How Does a Trans Woman Get Bottom Surgery?

Medically reviewed by Jennifer Richman on Dec 8, 2025.

Bottom Surgery Options for Trans Women

Trans women interested in bottom surgery can choose from any of the following options:

• Orchiectomy: The removal of the testicles. This decreases the body’s natural production of testosterone.
• Scrotectomy: The removal of the scrotal skin. This is not recommended for patients that would like to eventually undergo a vaginoplasty or vulvaplasty as scrotal skin grafts will be used for these procedures.
• Vulvaplasty or “Zero-Depth Vaginoplasty”: A vulvoplasty or vulvaplasty creates a fully-functional clitoris and vulva without a vaginal canal. Instead, a dimple will be placed where the vaginal opening would be.
• Vaginoplasty: The creation of a fully-functional vaginal canal for penetrative sex, a clitoris and vulva. This involves the removal of the penis (penectomy), the testicles (if they have not already been removed) and the shortening of the urethra.

How to Get Bottom Surgery

Interested patients can review the following steps for how to undergo transfeminine bottom surgery:

Age and Informed Consent

Patients must be at least 18 years old and mentally capable of participating in an informed consent process to undergo bottom surgery.

Requesting a Consultation

The first step in anyone’s surgical journey is scheduling a consultation with a board-certified surgeon. Dr. Zara Ley (she/they) currently offers free consultations for bottom surgery, top surgery, body contouring and facial surgery; you can request one with her here. Please note that for some bottom surgery procedures, Dr. Ley requires patients come in-person to her San Francisco office to complete a physical examination.

BMI Limitations

For some types of bottom surgery, there are BMI qualification cutoffs. For a vaginoplasty, patients must have a BMI of 34 or less. Vulvaplasty patients must have a BMI no greater than 38.

Health Requirements

In order to undergo bottom surgery, patients should be in good overall physical health. Patients must quit tobacco and nicotine consumption 3-4 weeks prior to surgery or, ideally, earlier.

Support Letter

Patients who are undergoing bottom surgery for the first time must present two support letters from gender-affirming care providers that have a long-standing relationship with the patient (at least 9 months of providing service). One of these letters should be from a licensed mental health professional, whereas the other can be from a patients’ hormone therapy provider.

Please note that if you would like your insurance provider to cover bottom surgery, you may have to meet their specific requirements. For example, some insurance providers require that at least one of the support letters for bottom surgery come from a licensed mental health provider with a doctorate degree (e.g., PhD, PsyD, etc.). You can confirm these requirements with your insurance provider or by calling our office: (415) 780-1515

Hormone Therapy

Most insurance providers that cover gender-affirming bottom surgery require that a patient undergo at least 12 months of hormone replacement therapy (HRT) prior to surgery. Exceptions can be made if the patient has medical contradictions with HRT. This information should be included in your support letter(s).

Hair Removal

Patients interested in undergoing a vaginoplasty or vulvaplasty will need to undergo permanent hair removal on the scrotum and/or penile shaft.

Fertility Preservation

An orchiectomy (testicle removal) permanently makes a patient infertile. Since this is an irreversible effect of bottom surgery, we encourage our patients to look into fertility preservation options prior to their operation.

Vaginoplasty and Vulvaplasty

Dr. Ley conducts vaginoplasty and vulvoplasty in two stages because patients tend to be much more satisfied with their results. In the first surgery, Dr. Ley will construct the clitoris, vulva and vaginal canal. In the second labiaplasty procedure, she will add more defined aesthetic details, such as clitoral hooding, full labia minora, and alterations the overall configuration of the labia majora. This allows her to correct any functional issues, asymmetry or aesthetic concerns a patient may have once the first stage of healing is complete. Patients who undergo a “zero-depth vaginoplasty” or vulvaplasty with Dr. Ley will also undergo two stages of surgery to address these aesthetic and functional issues.

At this time, Dr. Ley only offers a two-stage penile-inversion vaginoplasty procedure for her patients. The penile-inverson technique has the most long-term evidence to support its durability and long-term patient satisfaction.

Recovery

After a vaginoplasty or vulvoplasty, patients will need to stay in the hospital for a few days (usually around 3 nights). Labiaplasty, however, is an outpatient procedure, which means patients can return home the day of surgery. A week after your procedure, you will meet with your surgeon in-person so they can check on your progress healing, address any questions and concerns you have, and take out any sutures that need to be removed.

Additionally, patients should avoid penetrative sex for the first three months after surgery. Patients will need to follow a strict dilation protocol. Dilation is a life-long commitment to maintain the depth and width of the vaginal canal. For more information on recovery from bottom surgery for trans women, click here.