Bottom Surgery: Types, Steps, Costs, and Post-op Care

Transgender people go through different stages to match their biological sex with their gender identity. One of the most important steps on their way is having the bottom surgery. This operation changes their reproductive organs to match their true gender. Of course, patients should obtain approval from a psychiatrist, a psychologist, and legal authorities before undergoing this surgery. After reading this article, you will know everything about bottom surgery, its types, costs, steps, and more.

What Is Bottom Surgery?

Bottom surgery, also known as genital surgery, is a complex and delicate operation that matches physical sex with gender identity. Almost all people with gender dysphoria undergo hormone therapy and live in their identified gender before getting this surgery. Unfortunately, although hormone therapy changes their appearance, they are legally recognized as their assigned gender until they undergo bottom surgery. Therefore, it’s safe to say that the genital surgery is the most important step in the gender confirmation process. 

Types of Bottom Surgery

Bottom surgery has various types. The person’s target gender determines what sort of treatment they need. Male-assigned patients should have male-to-female (MTF) surgery, while female-assigned patients should undergo female-to-male (FTM) operation. Here are the main types of bottom surgery based on the target gender.

Male-to-Female Bottom Surgery

Trans women undergo facial feminization, breast augmentation, chest surgery, and voice feminization surgery to have a more female-like appearance. However, changing the shape of their reproductive organs is much more important. In bottom surgery, the first step is to remove or reshape the male organs (such as testicles). In the next step, they are given a vagina and other female-specific organs.

Here are the common MTF surgeries:

Orchiectomy

Orchiectomy is the surgical removal of testicles that stops the production of male hormones in trans women. In this operation, the surgeon makes an incision in the groin (radical inguinal orchiectomy) or scrotum (simple orchiectomy) and takes out the testicle and spermatic cord. Sometimes, the skin of the scrotum is kept to be used in reshaping the vagina.

Penile Inversion Vaginoplasty

Since the tissue around the penis is removed and the penis is inserted into the body, its skin can be used to shape the vagina’s canal. This simple and quick technique prevents the surgeon from removing skin tissue from other parts of the body.

Rectosigmoid Vaginoplasty

The colon’s tissue is different from that of other parts of the body. It is thicker and more elastic and produces mucus naturally, so it’s perfect for those who prefer a more natural, lubricated vagina. In rectosigmoid vaginoplasty, the surgeon removes a part of the large colon (usually 7-8 cm) and attaches it to the genital skin flaps to form the new vaginal canal.

Non-penile Inversion

If the surgeon cannot use the penile skin to shape the vagina, they use tissue grafts from the peritoneum and rectum to create the vaginal wall.

Vulvoplasty

The last male-to-female bottom surgery is vulvoplasty, also known as zero-depth vaginoplasty. In this operation, the surgeons only change the external part of the genital, including the labia (minor and major), the clitoris, and the opening of the urethra. This means that the neovagina doesn’t have a canal, so the patient cannot have penetrative intercourse. Obviously, the trans women undergoing vulvoplasty face less trauma and don’t need vaginal dilations.

Female-to-Male Bottom Surgery

Trans men should undergo different treatments, including bottom surgery, mastectomy, hormone therapy, and phalloplasty, to have a more masculine appearance. They also get hysterectomies (to remove the uterus and cervix) and testicular implants (to make the scrotum feel and look natural). Fortunately, most of these operations can be done laparoscopically.

Hysterectomy

Trans men no longer need a uterus and cervix, so the surgeon removes them laparoscopically. This method is minimally invasive and has fewer complications.

Salpingo-oophorectomy

Ovaries produce female hormones, so removing them helps trans men have a more masculine appearance. In a salpingo-oophorectomy, the surgeon removes both ovaries and the fallopian tubes laparoscopically. This operation is usually done at the same time as the hysterectomy.

Vaginectomy

In vaginectomy, the vaginal epithelium and canal are removed, and the cut is sutured to create an even perineum. However, the surgeon may keep some of the vaginal skin to create the new male genitalia.

Metoidioplasty

Metoidioplasty is a minimally invasive procedure and is usually done in several steps. After hormone therapy, the clitoris enlarges. The surgeon first cuts the tissue that surrounds the clitoris to free it from the pubic bone and then uses the enlarged clitoris to create a 6-cm penis.

