad term for gender-affirming surgical procedures that reconstruct the genitals to match a person’s gender identity. The specific operation varies widely depending on the individual’s goals, anatomy, and how much surgical complexity they’re comfortable with. Some procedures are single-stage operations with relatively quick recoveries, while others involve multiple surgeries over a year or more. Here’s what each type involves and what to realistically expect.
Feminizing Procedures
For trans women and transfeminine people, bottom surgery reshapes existing genital tissue into a vulva, and in most cases, a vaginal canal. There are several approaches, and the right one depends on what outcomes matter most to you.
Vaginoplasty
Vaginoplasty creates both a vulva and a vaginal canal. The most common technique, penile inversion vaginoplasty, uses the skin of the penis to line the canal. The scrotal skin is used to form the labia majora. Nerve tissue is preserved to create a clitoris capable of sensation. When there isn’t enough skin to achieve adequate vaginal depth, surgeons may take full-thickness skin grafts from the groin crease to supplement. A newer alternative, robotic peritoneal flap vaginoplasty, uses tissue from the peritoneal lining inside the abdomen to create or extend the canal. This approach is sometimes offered when someone has had a prior vulvoplasty or when more depth is desired.
The result closely resembles natal anatomy, though there are some typical differences: a slightly larger clitoris, a longer distance between the clitoris and the urethral opening, and labia minora that may not fully frame the vaginal opening. These are cosmetic distinctions rather than functional ones.
Vulvoplasty
Vulvoplasty creates the external vulva (labia, clitoris, urethral opening) without constructing a vaginal canal. This is sometimes called “shallow-depth” or “zero-depth” vaginoplasty. It’s a good fit for people who don’t want or need a vaginal canal, and it comes with a shorter recovery and no need for ongoing dilation. If you later decide you want a canal, vaginoplasty can be performed as a second procedure.
Orchiectomy
Orchiectomy, the removal of the testes, is sometimes performed as a standalone procedure. It eliminates the body’s primary source of testosterone, which can allow people to reduce or stop anti-androgen medications. Hospital stays are typically zero to one day, and recovery takes about two weeks.
Masculinizing Procedures
For trans men and transmasculine people, there are two primary approaches to constructing a penis, and they differ significantly in size, complexity, and trade-offs.
Metoidioplasty
Metoidioplasty works with tissue you already have. Testosterone therapy gradually enlarges the clitoris, and this procedure releases it from surrounding structures to increase its projection. The result is a small penis, typically 5.6 to 7 centimeters in length. It’s performed in a single stage, and about 74% of people who have urethral lengthening included are able to urinate standing up afterward. The trade-off is size: the result is not large enough for penetrative sex in most cases. Wound complications occur in roughly 63% of cases, though many are minor. Urethral strictures (narrowing) and fistulas (abnormal openings) each occur about 21 to 25% of the time.
Phalloplasty
Phalloplasty constructs a full-sized penis using tissue transplanted from another part of the body. The two most common donor sites are the forearm (radial forearm flap) and the outer thigh (anterolateral thigh flap). Both have distinct pros and cons.
The forearm flap tends to produce better initial results with fewer follow-up surgeries on the penis itself (15% needing revisions versus 45% for the thigh flap). However, it leaves a visible scar on the forearm and has higher early fistula rates (about 32% versus 15%). The thigh flap avoids the forearm scar, which is a significant cosmetic concern for many people, but comes with higher rates of secondary procedures to refine both the penis and the donor site. Standing urination rates are high for both: roughly 95% overall, though urethral complications remain common regardless of technique. Across all phalloplasty methods, the overall complication rate is around 76.5%, with urethral fistulas at 34% and strictures at 25%.
These complication numbers are high compared to most surgeries, but they reflect the extraordinary complexity of constructing a functioning urethra through newly built tissue. Many complications are correctable with follow-up procedures.
