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The Ultimate Guide to Vaginoplasty, Vulvaplasty and Labiaplasty

Medically reviewed by Ellie Zara Ley, MD on December 16, 2024.

Vaginoplasty, vulvaplasty (sometimes written as “vulvoplasty”) and labiaplasty are gender-affirming genital reconstruction procedures that can have been clinically proven to help certain transgender women and non binary patients feel more aligned with their bodies. These procedures have extremely high rates of general satisfaction and satisfaction with sexual function when conducted by experienced surgeons in proper facilities with state-of-the-art techniques. Here we describe the techniques, staging and surgical results a patient can have undergoing a vaginoplasty, vulvaplasty (aka. “zero-depth vaginoplasty”), labiaplasty and penile-preserving vaginoplasty. We also explain eligibility requirements, costs and recovery guidelines.

The bottom surgery procedures described in this article can help patients achieve one or more of the following results:

• The creation of a vaginal canal to use for penetrative solo and/or partnered sex. The depth of the canal can be discussed with your surgeon. To maintain a vaginal canal, lifelong dilation is required.
• The creation of a vagina that either preserves the natal erectile tissue (i.e., the penis) or transforms into a clitoris.
• The creation of vulva with or without a clitoris that has a full erotic sensation and the possibility for orgasm. This can be created with or without a vaginal canal.
• The creation of labia minora and a clitoral hood.

All of the Gender Confirmation Center (GCC)’s bottom surgery procedures are performed by Dr. Ellie Zara Ley (she/her). She is a board-certified plastic surgeon and the only transgender woman of color to offer a full-spectrum specialization in gender-affirming top surgery, bottom surgery, facial surgery and body contouring. She is a leader in the field of genital reconstruction surgeries, using only tried-and-true methods backed by longitudinal research for her patients.  You can request a virtual or in-person consultation with her to create your unique, surgical plan here.

What is vaginoplasty?

Vaginoplasty is a surgery which creates a vaginal canal alongside a vulva or external genitalia, such as the clitoris, and labia majora, and labia minora. This procedure is well-suited for individuals looking to have a vulva with a clitoris, erogenous sensation, and a vaginal canal of approximately 5-7” in depth that can be used for penetrative solo or partnered sex.

Penile-Inversion Vaginoplasty

The creation of a vaginal canal can involve a variety of techniques. The most common vaginoplasty procedure is the penile-inversion vaginoplasty. After the removal of the penis, called a penectomy, erectile tissue is buried into the pelvic region to create a clitoris and the skin of the penis is turned inside out to create the lining of the vagina. Patients who are short on penile and scrotal skin may need 1 or 2 grafts from the hip region in order to line the vaginal canal. Please note that this is the only method that Dr. Ley performs.

The penile inversion method is preferred by patients because of its durability for penetration and it being the only technique that has longitudinal evidence to back its effectiveness. It also allows our patients to take control over many aspects of their results, from the depth of their vagina and the appearance of their vulva.

What is the two-staged approach to vaginoplasty? Why is it better to have the vagina and vulva constructed over the course of two surgeries instead of one?

At the GCC, we offer a two-stage approach to a traditional vaginoplasty.  Patients can also opt for a penile-preserving vaginoplasty or a vulvaplasty (also known as a “zero-depth vaginoplasty”). These options are explained below.

The first stage of a traditional vaginoplasty creates the vaginal canal, clitoris and labia majora. About 5 months later, if the vagina and vulva have healed properly, a clitoral hood and labia minora are constructed. By splitting up this operation into two stages, the vulva has a better chance of healing properly. This has given Dr. Ley’s patients more consistent results, leaving them more satisfied with the outcome of their surgery and less likely to request a revision procedure later on.

What is a labiaplasty (stage 2 of a vaginoplasty)?

The second stage of a traditional vaginoplasty is the labiaplasty. This typically happens 5 months after the first stage. In this surgery, the labia minora and clitoral hood are constructed.

A labiaplasty reconstructs the vulva to add more defined aesthetic details, such as clitoral hooding, full labia minora, and alterations the overall configuration of the labia majora. It allows the surgeon to correct any functional issues, asymmetry or aesthetic concerns a patient may have.

In this surgery, the labia minora and clitoral hood will be made primarily from skin grafts from the labia majora. This will allow your surgeon to tighten any loose skin that may have resulted from the first stage. For this reason, many patients choose to undergo this two-stage vaginoplasty to reduce the likelihood of needing a revision surgery.

Peritoneal Pull-Through and Robotic Vaginoplasty

Please note that the GCC does not offer the following procedures at this time.

