Top surgery and bottom surgery are the two broad categories of gender-affirming surgery. Top surgery reshapes the chest, either removing breast tissue to create a flatter contour or augmenting the breasts for a more feminine appearance. Bottom surgery reconstructs the genitals to better match a person’s gender identity. Both terms cover several distinct procedures, and most people pursue one or both based on their individual goals.
Masculinizing Top Surgery
For transmasculine individuals, top surgery means removing breast tissue and reshaping the chest to appear flat and more traditionally masculine. The specific technique depends mostly on breast size and skin elasticity.
The most common approach is double-incision mastectomy with free nipple grafting. This works best for medium to large breasts, especially those with any degree of sagging. The surgeon removes tissue through two horizontal incisions across the chest, then repositions and resizes the nipples. It produces the flattest result with the most control over chest shape, though it leaves visible scars along both sides of the chest.
For people with smaller breasts and good skin elasticity, periareolar (sometimes called “keyhole”) techniques use smaller incisions around the areola. These leave less visible scarring but offer less control over the final contour. Revision rates tend to be higher with periareolar approaches, around 37%, compared to about 20% for the double-incision method.
Feminizing Top Surgery
For transfeminine individuals, top surgery is breast augmentation using implants. Most surgeons use smooth, round silicone gel implants, and the typical implant volume is around 260 to 290 mL, though sizes range from 140 to 520 mL depending on the person’s frame and goals.
Placement is a key decision. In most transfeminine patients, roughly 80% in published case series, surgeons place implants in the subglandular plane (above the chest muscle rather than beneath it). This avoids animation deformities, where the implant shifts visibly when you flex your chest muscles. Subfascial placement, just beneath the tissue covering the muscle, is another option used in a smaller number of cases.
Masculinizing Bottom Surgery
Transmasculine individuals have two main options for genital reconstruction: metoidioplasty and phalloplasty. The choice often comes down to priorities around size, function, and tolerance for surgical complexity.
Metoidioplasty releases the clitoris (which typically grows from testosterone therapy) and uses local genital tissue to form a small penis. It can be done with or without urethral lengthening to allow urination from the tip. The procedure preserves natural erectile function and sensation, involves fewer surgeries, and carries lower complication risk. The tradeoff is size. The resulting phallus is generally not large enough for standing urination in all cases or for penetrative intercourse.
Phalloplasty constructs a larger penis using a skin flap, most commonly taken from the forearm or the front of the thigh. It offers a better chance of standing urination and, with a penile prosthetic placed in a later stage, penetrative sex. However, it’s a more involved process. Urethral complications (strictures and fistulas) affect a significant number of patients, with stricture rates around 63% and fistula rates around 27% in phalloplasty cases. About 73% of patients in one study needed at least one revision surgery to address these issues. Recovery is longer, and there’s a donor site scar on the arm or thigh that concerns some patients.
People who choose metoidioplasty tend to prioritize fewer complications, preserved sensation, and a simpler recovery. Those who choose phalloplasty tend to prioritize size, appearance, and the ability to urinate standing up.
Feminizing Bottom Surgery
The most common feminizing genital procedure is vaginoplasty, which creates a vaginal canal and vulva. Several techniques exist, but penile inversion vaginoplasty accounts for about 75% of cases in published literature. In this approach, penile skin is inverted and used to line a newly created vaginal canal. Scrotal skin grafts are routinely needed to provide enough tissue for adequate depth.
When there isn’t enough genital skin available, surgeons may use peritoneal tissue (the lining of the abdominal cavity) or, less commonly, a segment of intestinal tissue to create or supplement the vaginal canal. Peritoneal techniques have gained popularity in recent years as an alternative for patients with limited donor skin.
A shallow-depth vaginoplasty is also an option for people who want the external appearance of a vulva without a full vaginal canal. This involves a shorter recovery and avoids the ongoing dilation that full-depth procedures require. Orchiectomy (removal of the testes alone) is a simpler procedure that some people choose either as a standalone step or before a later vaginoplasty.
Recovery and Hospital Stays
Recovery varies widely depending on the procedure. Top surgeries (both masculinizing and feminizing) are typically outpatient or involve a short hospital stay, with most people returning to light activity within a few weeks.
Bottom surgeries require more recovery time. Full-depth vaginoplasty involves 3 to 6 days in the hospital and about 8 weeks of initial recovery before returning to normal activities. Shallow-depth vaginoplasty requires 1 to 3 days in the hospital and roughly 4 weeks of recovery. Orchiectomy is often same-day or one night, with about 2 weeks of recovery. Full healing and adjustment after any genital surgery takes 9 to 12 months.
Phalloplasty, because it’s typically staged across multiple procedures, involves the longest total recovery timeline. Each stage has its own healing period, and the full process can take a year or more from first surgery to final result.
Sensation and Sexual Function
Preserving or restoring sensation is a central goal in all of these procedures. In transfeminine vaginoplasty, the most important factor for sexual satisfaction is clitoral sensitivity. About 65% of post-operative transfeminine individuals in one study identified clitoral sensitivity as the biggest contributor to sexual enjoyment, more so than vaginal depth or vaginal sensation. Roughly 38% reported orgasms that were more intense after surgery, while 24% found them less intense and 38% noticed no change.
For transmasculine procedures, metoidioplasty generally preserves the existing nerve pathways and erectile function. Phalloplasty requires nerve reconnection, and sensation develops gradually over months as nerves regenerate. The degree of tactile and erogenous sensation varies by technique and individual healing.
Eligibility and Preparation
Current guidelines from the World Professional Association for Transgender Health recommend at least 6 months of hormone therapy before gonadectomy or genital surgery for adults, though this can be longer if needed to achieve the desired surgical result. Hormones aren’t required if they’re medically contraindicated or not desired. For adolescents, the recommended minimum is 12 months of hormone therapy before genital procedures. A mental health assessment is part of the process, focused on ensuring the person can consent and that any co-existing mental health conditions are addressed, but therapy specifically focused on gender identity is not required.
Fertility preservation is an important conversation to have early. Bottom surgeries that involve removing the ovaries or testes permanently eliminate the ability to produce eggs or sperm. Ideally, anyone interested in biological children should explore options like egg or sperm cryopreservation before starting hormone therapy, since hormones themselves can reduce reproductive potential over time.
Cost and Insurance Coverage
The cost of gender-affirming surgery varies dramatically by procedure. In commercially insured populations, average total payer costs per person (including multiple surgical stages) run about $53,645 for vaginoplasty and $133,911 for phalloplasty. Simpler procedures cost less: orchiectomy averages around $6,927 per episode. Out-of-pocket costs for insured patients are considerably lower, averaging $1,614 across all procedure types, with most people paying between 3% and 15% of the total depending on the surgery.
Insurance coverage has expanded significantly. As of early 2021, 24 U.S. states and territories prohibited blanket exclusions for transgender care in state-regulated private insurance. The number of people undergoing gender-affirming surgery with insurance coverage rose from 21 in 2011 to 794 in 2019 within one large commercial dataset, reflecting both broader coverage and growing access to qualified surgeons.
Satisfaction and Regret Rates
A meta-analysis pooling 7,928 transgender patients across 27 studies found a regret rate of 1% after gender-affirming surgery. For mastectomy specifically, the rate was below 1%. For vaginoplasty, it was about 2%. Research consistently documents significant improvements in quality of life, body satisfaction, and psychological well-being after these procedures. Among those who did express regret, some cited social pressures like difficulty maintaining relationships or workplace discrimination rather than dissatisfaction with the surgical outcome itself.