The Ultimate Guide to Bottom Surgery

All of our bottom surgery procedures and revisions at the GCC are performed by Dr. Ellie Zara Ley (she/her). As a former patient herself, Dr. Ley has a deep understanding of what the surgical journey entails and how to best meet her patients’ unique needs.

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.

Dr. Ley accepts most health insurance plans for the procedures she performs with the Gender Confirmation Center (GCC). At the GCC, we are committed to making gender-affirming care financially accessible to our patients. Through our insurance concierge service, we have helped 90% of interested patients secure coverage for their surgery. If you have specific questions about your case or are interested in getting bottom surgery, you can schedule a free, virtual consultation with Dr. Ley today.

Achieving your bottom surgery goals can require multiple or just one procedure. Removing natal reproductive organs is often the only step a patient takes, or the first step to getting a vaginoplasty, vulvoplasty, metoidioplasty and/or phalloplasty. You can learn more about these procedures below:

• Fertility Preservation

• Any surgery that involves the removal of reproductive organs has the potential to effectively be a sterilization procedure. We encourage patients to read about and consider their options around fertility preservation if they are interested in the possibility of having biological children.

• Orchiectomy (testicle removal)

• An orchiectomy is the removal of the testicles. This procedure is one of the quickest and easiest to recover from. It is usually required to undergo a vaginoplasty and can be done at least 8 weeks before or during said procedure. Likewise, patients can get an orchiectomy without undergoing a vaginoplasty to simplify their hormonal regimen; removing the testicles allows someone to get off testosterone blockers and take less estrogen, possibly preventing certain health complications. Read more here.

• Scrotectomy (scrotal sack removal)

• A scrotectomy is the removal of the skin that makes up the scrotal sack. We do not recommend this procedure for patients who are interested in a vaginoplasty because it throws away skin that can be used to construct the vagina and/or vulva. Read more here.

• Hysterectomy (uterus removal)

• A hysterectomy is a removal of the uterus. This procedure is pursued by patients to prevent or treat any medical complications associated with having a uterus; likewise, it can provide a sense of gender congruence to patients who do not wish to have this organ. Any patient who would like to have their vaginal canal removed should have this procedure done 8-12 months prior. Read more here.

• Vaginectomy (vaginal canal removal)

• A vaginectomy is a removal of the vaginal canal. This procedure can provide a sense of gender congruence for patients who do not wish to have a vaginal canal. Patients born with vulvas who would like to undergo a urethral lengthening to be able to urinate standing up are required to undergo a vaginectomy to prevent complications. Read more here.

• Oophorectomy (ovary removal)

• An oophorectomy is a removal of one or both ovaries. This procedure is pursued by patients to prevent or treat any medical complications associated with having a uterus; likewise, it can provide a sense of gender congruence to patients who do not wish to have this organ. It is not a requirement to undergo any other kind of bottom surgery procedure. Read more here.

• What do I need to do to get bottom surgery?

• We have compiled a guide on how to get bottom surgery. This includes information on scheduling a consultation, securing insurance coverage, candidacy requirements for surgery and more. Some instructions are specific to vaginoplasty patients. For example, you might need to first undergo permanent laser hair removal and/or electrolysis on the penis shaft and scrotum.

• Vaginoplasty

• A vaginoplasty is a procedure pursued by patients interested in having 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.

  At the GCC, the most common procedure we perform is a two-stage penile inversion vaginoplasty. This method is Dr. Ley’s signature approach and is preferred by patients because of its durability and the consistency of aesthetic results it produces. In other words, it yields a comparatively low revision rate to other procedures. Alternatively, the vaginal canal can also be lined with tissue from the rectum or inner abdomen.

  A traditional vaginoplasty creates a clitoris from the penile gland tissues. This means that full erotic sensation is preserved; most patients can expect to regain the capacity to orgasm 3-9 months after surgery. You can find more information on the recovery process here.

• “Zero-depth vaginoplasty” or vulvoplasty

• A vulvoplasty is commonly referred to as a “zero-depth vaginoplasty.” It creates a vulva–labia majora, labia minora, a vaginal dimple and/or a clitoris–without the vaginal canal. This procedure is ideal for patients interested in having a vulva without a vaginal canal because they are not interested in having receptive vaginal penetrative sex.

  A vulvoplasty usually creates a clitoris from the penile gland tissues. This means that full erotic sensation is preserved; most patients can have their first orgasm 3-9 months after surgery. You can find more information on the recovery process here.

• Penile-preserving vaginoplasty

• A penile-preserving vaginoplasty creates a vaginal canal and labia at the base of the penis, keeping the penis in-tact. The vaginal canal can be constructed from external skin (taking grafts from the scrotum and/or the hips) or internal tissue (such as the lining of the abdominal wall or the colon). 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.

  If you are curious about the recovery process, you can check this guide.

