Bottom Surgery in San Francisco

Medically reviewed by Lin-Lin Liu, PA on August 29, 2026.

MTF bottom surgery, FTM bottom surgery and bottom surgery for non-binary patients are major life decisions that involve reconstructing a patient’s genitals to treat their gender dysphoria. Our providers offer the following gender affirming surgery in San Francisco to qualified patients: vaginoplasty, vulvoplasty, orchiectomy, metoidioplasty, phalloplasty and vaginectomy. Here we discuss bottom surgery costs, medical candidacy requirements, travel into San Francisco for surgery, the difference between sex reassignment surgery (SRS) procedures, and more.

If you have questions about which procedures would be right for you, or would like a quote for your procedure, you can request a free, in-person consultation with Dr. Zara Ley (she/her/they) here. Bottom surgery is only available to qualifying adult patients.

Bottom Surgery at the Gender Confirmation Center in San Francisco

At the Gender Confirmation Center (GCC) of San Francisco, our bottom surgery procedures are offered by Dr. Zara Ley (she/her/they). Dr. Ley is a board-certified surgeon, a former patient and one of the few trans women of color to offer a full spectrum of gender surgeries. Dr. Ley welcomes patients from all over the US and internationally. She has trained younger generations of surgeons on some of the techniques most-backed by long-term evidence. Dr. Ley is sought out by patients because of her years of experience and her personal understanding of the surgical experience.

To reduce the barriers to access to gender-affirming surgery in San Francisco, Dr. Ley provides surgical consultations free of cost. For most bottom surgery procedures, she requires that patients come in-person to San Francisco for consultations to undergo a medical examination to determine surgical eligibility. However, for some procedures like orchiectomy, patients can elect to have a remote, virtual consultation.

The Bottom Surgery Procedures We Offer

At this time, the GCC offers the following bottom surgery options in San Francisco. If you have questions about any of the following procedures, you can request a free, in-person consultation with Dr. Ley––committment free.

Metodioplasty

Metodioplasty is a transmasculine or FTM bottom surgery procedure. A simple metoidioplasty or “meta” involves releasing the natal erectile tissue (i..e, clitoris) from its surrounding ligaments to give it a more forward, prominent position. Patients can also undergo a complex meta to lengthen their urethra (to urinate while standing), remove their vaginal canal (vaginectomy), and/or construct a scrotum (scrotoplasty) with or without testicular implants.

Phalloplasty

Phalloplasty bottom surgeries involve constructing a full-size phallus using a flap grafted from another part of the body. The RFF phalloplasty takes the donor flap from the forearm. The ALT phalloplasty takes the donor flap from the outer thigh. The groin flap phalloplasty takes the donor flap from the groin region, below the abdomen. The groin flap technique is the only one of the three that does not leave a large, visible scar on the body from surgery.

Vaginectomy

A vaginectomy involves the removal of the vaginal canal and closing of the vaginal opening. Dr. Ley requires that patients who undergo a primary urethral lengthening undergo a simultaneous vaginectomy to prevent urethral complications. Urethral lengthening surgery allows patients to urinate out of the tip of their penis, making it easier to pee while standing. Please note that to undergo a vaginectomy, patients should undergo a hysterectomy at least 8-12 weeks prior.

Mons Resection and Panniculectomy

Mons resection and panniculectomy are two body contouring procedures often paired with metoidioplasty or phalloplasty. A mons resection is a procedure that removes excess skin and fat from the mons pubis region, along the upper groin. A panniculectomy is a procedure that removes excess skin and fat from the lower abdomen to tighten the skin and remove overhang. These two surgeries, performed together or apart, help tighten the mons region, giving the penis a more forward, visually apparent position.

Vaginoplasty, Vulvaplasty and Labiaplasty.

Vaginoplasty reconstructs a penis and scrotum to construct a vulva and vagina with a fully sensate clitoris. At the GCC, Dr. Ley only offers the penile-inversion vaginoplasty technique at this time. This involves using skin from the penis and scrotum to construct the labia, clitoral hood and vaginal canal. A vulvaplasty, on the other hand, is sometimes called a “zero-depth vaginoplasty” because it involves the creation of a vulva and clitoris without a vaginal canal.

Labiaplasty

Labiaplasty is a surgery that involves altering the appearance of the labia to correct aesthetic or functional issues (like chaffing). Most often, it is a revision procedure after a vaginoplasty or vulvaplasty. However, in her own practice, Dr. Ley performs vaginoplasty and vulvaplasty as two-stage procedures, with a labiaplasty performed about five months after the initial procedure. Dr. Ley performs the labiaplasty as a second stage because it improves patient satisfaction, aesthetic outcomes and reduces the likelihood that a patient will need further revision surgeries.