Scrotoplasty and Implants
Scrotoplasty, the construction of a scrotum, is typically performed alongside or after phalloplasty or metoidioplasty. The labia majora are reshaped to form scrotal pouches, and saline-filled silicone testicular implants can be placed inside. In the United States, only one testicular prosthesis is FDA-approved, and it comes in four sizes. An erectile implant can also be placed in the penis at a later stage to enable penetrative sex, though this is a separate procedure usually done after full healing.
Sensation After Surgery
One of the most common concerns is whether you’ll retain erotic sensation. The evidence is reassuring. During both vaginoplasty and phalloplasty, surgeons connect nerves from the original genital tissue to the newly constructed anatomy. After vaginoplasty, high rates of orgasmic ability are reported, primarily through the neoclitoris. The neovagina itself develops vibratory and pressure sensation comparable to a natal vagina.
After phalloplasty, sensation returns more gradually as nerves regenerate through the transplanted tissue. The largest studies report sensation in the new penis that’s slightly less than what’s measured in non-trans men, but erogenous sensation and the ability to orgasm are present in nearly all patients after several months. Researchers note that genital surgery patients experience faster and more complete nerve recovery than in almost any other peripheral nerve repair scenario.
Preparing for Surgery
Bottom surgery requires significant preparation, and one of the most time-consuming steps for vaginoplasty is hair removal. Hair-bearing skin from the penis and scrotum is used to line the vaginal canal, so that skin needs to be permanently cleared of hair before surgery to prevent hair growth inside the body afterward.
Laser hair removal is the faster route for people with dark-pigmented hair: it averages about 8 sessions spaced roughly 5 weeks apart, with each session lasting around 14 to 26 minutes. Total time in treatment comes out to about 2 hours across all sessions. Electrolysis, which is necessary for people with blond, red, or white hair, requires an average of 24 sessions every 2.4 weeks, with each session lasting about 2.5 hours. Total treatment time averages 48 hours. Treatment is considered complete when fewer than 5 hairs regrow in the treatment area for two consecutive months.
Planning your logistics 4 to 6 weeks before surgery is recommended. You’ll need to arrange time off work, set up a recovery space at home, and ideally have a caregiver available for at least the first week or two.
Recovery and Dilation
Hospital stays vary by procedure. Full-depth vaginoplasty typically requires 3 to 6 days in the hospital, shallow-depth vaginoplasty 1 to 3 days. Overall recovery, meaning the point at which you can return to work and daily activities, takes about 8 weeks for full-depth vaginoplasty and about 4 weeks for shallow-depth. You’ll need to avoid lifting anything over 10 pounds for the first month.
If you’ve had a full-depth vaginoplasty, dilation is a non-negotiable part of recovery. The vaginal canal will naturally try to close, and regular dilation with medical dilators keeps it open and maintains depth. The schedule is intensive at first: three times a day for 10 minutes each session during the first three months. From months 3 to 6, it drops to once daily. After 6 months, every other day is sufficient. By 9 to 12 months post-surgery, most people dilate once or twice a week. Many continue some level of dilation long-term, though the frequency becomes much less demanding over time.
Phalloplasty recovery is harder to generalize because the surgery is often staged across multiple operations over 12 to 18 months, with each stage having its own recovery period. Urethral complications may require additional corrective procedures, which extends the overall timeline.
Choosing Between Procedures
The choice between procedures comes down to your priorities. For masculinizing surgery, metoidioplasty offers a simpler, single-stage surgery with natural erections and sensation, but a smaller result. Phalloplasty provides a full-sized penis with high standing urination rates, but involves more complex surgery, donor site scarring, and a higher likelihood of complications and revisions. For feminizing surgery, the main decision is whether you want vaginal depth. Full-depth vaginoplasty provides a functional vaginal canal but requires months of committed dilation. Vulvoplasty is a simpler surgery with a faster recovery if a canal isn’t important to you.
Most surgical teams will walk you through these trade-offs in detail during consultations, and many people find it helpful to connect with others who’ve had the specific procedure they’re considering.