• Revision surgeries

• Dr. Ley is renowned for her bottom surgery revision procedures. As a former patient herself, she has a deep and personal understanding of how to support patients through revision surgeries. She offers the following services and more:

  • Revisions to the labia and/or clitorial hood to conform with a patient’s goals around size, symmetry, tightness and protrusion
  • Deepening or otherwise reconstructing the vaginal canal (for example, if it becomes shallower because of a lack of dilation)
  • Fixing urinary issues
  • Excising excess erectile tissue

• What do I need to do to get bottom surgery?

• We have compiled a guide on how to get bottom surgery. This includes information on scheduling a consultation, securing insurance coverage, candidacy requirements for surgery and more. Some instructions are specific to your procedure. For example:

  • If you would like to undergo a urethral lengthening to pee standing up, a vaginectomy (removal of the vaginal canal) needs to be performed to prevent complications. That means you will need to undergo a hysterectomy beforehand.
  • The GCC does not require that patients undergo testosterone hormone replacement therapy (HRT) to undergo either a metoidioplasty or phalloplasty. That said, if you would like to maximize bottom growth before a metoidioplasty, we recommend that you wait 1-2 years on HRT before surgery.
  • You might need to first undergo permanent laser hair removal and/or electrolysis on your forearm if you are using it as a phalloplasty donor site.

Metoidioplasty vs. Phalloplasty

A metoidioplasty is a procedure that releases the natal penis (a.k.a. the clitoris) from its ligaments so that it becomes more prominent. A phalloplasty is a procedure that constructs a penis using a large piece of skin (called a skin graft) taken from either the forearm, groin or outer thigh. The following are the factors that patients usually weigh to make a decision between these two procedures:

• Scarring, intensity of surgery & recovery
• • Generally speaking, phalloplasties are more taxing surgeries that have a more difficult recovery process than metoidioplasty. Some phalloplasties require multiple surgeries to construct the penis. You can learn more about recovery from a phalloplasty here.
  • A metoidioplasty leaves virtually no visible scarring. A groin flap phalloplasty leaves a very concealable scar on the groin, a thigh flap phalloplasty leaves a large scar that can be covered up by shorts, whereas a forearm flap phalloplasty leaves a large scar across the forearm.
• Urinate standing up
• • For both metoidioplasty and phalloplasty, it is a patient’s choice as to whether or not they undergo urethral lengthening. This is the procedure that extends the urethra to the tip of the penis, which facilitates peeing standing up. That said, a vaginectomy is required to extend the urethra to prevent medical complications.
• Erotic sensation and orgasms
• • For both procedures, we recommend that patients wait at least three months before they try to stimulate (orally or manually) their penis, especially if a urethral lengthening is performed. By this time, you can begin exploring your new genitals to see how you can reach an orgasm.
  • A metoidioplasty simply releases the natal penis (or clitoris) from its surrounding ligaments. This means there is virtually no risk of sensation loss since the nerves will not be touched during surgery.
  • A groin flap phalloplasty gives the penis a regular tactile sensation as opposed to heightened, erotic sensation. With both a forearm and thigh flap phalloplasty, the nerve of the donor site can be hooked up to the clitoral nerves to allow for erotic sensation. Still, there is a greater risk of sensation loss with this procedure patients should consider. That said, even if the clitoris is buried, the skin above it can still be stimulated to help someone reach orgasm.
• Penetrative sex
• • Some metoidioplasty patients report that they are able to have penetrative sex with their penis. Many of these patients will use a penis pump to enlarge their results and facilitate penetrative sex. Patients should wait at least 3 months after surgery before using a penis pump.
  • A phalloplasty gives a patient a larger penis than a metoidioplasty, which facilitates its use for penetrative sex. That said, a phalloplasty penis cannot get erect on its own. Many patients use silicone erectile sleeves to help with this. Others will have an erectile device surgically inserted into their penis 1 year post-op. Both of these erectile devices can increase the girth, but not the length of the penis.
• Penis size & girth
• • If maximizing the size and girth of the penis is a priority for the patient, the forearm flap and thigh flap phalloplasties have the greatest potential. Groin flap phalloplasties usually create a penis in the range of 3-5 inches of length. Metoidioplasty results are comparatively smaller because the natal penis (or clitoris) is merely released.
• Additional procedures (e.g., liposuction, scrotoplasty and testicular implants, etc.)
• • With both surgeries, a patient can undergo a variety of additional procedures. For example, you can get a mons resection and/or panniculectomy to remove excess fat and skin in the upper pubic area, making the penis more visually apparent. Likewise, Dr. Ley can construct a scrotum and insert silicone testicular implants if a patient would like.
• Revision surgeries and complications
• • As a former patient herself, Dr. Ley has an insider’s perspective on the importance of getting your bottom surgery results right. She is sought after in the transgender community to revise bottom surgeries for medical complications and/or aesthetic motives. If you are interested in undergoing surgery with Dr. Ley, you can schedule a free, virtual consultation with her here.
  • The most common complications associated with these procedures–like urinary fistulas and wound opening–will resolve on their own with at-home treatments. Frustratingly, they may delay the amount of time required to heal.