Bottom Surgery

Who bottom surgery is for

Anyone with dysphoria about their genitals who has sat with the decision rather than arrived at it in a hurry. The paperwork is covered under eligibility below.

Then there is the practical half. Nicotine has to stop for weeks either side, and surgeons are strict about it here, because the result depends on small vessels feeding skin that has been moved. Most set a BMI range as well.

The step that sets your timeline is hair. Anything that ends up lining a canal has to be permanently cleared first, by electrolysis or laser, and that runs over months rather than weeks. It needs to be finished before your date, not chased around it.

Fertility belongs in this conversation too. Orchiectomy and vaginoplasty both end sperm production permanently, and storing sperm has to happen before either one.

At your first consultation

Ask what has to be cleared of hair, and how long before the date it needs to be done. That single answer sets your whole timeline, and asking it early is the easiest way to keep your date.

Choosing between them

Start with the canal, because everything else follows from it. If you want depth, you are choosing between vaginoplasty techniques and accepting dilation for life. If you do not, vulvoplasty gives you the same outside with a far lighter recovery and nothing to maintain.

Neither is the lesser operation. Zero-depth is a full reconstruction in its own right, a different answer to a question only you can answer, and the right choice is the one that fits the life you want afterwards.

If you want depth, penile inversion is the default and the technique with the longest track record. The peritoneal pull-through comes in when there is not enough penile and scrotal skin to line a canal, which is common for anyone who went through puberty on blockers. Surgeons differ on whether it should be offered more widely than that. Its results are good, and its long-term track record is still building.

Orchiectomy is a smaller question. It is worth having on its own if you want the hormone picture simplified and are not ready for anything built. Tell the surgeon that vaginoplasty may follow, because it changes how they close and how much scrotal skin they leave behind.

Before you book anything

Write down what you want the result to do, in plain words, and be specific about penetration. Everyone talks about how it will look. The difference between the operations is what it will ask of you afterwards, and that is the part worth deciding first.

The bottom surgery procedures

Two groups sit below. Reconstruction builds a vulva. Removal takes the testicles out and builds nothing. Most people have one operation from the reconstruction group rather than several, and an orchiectomy is either a step on the way to it or the whole of what they want.

Inside reconstruction the first fork is the canal. Vulvoplasty leaves it out. The other two build one, and the only real difference between them is where the lining comes from, penile skin or abdominal membrane. Start with penile inversion in any case. It is the operation the other two get described against, and the one whose trade-offs they are answering.

Reconstruction

Removal

Revision

Bottom surgery recovery

Orchiectomy recovers like a minor day-case operation. Sore for a few days, back at a desk inside a week, careful for two or three.

Vaginoplasty is a different scale entirely. Several nights in hospital, a catheter, packing that comes out in the first week, and a first month where sitting, walking and sleeping all take planning. Desk work is realistic somewhere around six to eight weeks, and swelling takes months to leave. Then dilation starts in hospital and keeps going, several times a day at first, dropping to a maintenance rhythm over the first year.

Vulvoplasty follows the same shape with the hard part taken out. Shorter operation, shorter stay, no dilation schedule at the end of it.

Bottom surgery cost

Bottom surgery is the group most likely to be covered, in the US by insurance once the letters are in and in Europe by public systems with waits measured in years. Where it is funded, the funding usually covers the primary operation, and not always the touch-up work that follows it a year later.

Self-pay, ask for the all-in figure across surgeon, anaesthetist and hospital, and ask separately what a revision costs if one is needed. The cost worth budgeting for alongside the surgery is hair removal, which is paid for in instalments over the year before and is rarely funded anywhere.

Where it fits

Bottom surgery tends to come last, not because it matters least but because it has the biggest recovery to plan around. It has the longest hospital stay, the longest recovery and an aftercare routine that outlasts every other procedure on this site.

Orchiectomy is the exception and often comes early, sometimes years before anything else. Facial and voice work sit wherever you want them, and many people do them first because the effect on daily life is immediate. Vaginoplasty is rarely combined with anything else under the same anaesthetic. Surgeons stage it on its own, and any refining work waits until the swelling has gone, which means the better part of a year.

Eligibility

Stricter than anything else here. The current WPATH standards ask for one letter of support, but for vaginoplasty and vulvoplasty two is still common, because many insurers, NHS England and a good number of surgeons have kept the older rule. Assume two until someone tells you in writing that one will do. Orchiectomy usually needs one.

Most surgeons also want a stretch on oestrogen behind you, often a year, though informed-consent routes ask for less. Age limits are firm and vary by country.

Public systems add their own criteria and their own queues. The eligibility section covers the letters, the criteria and what changes if you are non-binary.

Frequently asked questions

Do I have to dilate forever?

If you have a canal, yes, in a tapering form. The schedule drops a long way after the first year but never reaches zero. See recovery.

Can I have a vulva without a canal?

Yes. Vulvoplasty builds everything on the outside and skips the dilation entirely. It is a legitimate choice, not a downgrade.

Will I keep sensation and orgasm?

Usually. The clitoris is built from glans tissue kept on its own nerve supply, and most people report orgasm afterwards, though timelines vary a lot.

Why does hair removal take so long?

Because it has to be permanent, and permanent means many sessions spread over months. See who it's for.

Is it covered?

Often. US insurers increasingly cover genital surgery once the letters are in, and public systems fund it with long waits. Hair removal usually is not. See cost.