Bottom Surgery
Bottom surgery is two groups of operations. Orchiectomy removes the testicles and takes the body's own testosterone out of the picture. The reconstructions build a vulva from the tissue that is already there, and in most cases a vaginal canal behind it: penile inversion vaginoplasty, the peritoneal version that borrows lining from inside the abdomen, and the rarer sigmoid colon version.
Vulvoplasty is the fourth option and the one people hear least about. It builds everything on the outside, with no canal, and asks nothing of you afterwards.
That is the decision the whole group turns on. Depth is not a free upgrade. A surgical canal is a space held open against a body that would rather close it, which means dilating on a schedule that tapers over the years and never quite stops. The people I have walked through this were rarely surprised by the operation. They were surprised by the dilation.
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. Most systems want two letters of support for genital surgery. Most surgeons want a stretch on oestrogen behind you, though informed-consent routes exist and ask for less.
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 condition that derails timelines 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 people who ask it late are the ones who end up postponing.
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.
I have watched people talk themselves into depth they did not want, because they took the zero-depth version for the lesser operation. It is not. It is a different answer to a question only you can answer.
If you want depth, penile inversion is the default, and it is the technique with the longest track record. Peritoneal vaginoplasty comes in when there is not enough penile and scrotal skin to line a canal, which is common for people who went through puberty on blockers, and surgeons differ on whether it should be offered more widely than that. Sigmoid colon is a third line, usually after something else has fallen short.
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
The operations below fall into two groups. Removal takes something out and builds nothing. Reconstruction builds the vulva, and either includes a canal or deliberately leaves it out. Most people have one operation from the second group, not several.
The techniques within vaginoplasty are versions of the same operation that differ in where the canal lining comes from. Labiaplasty and revision sit apart from all of it, as a second, smaller procedure that refines the result once things have settled. Read the page for the operation your surgeon named first.
Penile Inversion Vaginoplasty
A vaginoplasty that lines the canal with penile skin, builds the clitoris from glans tissue on its own nerve, and shapes labia from scrotal skin. The longest track record of any technique, at the price of lifelong dilation.
Best for: anyone who wants depth and has enough penile and scrotal skin to line a canal
- Scar
- Along the labia and in the groin creases, settling into the natural folds
- Sensation
- Usually kept; the clitoris is built from glans tissue on its own nerve
- Back to work
- 6–8 weeks
- Typical cost
- $20,000–$35,000
Bottom surgery recovery
Orchiectomy recovers like a minor day-case operation. Sore for a week, careful for a fortnight, done.
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 two 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 but not always the revision or the labiaplasty that follows it.
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 expense that surprises people is not the surgery. It is the 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 takes the most out of you. 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 a labiaplasty or revision is planned for months later.
Eligibility
Stricter than anything else here. Most surgeons follow WPATH's Standards of Care and want two letters of support for genital surgery, along with a documented period living in your gender and, usually, a year or more on hormones. 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 to do 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 choosing between them.
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 with two letters, and public systems fund it with long waits. Hair removal usually is not. See cost.
New to MTF surgery?
Start with the guide: what each operation actually involves, where hormones stop and surgery begins, and how people decide the order.
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