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Everything you Need to Get Bottom Surgery

Medically reviewed by Ellie Zara Ley, MD on February 6, 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 and Fertility Preservation:

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. Please note that the GCC (Gender Confirmation Center) does not offer hysterectomies at this time, so you will need to seek out a gynecological surgeon.

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 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.

Candidacy Requirements

At the GCC, Dr. Ellie Zara Ley (she/her/they) has a number of requirements for bottom surgery patients. Regardless of whether or not a patient is seeking insurance coverage, a support letter is required for first-time vaginoplasty, vulvoplasty, orchiectomy metoidioplasty and phalloplasty patients. Please note that at this time, due to hospital restrictions, Dr. Ley is only able to take phalloplasty patients with insurance coverage.

Additionally, due to health concerns around post-surgical complication risks, bottom surgery is one of the only gender-affirming procedure types that we have BMI candidacy requirements for. We encourage you to read more about them here.

Insurance, Prices & 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 one to 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) Before Surgery:

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.

Patients who are taking testosterone and would like to maximize their bottom growth are recommended to wait 1-2 years after beginning treatment. That said, the natal erectile tissue (sometimes called a penis or clitoris) does not always grow as a result of exposure to testosterone. Bottom growth is also not a requirement to undergo a metoidioplasty with us.

Additionally, the GCC does not require our patients to temporarily discontinue testosterone HRT before bottom surgery.

The final countdown: Your Pre-Surgery Checklist

Organize a care team: 

Recovery from a gender affirming surgery can be a difficult process both physically and emotionally. We encourage you to reach out in advance to friends, family (chosen or otherwise) and a mental health professional to help accompany you while you are healing. Most patients are dependent on external support for at least 1-2 weeks after surgery.

Remember that it is normal to feel temporary frustration, sadness, exhaustion and even regret while you experience high levels of pain and inflammation, cannot partake in your normal daily activities and are waiting months to see your final surgical results.

Ask for time off of work 6 weeks before surgery:

You will receive a doctor’s note from our office soliciting time off of work to recover for your surgery. We suggest that you present this letter to your employer 6 weeks prior to your surgery date. In states like California, it is illegal for employers to retaliate against employees for taking time off to seek medical attention.

Stop all smoking 8 weeks before surgery:

If you are undergoing any kind of microsurgery––which is most common with a radial forearm flap phalloplasty––you will need to stop smoking tobacco and other substances 8 weeks prior to surgery. Other positive lifestyle habits like eating a balanced, healthy diet and exercising regularly can also help prevent surgical complications. Please note that recent quitters may need to undergo a nicotine test to determine their surgical eligibility. This is because smoking, especially tobacco, reduces blood flow and restricts oxygen levels, which greatly increase the chances of surgical failure.

Suspending (or not) estrogen hormone replacement therapy (HRT):

Though the medical data is not conclusive on the exact risk that hormones present in terms of increased complication rates (such as clotting or emboli), we want to make every effort to decrease your surgical and recovery risk. In our practice, we recommend that our patients stop estrogen HRT 2 weeks prior to surgery. Progesterone and hormone blockers do not need to be stopped.

We also recognize that some patients have significant and legitimate concerns around suspending or withdrawing from estrogen. These can be discussed with your surgeon to gain a better understanding of the benefits of continuing hormones against potential risks. For patients who have a high risk for blood clots––such as those with inherited or acquired blood disorders and prior history of blood clots––your surgeon may have different recommendations.

After most bottom surgeries, you may resume your hormone therapy one week post-op. Your surgeon will give you specific instructions when to safely resume your hormone therapy regimen. Following these recommendations is crucial to ensure a safe and successful recovery.

Collect your medications from the pharmacy:

A week before surgery, we ask that you fill your surgical prescriptions and get any other supplies you will need in recovery, such as additional gauze. In some cases, prescription medications will be administered to you during your stay at the hospital. Your surgical care team will provide you with a list of materials you will need for the recovery.

Stop shaving:

The week prior to your operation, we ask that you not shave the area where surgery will be performed. This will help minimize the risk of infection that could delay your procedure.

24 hours before surgery:

Try to eat only light meals the day before your operation. By midnight, you should no longer consume food or liquids. That said, in the morning you may take your medications with a small sip of water, unless told otherwise.

Bowel preparation must be done for the following procedures: vaginoplasty, vaginal deepening, vulvaplasty, phalloplasty, and metoidioplasty with primary urethral lengthening. Detailed instructions and prescribed medications will be provided by your surgical care team.