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Everything you Need to Get Bottom Surgery

Medically reviewed by Nicole M, RN on September 9, 2024.

Gender affirming bottom surgery for transmasculine, transfeminine and other gender non-conforming individuals can be a transformative life experience. We know that the process required to get surgery can be daunting and confusing for many. With that in mind, we have created a comprehensive guide on how to get a surgery date and prepare for metoidioplasty, phalloplasty, vaginoplasty, vulvaplasty (or “zero-depth vaginoplasty”), labiaplasty and more. 

We begin by providing tips on researching your options so that you make the most out of your bottom surgery consultation. From there, we go over frequently asked questions about pre-surgical requirements like insurance and costs, laser hair removal/electrolysis, suspending hormone therapy and suspending tobacco and other drug use. Once you have your surgery date, you can consult the final to-do list here as well as in your pre-operative information packets.

Beginning your journey: creating your unique surgical plan

• Do some research to prepare for your consultation:
  You do not need to become an expert on surgical techniques, risks and options; it is our job as surgeons to inform you about all of those topics. Rather, what helps us the most is when patients come with a clear sense of what they want out of bottom surgery: aesthetically and functionally. To make the most out of your free surgical consultation, we recommend that you do some me-search.
  We encourage you to start listing and ranking your priorities so we can craft the best surgical plan for you. Common priorities include, but are not limited to: giving your genitals a certain appearance, maintaining erotic sensation, being capable of engaging in a certain kind of penetrative sex, being able to urinate standing up, minimizing the recovery process and/or minimizing scar visibility.
  Reading about other patients’ experiences and results is a great way to explore what would affirm you the most. We especially encourage you to check the patient reviews and certification of your surgeon. Making sure that your provider is a board-certified plastic surgeon experienced in gender affirming procedures is crucial to making sure that you are in safe, trustworthy hands.
  
• Inform your surgeon of your medical history:
  If you have medical conditions such as high blood pressure, diabetes, heart or lung problems, or a bleeding disorder, it is important to disclose these to your surgeon. Likewise, we encourage you to be transparent about your recreational drug and alcohol use. Doing so will allow us to design a plan to keep you safe, minimize the possibility of complications and maintain the integrity of your surgical results.

“I want a date”: the roadmap to getting your surgery scheduled

• Prior surgeries:
  Patients who would like a vaginectomy (removal of the vaginal canal) as a part of their bottom surgery procedure should undergo a hysterectomy (removal of the uterus) 8-12 weeks beforehand. A removal of one or both ovaries (an oophorectomy) is not required.
  Patients who would like to have a vaginoplasty or vulvaplasty (aka “zero-depth vaginoplasty) will need to undergo an orchiectomy (removal of the testicles). If this is not done weeks prior to your vaginoplasty or vulvaplasty, we can perform it during this procedure.
  It is important to work with your hormone provider after surgery to ensure your medications are adjusted adequately. Especially if one or both of your testicles or ovaries are removed, your gender affirming hormone therapy regimen will have to be altered.  Likewise, we encourage you to consider your fertility preservation and other reproductive health options beforehand as these procedures result in sterilization.
• Laser Hair Removal and/or Electrolysis:
  Patients that are required to undergo hair removal to prepare for their operation should do so starting 6-10 months before their phalloplasty or vaginoplasty. Hair removal results may vary based on individual factors, so your unique timeline may differ. Please note that Electrolysis is permanent hair removal, while Laser Hair Removal is a reduction of hair. Some patients have reported a regrowth of hair, 2 years after laser hair removal.
  Prospective vaginoplasty patients can consult hair removal requirements here. Please note that this group should finish their laser and/or electrolysis treatments two weeks prior to surgery at the very latest.
  On the other hand, phalloplasty patients are required to undergo electrolysis (permanent hair removal) of the skin that will be used to extend the urethra. This must be finished 6 weeks prior to your surgery date. Most commonly, this is a 2” by 7” segment of the forearm.
  If hair grows inside of the urethra, a variety of complications like infections, stone formations and strictures can occur. However, removing hair from the skin that will be used to construct the penis is not required and is left up to the patient based on their aesthetic preferences and pre-surgical possibilities.
• Insurance, Fees & Financing:
  For patients with health insurance, our practice’s insurance advocacy team has a 90% success rate in securing coverage for the gender-affirming procedures we perform. Most insurance companies require two support letters to cover bottom surgery. At least one letter should come from a licensed mental health professional. The second can come from a mental health or a healthcare provider: for example, an endocrinologist or primary care provider who has been involved in your hormone therapy. Additionally, if Dr. Ley is not an in-network provider within your insurance plan, you will need to provide an additional referral letter from your primary care provider to your insurance. This is also a step we can help our patients out with once they have solicited a consultation.For patients who will not be using insurance to cover bottom surgery, per the WPATH’s Soc 8 guidelines, patients interested in bottom surgery will need to present one support letter from a licensed mental health professional to be eligible for bottom surgery. However, Dr. Ley does not require that patients present a support letter to undergo a bottom surgery revision procedure. Whether or not you underwent your initial bottom surgery procedure with her, the support letter eligibility requirement will be waived.We have compiled this guide on scholarships and trusted medical credit providers for patients who need financial assistance to pay for their surgery. We use an informed consent model for all of our procedures, so if you are not seeking insurance coverage, we do not require referral or support letters.
• Starting (or not) testosterone hormone replacement therapy (HRT):
  At the GCC, we have no requirements around undergoing testosterone HRT prior to bottom surgery. We strive to make our metoidioplasty, phalloplasty and related bottom surgery procedures accessible to patients regardless of their gender identity.