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“MTF” is widely considered an outdated term.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

Penectomy and “Gender Nullification” Surgery

Vulvaplasty/vulvoplasty or “Zero-Depth Vaginoplasty”

Vaginoplasty

Labiaplasty

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.