Search

    A Comprehensive Guide to MTF Bottom Surgery

    Medically reviewed by Jennifer Richman on July 2, 2025.

    What is MTF Bottom Surgery?

    Male-to-female (MTF) bottom surgery is a term that refers to a series of gender-affirming genital reconstruction procedures that remove natal genital tissue, such as the testicles and penis, and construct organs such as a vulva and/or vagina. Feminizing bottom surgery can include an orchiectomy, vaginoplasty, vulvaplasty or vulvoplasty, and labiaplasty, amongst other procedures.

    “MTF” is widely considered an outdated term. Still, we use the term “MTF” in this article out of the recognition that many patients use it to search for information about these surgeries.

    The primary goals of what is called feminizing or MTF bottom surgery can be any of the following:

    1. Remove the testicles, the body’s main source of testosterone production, eliminating the need for blockers and lowering the amount of external estrogen (estradiol) a patient needs to take
    2. Construct a functional vulva with labia, a clitoris, and clitoral hood––with or without a vaginal canal
    3. Maintain heightened sensitivity and capacity for orgasm in genital tissue
    4. Alleviate gender dysphoria and improve overall quality of life

    Frequently Asked Questions

    How can I get bottom surgery?

    The first step in any surgical journey is soliciting a consultation with a surgeon. For your own safety, it is important that you choose a board-certified provider that has hospital privileges and experience working with transgender and non-binary patients. Looking for bottom surgeons (i.e., plastic surgeons, gynecologists and urologists) in the World Professional Association for Transgender Health’s (WPATH) provider directory is one way to start.

    At the GCC, Dr. Ellie Zara Ley (she/her/they) is a world-renowned bottom surgeon and a former patient herself. She is the only trans woman of color who is a board-certified plastic surgeon and offers a full spectrum of gender-affirming surgeries. Because of her expertise, many patients come to her to begin their bottom surgery journey or for revisions to previous vaginoplasty and vulvaplasty procedures. You can request a free, in-person consultation with Dr. Ley here to answer any questions you have about bottom surgery and/or create a unique surgical plan for you.

    Are there BMI limits for MTF bottom surgery?

    To undergo surgery, vaginoplasty patients must have a BMI of 30 or less, while vulvaplasty patients must have a BMI no greater than 38.

    Do I need to dilate for the rest of my life after vaginoplasty?

    Yes. To maintain the depth and width of the vagina, patients will need to dilate for the rest of their lives or for however long they would like to have a functional vaginal canal. Patients that lose desired depth and width can undergo a revision procedure. For our general dilation protocol, click here.

    How can I prevent complications after bottom surgery?

    While rare, many patients come into surgery anxious about experiencing complications post-op. Familiarizing yourself with recovery instructions prior to surgery can help you feel more confident about how to minimize your risk of complications. Likewise, reviewing the list of urgent issues in the link above can help you distinguish between a normal discomfort and an urgent complication that requires attention in an Emergency Room.

    Candidacy for MTF Bottom Surgery

    The threshold for qualifying for bottom surgery tends to be higher than other types of gender-affirming procedures. For example, surgeons are more likely to require that a patient present a support letter to undergo bottom surgery, regardless of whether or not they wish to pay with insurance. The following is a general overview of the requirements:

    • Age 18 or older
    • A support letter from a licensed gender health professional who has a well-documented and established provider-patient relationship over an extended period of at least nine months. The letter should include the following elements:
      • A gender dysphoria diagnosis
      • Any other existing psychiatric diagnoses and whether or not they impact the patient’s readiness for surgery
      • A statement that informed consent has been obtained from the patient: that they understand the risks, benefits and potential long-term effects (e.g., permanent infertility) of bottom surgery.
    • Continuous hormone therapy for a minimum of 12 months (while not required by the GCC, many insurance companies include this as a part of their clinical guidelines)
    • Vaginoplasty and some vulvaplasty patients will need to undergo hair removal in the months leading up to surgery.
    • Nonsmokers or individuals who quit tobacco and nicotine consumption at least 6 weeks prior to surgery
    • Good overall physical health
    • Vaginoplasty patients must have a BMI of 30 or less, while vulvaplasty patients must have a BMI no greater than 38
    • Reliable support system including friends or family, mental health professionals as needed, and a safe home environment
    • Commitment to adhering to post-operative care (e.g., dilation protocols)

    It’s important to note that these criteria may vary depending on your surgeon’s recommendations for your individualized surgical plan. If you have questions about bottom surgery or are ready to make a plan for your procedure(s), you can request a free, in-person consultation with Dr. Ley today.

