The Ultimate Guide to “Feminizing” Bottom Surgery: Vaginoplasty, Vulvoplasty and Labiaplasty

Medically reviewed by Jennifer Richman on February 16, 2024.

For many of our patients, gender affirming bottom surgery is one of the most gratifying steps of their medical transition. This article gives an overview of the three procedures that often get lumped together when people talk about “gender reassignment surgery” (GRS) or “female to male (ftm) bottom surgery.” We describe the techniques, staging and surgical results a patient can have undergoing a vaginoplasty, vulvoplasty (aka. “zero-depth vaginoplasty”), labiaplasty and penile-preserving vaginoplasty. We invite you to consult our additional content on preparing for bottom surgery and the recovery process to answer additional questions you may have.

These bottom surgery procedures can help patients achieve one or more of the following results:

  • The creation of a vaginal canal to use for penetrative solo and/or partnered sex. The depth of the canal can be discussed with your surgeon. To maintain a vaginal canal, lifelong dilation is required.
  • The creation of a vagina that either preserves the natal erectile tissue (i.e., the penis) or transforms into a clitoris.
  • The creation of vulva with a clitoris that has a full erotic sensation and the possibility for orgasm. This can be created with or without a vaginal canal.
  • The creation of labia and a clitoral hood that heal properly and conform with a patient’s goals around size, symmetry, tightness and protrusion.

All of the Gender Confirmation Center (GCC)’s bottom surgery procedures are performed by Dr. Ellie Zara Ley (she/her). She is a board-certified plastic surgeon and the only transgender woman of color to offer a full-spectrum specialization in gender affirming top surgery, bottom surgery, facial surgery and body contouring. She is a leader in the field of sex reassignment or genital reconstruction surgeries, using the most tried-and-true methods backed by longitudinal research for her patients.  You can request a free, virtual consultation with her to create your unique, surgical plan here.

The following chart explains what each bottom surgery procedure can accomplish. Below that we provide a description of each surgery and the results they provide.

Clitoris Clitoral Hood Labia Minora Labia Majora Vaginal Canal
Vaginoplasty (stage 1 of a traditional vaginoplasty)
Penile-Preserving Vaginoplasty
Vulvoplasty (aka. “zero-depth vaginoplasty)
Labiaplasty (stage 2 of a traditional vaginoplasty)

Although historically these procedures have been referred to as “feminizing” surgeries, we recognize that not everyone considers these bodily transformations or body parts to be feminine. We offer these procedures to patients regardless of their gender identity or expression.

What is vaginoplasty?

Vaginoplasty is a surgery which creates a vaginal canal alongside a vulva or external genitals, such as the clitoris, and labia majora, and labia minora. This procedure is well-suited for individuals looking to have a vulva with a clitoris, erogenous sensation, and a vaginal canal that can be used for penetrative solo or partnered sex. At the GCC, we offer a two-stage approach to a traditional vaginoplasty.  Patients can also opt for a penile-preserving vaginoplasty or a vulvoplasty (also known as a “zero-depth vaginoplasty”). These options are explained below.

The 2-Stage Approach: Vaginoplasty and Labiaplasty

  • What is the two-staged approach? Why is it better to have the vagina and vulva constructed over the course of two surgeries instead of one?
    The first stage of a traditional vaginoplasty creates the vaginal canal, clitoris and labia majora. About 5 months later, if the vagina and vulva have healed properly, a clitoral hood and labia minora are constructed. By splitting up this operation into two stages, the vulva has a better chance of healing properly. This has given Dr. Ley’s patients more consistent results, leaving them more satisfied with the outcome of their surgery and less likely to request a revision procedure later on.
  • What is the first stage of a traditional vaginoplasty? How is the vagina, clitoris and labia constructed?
    During the first stage of the vaginoplasty, your surgeon will construct the vaginal canal, the clitoris and the labia majora. To construct the vaginal canal, we most often use a penile-inversion technique. This method is preferred by patients because of its durability for penetration and it being the only technique that has longitudinal evidence to back its effectiveness. It also allows our patients to take control over many aspects of the results of their procedure such as the depth of their vagina and the appearance of their vulva.

