How Does Male-to-Female (MTF) Bottom Surgery Work?

Everyone deserves to see their true identity reflected in the mirror. To attain this, many transgender women choose to undergo bottom surgery, a procedure that matches a person’s genitals with their gender identity. Bottom surgeries account for over 35% of gender-affirming procedures in the US. What's more, around 50% of trans women dream of having the surgery in the future. So what’s stopping them from making this pivotal step towards a more fulfilling life right now? Many have natural concerns about the surgery, possible complications, results, and the recovery process. Now is the time to put these fears to rest.

This article will answer your questions and ease your concerns regarding male-to-female (MTF) bottom surgery. We'll break down the different types of surgeries available, give tips on choosing a surgeon, explore costs, discuss how to prepare, and walk you through the recovery process.

Table of Contents

1. What is MTF Bottom Surgery?
2. MTF Bottom Surgery Types
3. MTF Bottom Surgery Process
4. Best MTF Bottom Surgeons
5. Male-to-Female Bottom Surgery Cost
6. How to Prepare for MTF Bottom Surgery
7. MTF Bottom Surgery Requirements
8. MTF Bottom Surgery Recovery
9. Male-to-Female Surgery Results
10. Takeaways

What is MTF Bottom Surgery?

Male-to-female (or transfeminine) bottom surgery is a type of sex reassignment surgery that reshapes the male reproductive organs to look like female genitalia, aligning a patient's physical form with their gender identity. This procedure encompasses various surgical techniques tailored to each individual's needs and goals.

Bottom surgery can significantly improve self-esteem and overall mental health. By matching physical appearance with gender identity, bottom surgery helps people navigate social environments and personal relationships with greater confidence. Additionally, it can improve intimacy and personal comfort. 

Bottom surgery leads to reductions in:

• gender dysphoria;
• psychological distress;
• harmful habits like smoking;
• suicidal tendencies.

In essence, bottom surgery is not just about changing physical attributes; it enables a life where people can truly feel like themselves.

Who is the perfect candidate?

According to the American Society of Plastic Surgeons, male-to-female (MTF) bottom surgery can be beneficial to people who:

• experience persistent gender dysphoria;
• are recommended for surgery by two mental health professionals;
• have experience living in alignment with their gender identity;
• can legally consent to the procedure;
• maintain a positive outlook and realistic expectations;
• have their medical or mental health concerns well-managed.

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What does MTF bottom surgery look like?

Male-to-female bottom surgery usually involves creating a vagina, labia, clitoral hood, and clitoris from the existing genital tissue. The goal is to not only achieve an appearance that reflects the individual's gender identity but also to enable sexual function and sensation. Each surgical approach takes into account the patient's unique anatomy and objectives.

MTF Bottom Surgery Types

Orchiectomy

This procedure involves the removal of the testicles and may serve as an initial step toward further genital reconstruction. It is one of the more straightforward and cost-effective gender-affirming surgeries, typically completed in under 30 minutes under general anesthesia. Since the testicles produce the majority of testosterone, undergoing an orchiectomy means most patients can cease taking anti-androgen medications or testosterone blockers.

Transgender women can choose orchiectomy to:

• alleviate gender dysphoria;
• simplify hormone therapy;
• ease the discomfort of tucking;
• have more clothing options that reflect their identity.

How it’s done: An orchiectomy is performed through a small incision in the scrotum, where both testicles are removed. This procedure is typically done under general anesthesia and takes less than an hour. 

Full-depth vaginoplasty

One of the most common MTF surgeries, this technique not only forms the outer vulva but also constructs a complete vaginal canal. It allows for sexual intercourse and urination in a manner consistent with the individual's gender identity. This procedure is a go-to for those who want a natural-looking vagina with sensory functionality.

Full-depth MTF vaginoplasty is a go-to for trans women who want:

• a complete anatomical transition;
• a natural-looking vagina with sensory functionality;
• an ability to have penetrative sex and experience orgasm.

There are 2 main approaches to transgender vaginoplasty:

• Penile inversion vaginoplasty utilizes penile and scrotal skin to craft the vaginal canal. Surgeons carefully invert the penile skin to form the interior of the canal while using scrotal skin to build the exterior vulvar structures. Clitoris is formed from the tip of the penis.

• Robotic peritoneal vaginoplasty employs a robotic surgical system to create a canal. Through a small incision near the belly button, the robotic system allows surgeons to craft the vaginal canal using the peritoneum, a thin layer of tissue lining the abdomen. Although this technique is less common, it offers a shorter recovery time and reduced risk of complications.

Vulvoplasty (Zero-depth vaginoplasty)

Unlike transgender vaginoplasty, vulvoplasty does not create a vaginal canal, hence the term "zero-depth." It focuses on forming the external genitalia, such as the labia and clitoris, without the additional maintenance required for a neovagina. 

This option is suitable for transgender women who: 

• do not desire to have penetrative sex;
• prefer a less complicated procedure with shorter recovery times;
• wish to minimize the risk of surgical complications;
• want to avoid ongoing maintenance (e.g., dilation post-surgery).