    Types of MTF Bottom Surgery

    Feminizing or “MTF” bottom surgeries can be divided into two categories: (1) expiratory procedures that remove existing organs and (2) reconstructive procedures that reconfigure the genital tissue.

    Orchiectomy and Scrotoectomy

    What is this procedure? Common motives for undergoing this procedure:
    An orchiectomy is the removal of the testicles, whereas a scrotectomy is the removal of the scrotal sack or skin. Please note that it is not necessary for a patient to have their testicles removed prior to a vaginoplasty/vulvaplasty as this can be done during the surgery. To treat gender dysphoria: For some trans feminine people, having testicles and/or a scrotum is a source of dysphoria. Removing the body’s main source of testosterone can be a relief for many.

    Changes in hormone therapy regimens: When the testicles are removed, patients can take less external estrogen (estradiol), which can reduce the risk of health problems like blood clotting. This is because the body will likely produce more estrogen on its own without needing to block testosterone.

    Preparing for a vaginoplasty/vulvaplasty: Many patients undergo an orchiectomy as a first step prior to undergoing a vaginoplasty/vulvaplasty. Some patients express that getting an orchiectomy helps them reach greater clarity about whether a vaginoplasty/vulvaplasty would be right for them. Vaginoplasty/vulvaplasty patients must keep their scrotal tissue intact to be used as skin grafts for the labia.

    Penectomy and “Gender Nullification” Surgery

    What is this procedure? Common motives for undergoing this procedure:
    This procedure involves the removal of the penis and shortening of the urethra, which leaves a nub of tissue at the groin with an exit for the urethra. Gender dysphoria and genital dysmorphia: Some patients—transfeminine, transmasculine or non-binary—do not wish to have any genitals at all. This procedure allows them to experience relief from dysphoria/dysmorphia.

    Vulvaplasty/vulvoplasty or “Zero-Depth Vaginoplasty”

    What is this procedure? Common motives for undergoing this procedure:
    A vulvaplasty involves the complete reconstruction of the external genitalia to create a vulva complete with a clitoris, clitoral hood, urethra, and labia. Unlike a vaginoplasty, a vaginal canal is not constructed. Instead, patients are left with a dimple at the site of the vaginal opening. Gender euphoria: For many patients, having a vulva brings immense feelings of joy and satisfaction from experiencing greater gender alignment with their genitals.

    No dilation or penetrative sex: Patients who are sure that they are not interested in having penetrative or receptive vaginal sexual intercourse opt for a vulvaplasty. Having a “zero depth vaginoplasty” allows patients to have the external genitals (vulva) without having to follow a lifetime dilation regimen to keep their vaginal canal functional.

    Vaginoplasty

    What is this procedure? Common motives for undergoing this procedure:
    A vaginoplasty involves the complete reconstruction of the internal genitalia (a functional vaginal canal) and external genitalia (a vulva complete with a clitoris, clitoral hood, urethra, and labia). The most common procedure used to create the internal lining of the vaginal wall is the penile-inversion technique, although the internal lining can also be taken from the internal abdominal wall or rectum. At the GCC, Dr. Ley only offers the penile-inversion technique at this time. Gender euphoria: For many patients, reconstructing their genitalia to have a vulva and functional vaginal canal is a source of immense euphoria. For this reason, patient satisfaction for vaginoplasty is enormously high.

    Penetrative sex: Patients opt for this procedure if they are interested in having receptive vaginal intercourse. In order to maintain the depth and width of the vaginal canal, dilation is a life-long commitment.

