Medically reviewed by Jennifer Richman on July 2, 2025.
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“MTF” is widely considered an outdated term.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:
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.
To undergo surgery, vaginoplasty patients must have a BMI of 30 or less, while vulvaplasty patients must have a BMI no greater than 38.
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.
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.
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:
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.
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.
What is this procedure? | Common motives for undergoing this procedure: |
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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. |
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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. |
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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. |
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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. |
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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 |
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:
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.