The procedure involves the following steps:

• Tissue reconfiguration. Surgeons reconfigure and sculpt the existing genital tissue to form the labia and clitoral hood.
• Clitoral creation. A part of the glans penis is preserved and reshaped to create a clitoris, positioned to enable sensation and, potentially, orgasmic function.
• Introitus formation. Although no vaginal canal is created, an opening is made at the site of the vaginal entrance to mimic the appearance of a vulva.

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MTF Bottom Surgery Process

Your surgeon will detail the surgery plan, which might include one or multiple procedures. For example, you might have an orchiectomy and a vaginoplasty in one go. 

Surgical steps generally include:

• removing or altering existing organs and tissues;
• constructing new anatomical structures to achieve a feminine appearance.

Surgeons might place drains to manage fluids or insert a catheter for urination.

How long does gender reassignment surgery take?

• Orchiectomy typically takes about 30-60 minutes, making it one of the shortest and easiest gender-affirming surgeries.
• Vaginoplasty is a more complex procedure lasting between 2 and 6 hours.
• Vulvoplasty takes less time than vaginoplasty (2-3 hours) since no vaginal canal is created.

Is bottom surgery painful?

Any gender-affirming procedure is performed under anesthesia, preventing pain during surgery. However, you will experience some post-operative discomfort. Pain management, including prescribed medications, is an essential part of the recovery process. Substantial pain should subside in the first few days after the surgery and clear up completely within 2 months.

Best MTF Bottom Surgeons

The path to gender congruence involves making many choices. Arguably, the most crucial one is choosing a skilled and experienced surgeon. Bookimed partners with over 20 gender-affirming clinics and doctors worldwide. This network can simplify the process of finding the right surgeon for you.

Male-to-Female Bottom Surgery Cost

On average, the total cost for male-to-female bottom surgery is around $25,000. However, this figure can vary significantly based on the specific procedure, the surgeon's expertise, the facility's location, and additional medical expenses. 

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How to Prepare for MTF Bottom Surgery

Preparing for male-to-female bottom surgery involves several steps to ensure your health and readiness for the transformation ahead. Here’s a concise guide to get you started:

Medical and health preparation

• Surgical planning. Communicate your priorities and medical history to your surgeon, including conditions like high blood pressure or diabetes.
• Lab tests and evaluations. You will be asked to undergo necessary medical checks to assess your fitness for surgery.
• HRT. It is recommended to be on estrogen hormone replacement therapy (HRT) for at least 1 year before surgery. You will be required to stop HRT 2 weeks before surgery and will be able to resume it 1-2 weeks after.
• Quit smoking. Cease smoking 3-6 weeks before surgery to enhance healing and reduce surgical risks.
• Medications adjustments. Doctors will ask you to stop taking anti-inflammatory drugs, aspirin, blood thinners, and certain herbal supplements to lower bleeding risks.
• Allergy disclosure. Inform your surgeon about any allergies to medications, skin cleaners, latex, or foods.
• Hair removal. Permanent hair removal, like laser hair removal or electrolysis, should be started 9-12 months before vaginoplasty to clear the area that will become the neovagina. If hair remains on the skin used to create the vaginal canal, this can lead to discomfort, infections, and hygiene issues.
• 24 hours before surgery. Eat only light meals and stop all food and liquid intake by midnight. You may take medications with a sip of water in the morning.

Lifestyle and support

• Organize a support system. Arrange for help from friends, family, or a mental health professional for at least 1-2 weeks post-surgery.
• Time off work. Request 6-8 weeks off from work to recover.

Special considerations

• Weight. Maintain a healthy lifestyle, as a high body mass index (BMI) can increase risks and complicate healing.
• Fertility preservation. Consider options for sperm preservation before surgery to maintain the possibility of having biological children in the future.

MTF Bottom Surgery Requirements

Informed consent vs. WPATH standards of care

When judging patients’ eligibility for surgery, sex reassignment clinics and doctors usually follow one of the 2 approaches:

• informed consent model;
• World Professional Association for Transgender Health (WPATH) guidelines.

➤ The informed consent model empowers you to make decisions about your surgery after being fully informed of the risks by your physician without needing additional approval from other healthcare professionals.

➤ WPATH guidelines require letters of readiness from a mental health professional verifying your readiness and eligibility for surgery. Genital surgeries require two such letters from different experts. While WPATH standards aim to ensure patient safety and preparedness, they've faced criticism for limiting personal autonomy.

At what age can you get bottom surgery?

Most regions require you to be at least 18 years old to consent to surgery. 

➤ In Europe, you generally need to be 18 for surgery without parental approval. However, some countries have lower age limits (e.g., 15 in Slovenia, 16 in Scotland, and 17 in England). 

➤ In the US, the situation varies, with 22 states prohibiting gender-affirming surgeries for minors. Among these, 21 states also limit access to hormone therapy for those under 18.

MTF Bottom Surgery Recovery

Recovery from male-to-female bottom surgery varies depending on the type of procedure you've undergone. It is crucial to avoid applying excessive force or movement to surgical incisions during the healing process. 

Below are approximate recovery timelines for different procedure types:

Dilating after bottom surgery

🤔What is dilation? 

