MTF bottom surgery, also called feminizing genital surgery, is a set of procedures that reshape existing genital tissue to create female anatomy. The two main options are vaginoplasty, which creates both a vulva and a vaginal canal, and vulvoplasty, which creates a vulva without a vaginal canal. Which procedure someone chooses depends on personal goals, anatomy, and lifestyle preferences.
Vaginoplasty vs. Vulvoplasty
These two surgeries look nearly identical on the outside. Both create a labia, clitoris, and shortened urethra. The key difference is internal: vaginoplasty includes a vaginal canal for penetrative intercourse, while vulvoplasty does not.
Vulvoplasty is a shorter procedure with a simpler recovery. It requires no pre-surgical hair removal on the donor skin and no post-operative dilation (a maintenance routine that vaginoplasty patients follow for months to years). People choose vulvoplasty when they want the outward appearance of female genitals but have no interest in having a vaginal canal, or when they want to avoid the longer recovery process.
Vaginoplasty is the more common choice. The surgeon creates a canal between the rectum and urethra, then lines it with tissue. The result allows sitting urination, sexual sensation, and penetrative intercourse. The specific technique used to line that canal varies.
How Penile Inversion Works
Penile inversion is the most widely performed technique. The surgeon makes a space between the rectum and the urethra, forming a tunnel that becomes the vaginal canal. Skin from the penis and scrotum is then used to line the inside of that tunnel. If there isn’t enough penile or scrotal skin, the surgeon may graft skin from another area of the body.
The nerve-rich tissue at the tip of the penis is preserved and repositioned to form a clitoris, which is why most patients retain the ability to feel sexual pleasure after surgery. Scrotal skin is reshaped into the labia. The urethra is shortened and repositioned for sitting urination.
Peritoneal and Bowel-Based Techniques
When someone has limited penile and scrotal skin, or when a previous vaginoplasty needs revision, surgeons may use tissue from inside the abdomen. In the peritoneal flap technique, a surgeon uses robotic instruments inserted through small abdominal incisions to harvest tissue from the peritoneum, the thin membrane lining the abdominal cavity. This tissue is pulled down and stitched to the penile or scrotal skin tube, adding depth to the vaginal canal. The technique avoids the need for skin grafts from other body sites.
A less common approach uses a segment of the sigmoid colon. The surgeon removes a 12 to 15 centimeter section of bowel, reroutes it, and uses it to line the vaginal canal. This technique is naturally self-lubricating and requires less dilation afterward, but it involves abdominal surgery with a higher risk of serious complications. It’s typically reserved for revision cases or for patients with a stretched penile length under about 4.5 inches (11.4 centimeters), where there simply isn’t enough genital skin for standard inversion.
Preparing for Surgery
Preparation starts months before the operation. The most time-consuming step is permanent hair removal on the skin that will be used to line the vaginal canal. This means removing all hair from the scrotum and perineum (the area between the scrotum and anus), because hair-bearing skin placed inside the body can cause irritation and complications. Electrolysis is the standard method, and it often takes 6 to 12 months of regular sessions to clear the area completely.
Current international guidelines recommend at least 6 months of hormone therapy before surgery, unless hormones are not medically appropriate or desired. Estrogen therapy softens skin and changes fat distribution, which can improve surgical outcomes. A single letter of assessment from a qualified health care professional is the standard requirement, a change from older guidelines that required two separate evaluations.
Recovery and Dilation
Hospital stays typically last up to five days, though some patients go home sooner. Full recovery takes anywhere from a few weeks to a few months depending on the extent of surgery. During that time, you’ll need to avoid sexual intercourse and strenuous activity.
For vaginoplasty patients, dilation is the defining feature of recovery. This involves inserting a medical dilator into the vaginal canal on a regular schedule to maintain its depth and width while the tissue heals. In the early weeks, dilation happens multiple times per day and takes about 15 to 20 minutes per session. The frequency gradually decreases over the first year, but most surgeons recommend continuing some form of dilation indefinitely, though far less often. Skipping dilation, especially in the first several months, can lead to the canal narrowing or closing. Vulvoplasty patients skip this step entirely.
Risks and Complications
A large analysis of over 1,400 penile inversion vaginoplasty patients found that minor complications are relatively common. Vaginal stenosis, where the canal narrows, occurred in about 10.4% of patients. Urinary tract infections affected 9.2%, and persistent pain complications occurred in 9%. These are generally manageable with additional dilation, antibiotics, or time.
Major complications are less frequent. Hemorrhage occurred in 1.8% of patients, urethrovaginal fistula (an abnormal connection between the urethra and vagina) in 1.2%, and rectovaginal fistula (a connection between the rectum and vagina) in 0.8%. Blood clots occurred in about 1% of cases. Some of these complications require additional surgery to correct.
Sexual Sensation and Orgasm
One of the most common concerns people have before surgery is whether they’ll retain sexual feeling. The data on this is reassuring. In a study of transgender women who underwent feminizing genital surgery, 90% reported the ability to orgasm within 6 months of the procedure. This is possible because the surgery preserves the nerve bundle from the penis and repositions it as a clitoris, maintaining the same sensory pathways that existed before.
Sensation continues to develop and change over the first year as swelling resolves and nerves heal. Some patients report that the quality of sensation shifts over time, with many describing it as different from what they experienced before surgery but still satisfying.
Satisfaction and Regret Rates
Gender-affirming surgery has one of the lowest regret rates of any surgical category. A systematic review published in The American Journal of Surgery found that regret after gender-affirming surgery is approximately 1%. For comparison, regret after breast reconstruction ranges from 0 to 47%, regret after bariatric surgery reaches up to 19.5%, and regret after prostatectomy hits 30%. Even common life decisions carry higher regret rates: 7% for having children and 16.2% for getting a tattoo. The surgery consistently improves quality of life measures and reduces gender dysphoria in appropriately selected patients.