Orchiectomy

An orchiectomy is the permanent, surgical removal of the testicles. This procedure can be performed prior to or simultaneously with a vaginoplasty or vulvaplasty. Many patients undergo orchiectomy without undergoing further bottom surgery––like a vaginoplasty––because it eliminates the need to take testosterone blockers.

Choosing the Right Procedure for You

Bottom surgery is a very personal, life changing decision that we encourage patients to come to with the help of a gender-competent, licensed mental health provider.

Every patient has their own, unique timeline for coming to the decision about which bottom surgery procedures are right for them. For example, many transfeminine patients wait until after undergoing an orchiectomy to understand if they also need a vaginoplasty to treat their gender dysphoria. Alternatively, several transmasculine patients undergo a metoidioplasty first to reduce their bottom dysphoria, and later go on to get a phalloplasty once they are able to qualify (e.g., needing to reduce their BMI, meet insurance requirements, or save up for a more intense recovery).

Weighing Transmasculine Bottom Surgery Options

Patients often contemplate the following factors when deciding between phalloplasty and metoidioplasty procedures:

• Penis size: whereas metoidioplasty results are usually around the size of a thumb (depending on a patient’s bottom growth from testosterone), phalloplasty results more commonly range between 4-6” in length.

• Multiple stages of surgery: Phalloplasty is more likely to require multiple stages of surgery to get patients to their final results. That said, even some metoidioplasty patients need to undergo multiple stages of surgery, for example, for a scrotoplasty and testicular implants.

• Erogenous sensation: Since a metoidioplasty does not alter the natal erectile tissue, it will maintain the same level of sensation after surgery. Phalloplasty techniques have different probability levels for maintaining sensation depending on the procedure you undergo.

• Scarring: Metodioplasty and groin flap phalloplasty leave little to no visible scarring. Radial free forearm (RFF) flap and anterolateral thigh (ALT) flap phalloplasties leave large rectangular scars on the forearm and outer thigh respectively, that heal to look similar to burn marks.

• Insurance: Due to hospital requirements, the GCC is only able to take phalloplasty patients whose insurance providers pre-approve the surgery. Insurance coverage is not a candidacy requirement for metoidioplasty, but it can help reduce costs for the surgery.

• BMI: Due to health and safety concerns, as well as anatomical limitations, Dr. Ley is only able to offer metoidioplasty and phalloplasty to patients who meet the following BMI requirements:
  • Simple metoidioplasty: ≤40
  • Metoidioplasty with primary urethral lengthening: ≤35
  • Groin-flap phalloplasty: ≤30
  • ALT (anterolateral thigh) phalloplasty: ≤23
  • RFF (radial forearm flap) phalloplasty: ≤30
  • Radial forearm urethral lengthening: ≤30

Weighing Transfeminine Bottom Surgery Options

Patients often contemplate the following factors when deciding between vaginoplasty, vulvaplasty and orchiectomy procedures:

• Timing: An orchiectomy can be performed during or prior to a vaginoplasty/vulvaplasty. Some patients choose to undergo an orchiectomy first before committing to another bottom surgery procedure, to give themselves time to understand their needs. If you undergo an orchiectomy and would like to keep open the possibility of a vaginoplasty/vulvaplasty, please do not undergo a scrotoectomy as the scrotal skin will be necessary to construct your future vulva and/or vagina.

• Penetrative sex: For whom being able to have receptive, vaginal penetrative sex is important, vaginoplasty may be an ideal procedure. This is because vulvaplasty and orchiectomy do not involve the construction of vaginal canals.

• Dilation: For patients who undergo a vaginoplasty, dilation is a lifelong commitment if you would like to maintain the length and depth of your vagina over time. Many patients take into account whether they can keep up with the dilation protocol when deciding between surgery types.

• BMI: Due to health and safety concerns, as well as anatomical limitations, Dr. Ley is only able to offer vaginoplasty and vulvaplasty to patients who meet the following BMI requirements:
  • Vaginoplasty: ≤34
  • Vulvoplasty: ≤38

Bottom Surgery Cost and Insurance in California

Insurance coverage can significantly reduce the costs of bottom surgery for many patients. California state law requires that all insurance providers cover some forms of gender-affirming medical care. In most cases, providers will cover bottom surgery so long as patients meet candidacy requirements––for example, a support letter from a licensed mental health provider. Please be sure to check your insurance provider’s clinical requirements for gender-affirming surgery coverage.