    Self-lubrication: The peritoneal pull-through and robotic vaginoplasty techniques use the mucus membrane of the rectal tissue or the internal abdominal wall to line the vaginal canal. While this tissue may produce a vagina that is self-lubricating, results are not consistent and lubrication should still be used in penetrative sex. While the penile-inversion technique does not create a self-lubricating vagina, it has long-term evidence to back its durability and overall success.

    Labiaplasty

    What is this procedure? Common motives for undergoing this procedure:
    A labiaplasty reconstructs the vulva to add more defined aesthetic details, such as clitoral hooding, full labia minora, and alterations to the overall configuration of the labia majora. A labiaplasty is often the second stage to a vulvaplasty or vaginoplasty. It can also be a revision procedure for patients who are unsatisfied with the configuration of their labia and/or clitoral hood. Functional and aesthetic concerns: A labiaplasty allows the surgeon to correct any functional issues, asymmetry or aesthetic concerns a patient may have.

    Second-stage after a vaginoplasty/vulvaplasty: Dr. Ley uses the two-step method for all of her vaginoplasty/vulvaplasty procedures. This involves the creation of a vulva in the first surgery, and the detailing of the labia and clitoral hood in a second procedure five months later. The advantage of performing the vaginoplasty/vulvaplasty and labiaplasty as separate procedures is that patients tend to have better healing and therefore improved aesthetic outcomes.

    Revision surgery: Many but not all patients who undergo a vaginoplasty/vulvaplasty in one stage end up wanting a
    revision procedure to correct aesthetic and functional concerns. When the labia minora and majora are constructed at the same time as the vaginal canal, the body is often overwhelmed and the tissue does not heal as intended.

    Recovery and Aftercare

    The recovery for each bottom surgery procedure listed above is unique. You can consult our vaginoplasty recovery guide here for more specific instructions. After your surgical consultation, our office staff will give you a more detailed recovery guide tailored to your procedure(s). Likewise, dilation instructions and other recovery guidelines will be given to you in the hospital after surgery.
    We encourage you to keep the following points in mind for recovery:

    1. Initial Hospital Stay: Most vaginoplasty patients will need to stay in the hospital for approximately 3 nights after surgery for close monitoring and initial recovery. Labiaplasty and orchiectomy patients can usually return home same-day.
    2. Pain Management: Expect significant swelling, bruising, and discomfort in the first few weeks. Your team will help you manage this with medications.
    3. Bladder Management: Patients will most often have an indwelling catheter in the urethra to drain urine for the first week after a vaginoplasty/vulvaplasty.
    4. Dilation Protocol: Patients undergoing vaginoplasty will be provided with our protocol for dilation, which needs to be continued life-long in order to maintain adequate width and depth of the vaginal canal.
    5. Return to Activity: Patients should avoid lifting greater than 10 lbs for at least 3 weeks after surgery. Light physical activity can be attempted after this point in the healing process. Patients should avoid manual stimulation of their external genitalia and receiving oral sex until 6-8 weeks post-op. Patients should avoid receptive penetrative sex (vaginal or anal) for 3 months.
    6. Erogenous Sensation and Orgasms: Since the creation of the clitoris does not involve removing the penile glans from its original blood and nerve supply, there is virtually no risk of losing sensation in the clitoris. However, most patients report that it takes 3-9 months to regain full sensation and be able to orgasm. This is because swelling around the nerves during recovery can impact sensation.
    7. Emotional Recovery: Patients can expect various emotional challenges during the recovery process. Sometimes, pain or dealing with potential complications can prolong one’s feelings of euphoria. We encourage patients to plan for temporary emotional hardships by preparing a support network and a supportive environment to heal in.

    Request a Free Surgical Consultation Today.

    All virtual and in-person consultations with our board-certified surgeons are free. Once you fill out this form, our patient care team will reach out and guide you through every step to get to surgery.

    Preferred Name(Required)
    Legal Name(Required)
    This field is for validation purposes and should be left unchanged.