Dilation is a crucial post-operative practice for transgender patients who have undergone vaginoplasty. It ensures the newly formed vaginal canal remains open, flexible, and maintains its depth and width.

🤔Is dilation painful?

Dilating after bottom surgery should not be extremely painful, although it will initially cause some discomfort as you find the most comfortable angles and techniques for your body. Using lubricant and adjusting the dilator's position can help alleviate discomfort. If you experience severe pain, it's essential to stop and seek advice from your care team. 

🤔How to dilate after bottom surgery? 

Dilation involves the regular insertion of medical dilators into the vaginal canal. These specially designed devices help keep the canal from narrowing or closing, which is vital for the neovagina's functionality and health.

🤔How long do you have to dilate after gender reassignment surgery?

Following SRS, dilation is a life-long commitment, though the frequency will decrease over time. During the first weeks post-surgery, you'll need to dilate 3 times a day for 20 minutes. After the first year, many can reduce dilation to once daily or weekly, depending on their surgeon's advice.

Sex after bottom surgery

You can have sex after bottom surgery, with the type of sex depending on the specific procedure you've undergone:

• Vaginoplasty. You can engage in penetrative vaginal sex at least 12 weeks after surgery. Research shows that over 80% of people have no problem experiencing orgasm after the procedure.
• Vulvoplasty. While this procedure does not create a vaginal canal needed for penetrative sex, it does involve the construction of a sensitive clitoris. Therefore, patients who have undergone vulvoplasty can experience orgasm through clitoral stimulation.

In all cases, including orchiectomy, your body will need several weeks to heal adequately. It's essential to wait until your surgeon gives the green light to resume sexual activities.

Showering and bathroom use

Maintaining cleanliness in the genital area after bottom surgery is crucial to prevent infections. 

• Keep the area dry. Initially, you will have to keep the external part of your vagina dry. Using an absorbent pad between the labia can help absorb any extra moisture.
• Gentle washing. Once you're cleared to wet the area, gently wash with soap and water without scrubbing or directing shower spray directly onto the surgical site.
• Wiping. Always wipe from front to back when using toilet paper or cleaning the genital area. This practice prevents bacteria from the anal region causing infections.

Male-to-Female Surgery Results

MTF bottom surgery marks a pivotal point in many transgender women's lives, offering profound relief from gender dysphoria. Here are some of the impressive male-to-female surgery results you can expect:

• High satisfaction rates. According to the Journal of the American Society of Plastic Surgeons, 99.7% of patients report satisfaction with their surgical outcomes. 
• Improved sexual function. For many, sexual function post-surgery is a concern, but the data is encouraging. Another study highlights that 91.4% of respondents were pleased with their sexual function following penile inversion vaginoplasty. 
• Healing process. The body undergoes a natural healing process after surgery. While scars may never vanish entirely, they significantly fade over time, becoming a small trade-off for the vast improvements in quality of life. 
• Prostate health. The surgery does not remove the prostate gland. While estrogen therapy may slightly affect prostate size, the risk of prostate cancer remains. Regular medical exams are crucial to monitor prostate health and ensure long-term well-being.
• Revision surgery. Sometimes, achieving a desired outcome requires more than one surgical procedure. Medicine and surgery are complex, and adjustments might be necessary to fully realize one's vision.

Bottom Surgery Risks and Complications

Like any serious surgical intervention, feminizing bottom surgery comes with certain risks. Although serious complications are rare, sometimes patients may experience:

• changes in sensation;
• difficulty in emptying the bladder;
• difficulty during intercourse due to a shallow vagina;
• narrowing of the vaginal opening;
• tissue necrosis (breakdown);
• rectovaginal fistula (a hole between the rectum and vagina);
• narrowing of the urethra.

Like with any surgery, there is a small risk of general surgical complications like anesthesia side effects, bleeding, blood clots, and infection.

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Takeaways

• Over 35% of gender-affirming procedures in the U.S. are bottom surgeries, with 54% of transgender women considering it for the future.
• Male-to-female (MTF) bottom surgery is a good option for healthy individuals with consistent gender dysphoria, support from mental health professionals, and legal consent ability.
• Surgical options include orchiectomy (testicle removal), full-depth vaginoplasty, and zero-depth vaginoplasty.
• MTF bottom surgery costs range significantly, with general estimates around $25,000.
• The informed consent model and WPATH guidelines represent two approaches to surgery eligibility. While WPATH requires comprehensive mental health evaluations and letters of readiness, the informed consent model allows patients to proceed based on understanding the risks.
• Essential preparation steps for surgery include undergoing medical evaluations, adjusting hormone therapy, quitting smoking, and performing hair removal for vaginoplasty.
• Short-term recovery times vary between 2 and 6 weeks, with complete recovery sometimes taking up to a year. 
• Although rare, possible complications include changes in sensation, urinary retention, vaginal stenosis, and tissue necrosis.
• Male-to-female surgery results in impressive satisfaction rates, with 99.7% of patients reporting positive outcomes.
• Bottom surgery significantly reduces psychological distress, decreases harmful habits, lowers suicidal tendencies, and enhances the quality of life and self-esteem.

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