For more information on bottom surgery pricing and insurance, click here.

Cost Estimates for Bottom Surgery in San Francisco

Cost of feminizing/“MTF bottom surgery”

Vaginoplasty	Vulvaplasty	Labiaplasty
$23,000-24,500	$20,500-22,000	$8,500-15,500

Cost of masculinizing/“FTM bottom surgery”

Metoidioplasty	Phalloplasty	Hysterectomy*
$23,000-24,500	Price varies, depending on insurance provider	$32,000-50,000

*Please note that the GCC does not offer hysterectomies at this time. We recommend undergoing a hysterectomy 8-12 weeks prior to metoidioplasty or phalloplasty.

Why Choose the Gender Confirmation Center

For several years, the GCC has welcomed patients from all over the US and even internationally to undergo gender-affirming surgery with our world-class care team. Dr. Ley is particularly sought out because of her expertise in bottom surgery, her high standards for aesthetic outcomes and her personal experience as a former patient. Not to mention, San Francisco and the Bay Area at large boasts a variety of resources for our gender-diverse patient community.

If you are interested in undergoing bottom surgery with Dr. Ley, you can request a free consultation with her here––commitment free.

Transfeminine Patient Testimonials

The following testimonies come from transfeminine patients that have undergone bottom surgery with Dr. Ley:

“Love, love, love Dr. Ley, she is amazing!!! I had two rounds of labiaplasty with her, spaced several months apart, and she took such great care of me through both surgeries.

She really listened to what I wanted, was honest and realistic about what was possible, and has such an incredible eye for detail. As a trans woman herself, I felt like she genuinely understood what I was looking for and made me feel comfortable every step of the way. Her bedside manner is fantastic, as well.

She also went out of her way to advocate for me with management when it came to a payment mixup, which I really appreciated.”

“I had a breast augmentation and vaginoplasty with Dr. Ley in 2024, and both were very positive experiences. Gender Confirmation Center was very helpful with getting insurance squared away and scheduling everything, but Dr. Ley and her clinic staff really made the difference. I had all of my questions answered to my satisfaction, and I always felt my concerns were heard and addressed. Everything was handled very smoothly, even the surgical complications I experienced.

The best thing about the surgical team is that it‘s led by a transgender woman! I could really feel the understanding and empathy she had for me and my experience as opposed to other surgeons I consulted with. I also found the rest of her staff, especially her nurses and PA‘s, to be incredibly helpful and responsive. I never had to wait long to hear back about urgent questions and concerns.”

“I’ve gotten facial feminization, body contouring and, most recently, vaginoplasty from Dr. Ley. The results have been truly life-changing. I’m healing up wonderfully from my recent bottom surgery and it’s looking beautiful. Dr. Ley is a very skilled surgeon with a great eye for aesthetics and has a very warm, kind and affirming bedside manner. Thank you Dr. Ley!”

Transmasculine Patient Testimonials

The following testimonies come from transmasculine patients that have undergone bottom surgery with Dr. Ley:

“I’ve had three different surgeries in total at the Gender Confirmation Clinic, one with Dr. Ley. All my experiences at the GCC have been excellent; from the front desk to the surgery team, even the insurance coordinator all helped me feel reassured, supported and validated throughout every appointment. Dr. Ley and her team took time to go into all the details I needed before my surgery and were careful to be honest and transparent about the risks and results I could expect. And, I’m absolutely thrilled with the results!”

“I’m a nonbinary trans man…In my phone consultation with Dr. Ley, she spoke about her work as basically a calling to help other trans people achieve the bodies we feel right in. She was knowledgeable on a technical level, but I also felt I could trust her to respect and listen to me, which in my experience is not so common with medical professionals on transition-related care, even if they’re supportive. I had a good experience with the entire process, but Dr. Ley particularly made me feel safe. I would absolutely recommend her, including to people who aren’t sure what procedure(s) will meet their needs yet. She knows her stuff, and she cares.”