Phalloplasty

If the patient wants a larger and thicker penis, a more complex procedure called phalloplasty is done. In this genital surgery, the surgeon first creates a new urinary tract that runs through the penis and then creates the penis itself using forearm or groin tissues.

Scrotoplasty

During scrotoplasty, the surgeons reshape the labia to create a scrotum. After that, they place testicular prostheses inside the sac to make it look natural and stitch the area carefully. Obviously, these implants do not produce sperm or hormones.

Bottom Surgery Costs

The price of bottom surgery depends on different factors, including:

Type of surgery (MTF or FTM)

• Number of operations and hormonal treatments required
• Hospital/clinic bills
• Facilities required
• Insurance plans, and others.

The approximate cost of bottom surgery is mentioned in the table below. Note that if you have multiple procedures at the same time, you can probably reduce the additional costs. 



Steps of Bottom Surgery

Before undergoing bottom surgery, the trans people should:

• Receive necessary permissions from their psychologist, psychiatrist, and the court
• Undergo hormone therapy, and 
• Get top surgeries (like facial feminization, mastectomy, and breast augmentation)

Bottom Surgery Risks and Side Effects

Almost all types of bottom surgery are risky and invasive. So, even if the surgeons have high expertise and advanced equipment, the following side effects might happen:

• Formation of a fistula between the urethra and the rectum
• Narrowing or blockage of the urinary tract
• Bleeding and infection
• Tissue necrosis or loss of the transplanted tissues
• Fluid buildup under the skin (seroma)
• Deep or long-lasting scarring
• Pain during sex
• Changes in libido or the ability to reach orgasm

Bottom Surgery Post-Op Care

After genital surgery, you should do the following to recover faster.

• Rest for at least two weeks and avoid strenuous activities.
• Do not move heavy objects
• Avoid doing extreme and high-risk sports until your doctor allows.
• Clean the wounds with a wet wipe and dry them with a towel.
• Have healthy, nutritious food and drinks.
• Avoid smoking and drinking alcohol, as they cause constipation.
• Do not have intercourse until you are fully healed.

Life and Daily Routine after Bottom Surgery

Gender reassignment surgery will have various physical and psychological effects on you, so it’s normal to face new challenges in life after it. If you follow your surgeon’s instructions, you can maintain the results of your surgery and get back to your daily routine faster.

Also, you should regularly visit a psychologist to keep your confidence and spirit high and prevent anxiety and depression. Many counselors suggest taking part in friend/family gatherings and public spaces. This helps you to build new relationships and strengthen the current ones.

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FAQs

1. What is the difference between phalloplasty and metoidioplasty?

In metoidioplasty, the clitoris is first enlarged by hormonal medications, then it’s separated from its surrounding tissues to become a small-sized (max 6 cm) penis. However, in phalloplasty, the surgeon shapes the penis using arm or groin tissue.

2. Do you still feel pleasure after bottom surgery?

Yes. In this operation, the surgeons preserve the clitoris (in trans men) and the penis’s head (in trans women). So, they can still enjoy touch and sexual activities.

3. How much is the genital surgery?

The total cost of bottom surgery depends on the type and number of operations required. In general, the price of this surgery ranges between X and Y.

4. Is bottom surgery covered by insurance?

If you obtain the necessary approvals and use public healthcare services, your insurance probably covers a part of their expenses.

5. How long does it take to recover from bottom surgery?

You should rest for at least two weeks after bottom surgery. Remember that it takes months to recover from this procedure, so don’t expect a fast recovery. 

6. Can you have sex after genital surgery?

Yes! You can resume your sexual activities once you are fully recovered and your surgeon allows you.

7. If they take tissue from my arm, where would the scar be?

In phalloplasty, if the surgeon takes the graft from your forearm, there would be a small scar on it.

8. Should I get corrective bottom surgery?

If you choose an adept surgeon and take care of your body during the recovery period, you won’t need corrective bottom surgery. However, if the canals are obstructed or the internal organs are adhered, you should undergo the corrective surgery.

9. Is the result of bottom surgery permanent?

Yes, the results of bottom surgery are lifelong and irreversible.