The Real You: MTF Bottom Surgery

Reviewed by Mark P. Solomon, MD, FACS

Not every transgender female pursues a sex change or genital reconstruction surgery, but those who do are met with several choices based on their needs and goals. Genital reconstruction procedures for transgender females are often referred to as vaginoplasty or "lower" or "bottom" surgery.

There are many reasons why a transgender female may consider genital reconstruction, including the desire for female genital appearance and the ability to have sexual intercourse and orgasm as a female. It is a very personal decision. Surgery of this type is performed only after the recipient has lived as a woman and has taken hormones for more than a year.

Surgery Techniques

There are several techniques that MTF genital reconstruction surgeons can use to create a new vagina (vaginoplasty) based on a patient's unique anatomy and preferences. In one commonly used approach, the penile and scrotal tissue is converted into a vagina, clitoris and labia. Some surgeons prefer to create the new vagina using part of the colon which is isolated and moved into a newly created pelvic space. In both cases, the testicles are removed and the nerves to the penis head and skin are preserved to make a clitoris. The urethra is shortened and placed in a female position. Permanent hair removal on the genital area prior to surgery is also beneficial.

Obviously these are the basics; the actual procedures are very complex. An experienced surgeon can describe them to you in detail.

(Vaginoplasty surgery may combined with labiaplasty if needed.)

Risks and Recovery

These are major surgical procedures that require significant downtime. There are risks associated with vaginoplasty as well. These can be mitigated by following the surgeon's pre- and post-surgery advice, including quitting smoking if you are a smoker. Smoking greatly increases your risk for poor wound healing, infection and scarring. Other risks fall into several categories such as cosmetic concerns (poor outcome, unwanted hair), psychological complications (depression, regret) and general surgical risks (infection, anesthesia issues).

Treatment Planning and Cost

The first and most important step in your journey is to consult with a board certified plastic surgeon who has experience performing this procedure. Review before and afters and ask to speak to current and former transgender women who have had the procedure with your surgeon.

The cost of the procedure can be more than $17,000, but some insurers will cover all or some of the costs associated with gender reassignment surgery provided you meet certain criteria. Your insurer can provide you with the most accurate information regarding your policy.

(Learn more about cost of and criteria for gender reassignment surgery.)

About the Reviewer of This Article

Mark P. Solomon, MD, FACS, is a Philadelphia and New York plastic surgeon who is certified by the American Board of Plastic Surgery. He routinely treats transgender men and women.