Patients can also have their vaginal canal lined with the mucus membrane of the rectal tissue or the internal abdominal wall. The advantage to this method is that it may allow for the possibility of self-lubrication, although results have been shown to be inconsistent.

Some surgeons perform vaginoplasties using a robot. The robotic technique, also called the robotic peritoneal vaginoplasty, involves the creation of incisions around the navel where robotic surgical instruments are inserted into the abdomen. Visualization of the placement of the vaginal canal is achieved through a high definition camera and the surgeon constructs the canal from the inside using the peritoneum (lining of the abdominal wall). The advantage of this method is that it can allow for less skin grafts to be taken to create a longer vaginal canal.

What is vulvaplasty or “zero-depth” vaginoplasty?

A vulvaplasty is very similar to a vaginoplasty in all aspects, except a vaginal canal is not created. A vulvaplasty includes the creation of a vulva, clitoris and labia majora using tissue from the penis, scrotum, and associated skin and tissues. This procedure is selected by patients who would like a vulva, are not interested in having penetrative sex through a vagina nor are they interested in having to dilate their vaginal canal to maintain it. Most patients can still experience orgasm and full erotic sensation through their clitoris as early as 3 months post-op.

The majority of patients who undergo a vulvaplasty are happy with their choice and do not desire to have a vaginal canal. However, if someone does decide later on that they would like a vaginal canal after vulvaplasty, this is possible. Skin grafts can be taken from the hips, to create the canal. The surgical considerations and complications for this procedure would be similar to a vaginoplasty, and the new vaginal canal must be dilated for the rest of one’s life to maintain the width and depth.

What is a penile-preserving vaginoplasty?

Penile-preserving vaginoplasty is exactly what it sounds like: a vaginal canal is created without removing the penis. In this case, the vaginal canal is crafted not using penile tissue, but using scrotal tissue and grafts which come from the hips.

Candidacy requirements to undergo a vaginoplasty or vulvaplasty

Regardless of whether or not patients would like to seek insurance coverage for bottom surgery, they must present a support letter from a licensed mental health professional to qualify for bottom surgery. Please note that no support letters are required for patients to undergo a bottom surgery revision procedure.

That said, some insurance plans require that patients present two support letters to cover bottom surgery. At least one letter should come from a licensed mental health professional. The second letter 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.

We recognize that the two-letter insurance requirement can be an extra barrier for patients to access medically necessary, gender-affirming care. For this reason, we are committed to supporting prospective patients through this process. Once you have a requested a bottom surgery consultation with Dr. Ley, our team can help you find support and/or referral letters.

Aside from support letters, we require that patients be legal adults (at least 18 years old) to be candidates for bottom surgery. Although we do not have BMI requirements for most of our procedures at the GCC, patients must have a BMI under 36 to undergo a vaginoplasty and a BMI under 40 to undergo a vulvaplasty.

Do I need to undergo laser hair removal and/or electrolysis to get a vaginoplasty?

To undergo a penile-inversion vaginoplasty, patients should undergo permanent hair removal prior to their procedure. Laser hair removal and/or electrolysis of the penis shaft and scrotum are essential to prevent complications from hair growth inside of the vaginal canal and/or in the vulva. Specifically, these complications include infection, hairballs, and dyspareunia (pain during sexual intercourse).

Do I need to stop taking estrogen for surgery?

Many providers ask patients to stop estrogen hormone replacement therapy (HRT) 1-2 weeks prior to surgery to reduce the risk of blood clots. Patients who have personal or health concerns about suspending estrogen therapy can speak with our surgical team about the possibility of waiving this requirement for their specific case.

How much does a vaginoplasty, vulvaplasty and labiaplasty cost?

Many insurance providers recognize gender-affirming bottom surgery as a medically necessary form of treatment for gender dysphoria. With the proper requirements fulfilled, like one or two support letters from a therapist and/or healthcare provider, insurance can cover part or all of the costs of the procedure. For more information on insurance coverage, click here.

Patients who are interested in undergoing surgery without insurance are considered cash-pay patients. The full costs of the bottom surgery procedures can range depending on the specifics you request during your consultation. For resources on financing and grant opportunities for surgery, click here.

*Please note that the following ranges are estimates that vary procedure to procedure depending on an individual’s unique surgical plan. Additionally, these estimates do not include facility fees, anesthesiology fees or pathology fees.

How long is the procedure?

The time it takes to perform a vulvaplasty, vaginoplasty and labiaplasty varies depending on the specific goals of the patient in the procedure. For example, how many skin or tissue grafts are taken, whether an orchiectomy (testicle removal) will need to be performed simultaneously, etc. Procedures can take between 3-4 hours.

What is the recovery process like?