    In the first stage, the testicles and scrotal skin are removed, the urethra is shortened and the erectile tissue in the penis is removed. The removal of the testicles is called an orchiectomy. Since this is essentially a sterilization procedure, we encourage patients to learn about and discuss their fertility preservation options with their primary care provider.

  • What is a labiaplasty or the second stage of a traditional vaginoplasty?
    The second stage of a traditional vaginoplasty is the labiaplasty. This typically happens 5 months after the first stage. In this surgery, the labia minora and clitoral hood are constructed.

    A labiaplasty reconstructs the vulva to add more defined aesthetic details, such as clitoral hooding, full labia minora, and alterations the overall configuration of the labia majora. It allows the surgeon to correct any functional issues, asymmetry or aesthetic concerns a patient may have. The labia minora and clitoral hood are made primarily from skin grafts from the labia majora. This will allow your surgeon to tighten any loose skin that may have resulted from the first stage.

  • Does vaginoplasty and vulvoplasty allow for erotic sensation? When can patients start having orgasms?
    The clitoris is made by burying the glands of the penis, so it maintains a heightened, erotic sensation. Patients typically regain full sensation and can have an orgasm 3-9 months after the clitoris is constructed.
  • What determines the depth of the vagina?
    The depth of the vaginal canal is determined by the amount of tissue available from the penis and the scrotum. That said, we can deepen it by taking additional skin grafts from the hips. We encourage you to speak with your surgeon about your goals for depth during your consultation.
  • Will my new vagina self-lubricate?
    A penile-inversion vaginoplasty is lined with skin, meaning it does not self-lubricate. Techniques that use the rectal lining for the vaginal canal, for example, yield uneven results when it comes to a patient’s capacity to self-lubricate. For this reason and the lack of long-term evidence around this technique, Dr. Ley mostly performs the penile-inversion technique.
  • Do patients need to undergo laser hair removal and/or electrolysis to get a vaginoplasty?
    We require patients to undergo permanent hair removal prior to a penile inversion vaginoplasty to ensure that the skin used to line the vagina or create the labia does not grow hair. This allows us to prevent future complications.
  • How long will I need to dilate after surgery?
    After your vaginoplasty bottom surgery, dilation is necessary to keep the vagina healthy and open. Your surgeon will provide specific instructions for proper dilation and schedule. It is important to note that dilation is a lifelong commitment. Even years after surgery, if dilation is stopped, you can lose depth and girth.

Penile-preserving vaginoplasty

Penile preserving vaginoplasty is exactly what it sounds like: a vaginal canal is created without removing the penis. In this case, the vaginal canal is crafted not using penile tissue, but using scrotal tissue and sometimes grafts which come from internal parts of the body, such as the peritoneum (lining of the abdominal wall), the colon, or the hips. Vaginal canals created from the lining of the abdominal wall and the colon have the chance of being self-lubricating, although results are not consistent across patients.

What is vulvoplasty or “zero-depth” vaginoplasty?

A vulvoplasty is very similar to a vaginoplasty in all aspects, except a vaginal canal is not created. A vulvoplasty includes creation of a vulva, clitoris and labia majora using tissue from the penis, scrotum, and associated skin and tissues. This procedure is selected by patients who would like a vulva, are not interested in having penetrative sex through a vagina nor are they interested in having to dilate their vaginal canal to maintain it. Patients can still experience orgasm and full erotic sensation through their clitoris as early as 3 months post-op.

The majority of patients who undergo a vulvoplasty are happy with their choice and do not desire to have a vaginal canal. However, if someone does decide later on that they would like a vaginal canal after vulvoplasty, this is possible. Skin grafts can be taken from the hips to create the canal. The surgical considerations and complications for this procedure would be similar to a vaginoplasty, and the new vaginal canal must be dilated for the rest of one’s life to maintain the width and depth.

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