“Dr. Ley is amazing. I feel really lucky that I could find a competent and attentive surgeon who performs groin flap, especially since it isn’t as common as other techniques. Dr. Ley keeps it real and answers any questions honestly and directly. The team is also friendly, cheerful and open. Dr. Ley has also been very accommodating with my requests when possible. She even gave good advice about which of my tattoos would transfer best to the groin. I really enjoy that she has tattoos and piercings as well, because I knew I wouldn’t have to worry about experiencing stigma and stereotyping like I often have in medical environments. An additional benefit of working with Dr. Ley, is that as a trans person herself, she personally understands the perspective of patients undergoing gender-affirming surgery and can relate to their concerns authentically. That’s a rare opportunity to have as a patient.  I would absolutely recommend Dr. Ley for phalloplasty and I’m very happy to be in her care.”

“I had mons reduction with Dr. Ley in 2024 and had a really positive experience. The procedure did exactly what it was supposed to do in terms of positioning and making phalloplasty a possibility for me…I also can’t say enough good things about Dr. Ley, her nursing staff, and GCC as a whole. Dr. Ley is truly one of a kind. She’s incredibly skilled and honestly an artist at what she does, but she also has amazing bedside manner. I’ve never once felt unheard by her or uncomfortable around her, and that means a lot. I always feel listened to, cared for, and supported throughout the entire process. I have been through several surgeries with her personally, and I can’t say enough how much I truly appreciate her and Nicole.”

What to Expect: From Consultation to Recovery in San Francisco

If you plan on traveling into San Francisco for your bottom surgery, you may find the following information helpful:

• Free travel resources: After years of assisting patients coming in from out-of-town, we have compiled a free PDF guide on traveling to the GCC. It includes a list of low-cost housing and transportation recommendations, as well as resources for the trans and non-binary communities (e.g., out-patient recovery centers for trans patients) in the San Francisco Bay Area.

• Consultation: To reduce barriers to access, the GCC offers all consultations free of cost to patients. A consultation in San Francisco gives you the opportunity to undergo a medical exam to determine your eligibility for surgery and ask Dr. Ley any questions you may have. A consultation is not a commitment to undergoing surgery.

• Recovery & post-operative follow-ups: Depending on the type of surgery you undergo, you may need to stay several days in the hospital after waking up from anesthesia. Your care team will give you clear instructions at or after your consultation about hospital stays and in-person follow-up with Dr. Ley. If you are coming in from out-of-town, we can assist you in finding post-op care locally if something comes up after you have returned home from San Francisco.

Frequently Asked Questions

Who performs bottom surgery in San Francisco?

At the GCC in San Francisco, Dr. Zara Ley (she/her/they), is the board-certified surgeon who provides our bottom surgery offerings to patients. Dr. Ley is the only board-certified trans woman of color in the US to offer gender-affirming surgery.

What types of bottom surgery are available?

At the GCC, Dr. Ley currently offers vaginoplasty, vulvoplasty, orchiectomy, metoidioplasty, phalloplasty, vaginectomy and other additional procedures such as mons resection and scrotoplasty.

Does insurance cover bottom surgery in California?

Most insurance providers in California will cover gender-affirming bottom surgery for adult patients who meet clinical requirements. Please be sure to check your insurance provider’s clinical guidelines for transgender surgery coverage.

How do I choose between metoidioplasty and phalloplasty?

Patients that are choosing between a metoidioplasty and phalloplasty often weigh three principle factors: surgical eligibility, outcomes and resources. In terms of eligibility, each bottom surgery procedure has different medical prerequisites such as BMI limits and restrictions on smoking. Regarding outcomes, patients will need to weigh how important certain aesthetic and functional results are important to them. This often includes penis size, the ability to urinate while standing, the presence of a scrotum with testicular implants, scar visibility and more. Resources encompass a patient’s financial and emotional capacity to undergo and recover from surgery. This is especially important as many bottom surgery procedures require multiple rounds of surgery and/or insurance coverage to complete. For more information, click here.

Do you work with patients who travel to San Francisco for surgery?

Yes, at the GCC we have experience helping international and out-of-state patients with surgery. For resources on traveling to San Francisco for surgery, click here.

Conclusion

Undergoing bottom surgery is oftentimes one of the most monumental parts of a patient’s transition. It can take years for trans, non-binary and gender expansive individuals to understand which bottom surgery procedures, if any, are necessary to treat their gender dysphoria.

Dr. Zara Ley performs a full range of bottom surgery procedures in San Francisco, California. She is sought out by patients nationally and internationally because of her patient-centered approach, attention to detail, high aesthetic standards, utilization of surgical techniques with some of the most long-term evidence backing them, and, not to mention, the fact that she understands the patient experience first-hand. You can ask her about which surgery would be right for you by requesting a free consultation.