The recovery process from bottom surgery differs from procedure to procedure. Labiaplasty patients can usually leave the hospital the same day as their operation. Vaginoplasty and vulvaplasty patients can expect to stay in the hospital for at least 3 nights after surgery to monitor their health closely. The recovery process generally takes 6-8 weeks, although consistent dilation of the vaginal canal is essential during the first three months.

Bleeding and spotting is expected from the incisions for up to 6 weeks post-op.. It is normal to experience vaginal discharge in the first few months post-op. Swelling and bruising should also greatly subside by this time. That said, patients will likely not get a sense of the final appearance of their vulva until 3-6 months post-op.

What is urination like after a vulvaplasty or vaginoplasty?

For the first 8 days after the operation, patients will have an indwelling urethral catheter, which can be a source of discomfort. Even after the catheter is removed, it is common to experience spraying while urinating until the swelling has resolved.

Generally speaking, we recommend that after urinating or using the bathroom, patients wipe from front to back. This will help prevent contamination of the vaginal microbiome with the anus.

How long will I need to dilate after surgery?

After your vaginoplasty bottom surgery, dilation is necessary to keep the vaginal canal open. It is important to note that dilation is a lifelong commitment. Your surgeon will provide specific instructions for proper dilation. Even years after surgery, if dilation is stopped, you can lose depth and girth. Patients that are interested in correcting this issue can undergo a revision surgery to deepen or widen their vaginal canal.

Does vaginoplasty and vulvaplasty allow for erotic sensation? When can patients start having orgasms?

The clitoris is made by burying the glans of the penis, so it maintains a heightened, erotic sensation. Patients typically regain full sensation and can have an orgasm 3-9 months after the clitoris is constructed.

What determines the depth of the vagina?

The depth of the vaginal canal is determined by the amount of tissue available from the penis and the scrotum. That said, if there is not enough tissue available from these areas, we can take one or two skin grafts from the hips in order to line the canal.

Will my new vagina self-lubricate?

A penile-inversion vaginoplasty is lined with skin, meaning it does not self-lubricate. Techniques that use the rectal lining for the vaginal canal, for example, yield uneven results when it comes to a patient’s capacity to self-lubricate. For this reason and the lack of long-term evidence around this technique, Dr. Ley only performs the penile-inversion technique.

When can I engage in sexual activity after a vaginoplasty?

We recommend that patients wait at least 3 months after surgery to have solo or partnered penetrative sex. Beforehand, your genital tissue, especially the skin between the vaginal opening and the anus, is particularly fragile.

It is normal to take some time to learn and rediscover your new body. Starting gently and slowly is a good approach, with open verbal communication with your partner, if one is present.

When can I see my final results?

Generally speaking, it takes at least 3-6 months for swelling to resolve. That said, it can take up to a year after surgery for the final results of your procedure to be visible.

Benefits

The benefits of undergoing gender-affirming bottom surgery are overwhelmingly positive. 8 prospective cohort studies, 15 retrospective cohort studies, and 3 cross sectional cohort studies cited in the WPATH SoC 8 have demonstrated that vaginoplasties have extremely high rates of general satisfaction and satisfaction with sexual function. Qualified transgender and non-binary patients treated by board-certified gender-affirming surgeons have consistently shown increases in various indicators of the quality of their life, such as improvements of their mental health and greater satisfaction in their sex lives.

Risks

Most patients who undergo surgery with an experienced, board-certified surgeon can expect to experience minimal risks. Most surgical complications that arise can be resolved without the need for the patient to undergo a later revision surgery. Patients can reduce their risk of complications by taking the following steps:

• Stop all smoking at least 3 weeks before and after surgery
• Do not consume alcohol at least 1 week before and one week after surgery
• Keeping any chronic health conditions well-managed

Complications can include:

• Wound openings
• Hematomas
• Vaginal granulation
• Abnormal urinary stream
• Blood in the urine
• Urinary fistulae (small holes in the urinary tract)
• Urinary tract infections

Serious risks can include:

• Excessive bleeding
• Blood clots
• Infections
• Pain levels being unresponsive to medications
• Fever
• Abnormal swelling in the groin or lower leg
• An inability to keep foods/liquids down
• Shortness of breath, pain in your chest, lightheadedness or dizziness

Notify your provider immediately of any concerning symptoms, whether listed above or not. For more information, click here.

Conclusion:

The following chart explains what each bottom surgery procedure discussed in this article can accomplish.

Although historically these procedures have been referred to as “feminizing” surgeries, we recognize that not everyone considers these bodily transformations or body parts to be feminine. We offer these procedures to patients regardless of their gender identity or expression.