Bottom surgeries - Freedom of Form Foundation (2025)

Also frequently referred to as a “meta”, metoidioplasty is a surgery performed for AFAB individuals which aims to create a penis analogue, or “neophallus” using the clitoris. It is almost always required to be on testosterone prior to a meta operation as testosterone can enlarge the clitoris and provide more tissue to work with. Unlike a more elaborate multiple-stage phalloplasty operation, metas are often treated as outpatient procedures and are usually completed in one stage.

There are several methods that can be performed in a meta procedure:

• Simple release/simple meta: Clitoris is freed from the surrounding tissue and allowed to grow further, increasing the length and visibility of the resulting penis. It is referred to as “simple” because the vagina and urethra are unaltered.
• Full metoidioplasty/ring metoidioplasty: Clitoris is freed from the surrounding tissue, and tissue is grafted from either the cheek (in a full metoidioplasty) or the vaginal lining (in a ring metoidioplasty) to bring the urethra up to the penis. These methods allow for the option of a vaginectomy to remove the vagina and scrotoplasty to create a scrotum with implants.
• Centurion metoidioplasty: The clitoris is freed from the surrounding tissue along with the round ligaments that run through the labia to the labia majora, and uses the ligaments to create extra girth in the neophallus. No skin grafting is required with this method and as a result this method can see fewer complications.

Meta procedures come with their own strengths and drawbacks compared to a phalloplasty. For example, while metas are generally more cost-effective, have easier recovery, and result in having a functioning phallus capable of achieving erection, a meta phallus will very likely be very short compared to a phalloplasty, and may not be capable of penetration or the ability to stand while urinating. When considering a metoidioplasty, it is important to weigh the benefits and drawbacks of the procedure with your surgeon ahead of the operation. [13]

Phalloplasty refers to a complex series of procedures where the aim is to construct a functioning penis. Phalloplasty is very commonly performed in multiple stages due to its complexity. Most commonly during phalloplasty, a vaginectomy is performed, a large section of skin, most commonly from the forearm, thigh, or back, is rolled and grafted to form a shaft and attached to the groin. Optionally after this is done, additional stages to create a scrotum and head of the penis (glans) can be performed. Some phalloplasty stages can be performed in addition to and alongside a metoidioplasty. Since phalloplasty cannot commonly be performed in its entirety in one stage, patients may opt to only complete some of the stages as they see necessary for their own gender dysphoria.

The first stage of a phalloplasty operation involves removal of the female genitalia, lengthening of the urethra, and creation of the shaft of the penis using grafts of skin (known as flaps) from one of three donor sites:

• Radial Forearm Flap (RFF): The most common place to take a skin graft for phalloplasty. Uses skin from all around the forearm to construct the penis. Because this skin is thin and relatively easy to work with, the urethra-lengthening procedure can very commonly be completed in a single stage.
• Anterolateral Thigh (ALT) Flap: The ALT donor site uses skin from the front of the thighs to construct the new penis. Depending on the thickness of the thigh skin and subcutaneous fat, this option may not be ideal for all patients. Use of the ALT may result in less immediately pleasing aesthetics in the new penis, so some revisions may be required to improve aesthetics if desired. Some surgeons are able to use this donor site in a “delayed” fashion, where prior to the grafting of the thigh skin, blood flow from everywhere other than the body’s main blood supply is cut off, and for 4-6 months the skin is able to become accustomed to the blood supply it will be receiving in the post-op phallus.
• Latissimus Dorsi Myocutaneous Flap (LDMF): Located along the back from the rear of the ribcage to the upper buttocks, the LDMF is a section of skin used commonly for skin grafts for many reconstructive surgeries, including some phalloplasties. Despite being a versatile site, it does have the disadvantage of experiencing minimal physical sensation if used, and may require a second stage to complete the phalloplasty.

During a phalloplasty procedure, if desired, steps can be taken to give the new phallus the appearance of a circumsized penis. This can be done with either a glansplasty–where skin is grafted during construction of the penis to create the appearance of a penis crown–or a glans implant–where a silicone implant is inserted into a post-operative penis to create a naturally shaped penis crown–or both can be performed.

Once a phalloplasty has had enough time to properly heal (around 9 months post-op), a penile implant may be added to allow for the possibility of penetrative sexual activity. The implant is typically either inflatable, or semi-rigid, and is inserted into the phallus. [14,15]

For patients seeking the ability to stand to urinate post operative, urethroplasty is available as part of both metoidioplasty and phalloplasty procedures. This is done by relocating the opening to the urethra to the perineum, then extending the opening to the urethra with either neighboring tissue for metoidioplasty, or a newly-created skin tube for phalloplasty. If urethral lengthening is performed, a suprapubic catheter will typically be left in for 2-4 weeks to allow the opening to heal, until urination through the opening is possible.

It is important to note that this is not a mandatory requirement for any bottom surgery and the urethra may be able to remain in place, but the patient will still be required to sit to urinate post-op. It is not terribly uncommon for urethral lengthening to run into complications with urination becoming difficult or urine to not all make it out through the new urethral opening. If a patient chooses to not go through the urethroplasty procedure they have much lower risk of urethral complications. [14,15]

Scrotoplasty refers to procedures which aim to create an aesthetically pleasing scrotum alongside a phalloplasty or metoidioplasty. The new scrotum is constructed primarily using labia majora tissue, but additional tissue can be grafted to create a larger scrotum if the labia majora has insufficient tissue. Once the scrotoplasty has healed completely, the option to add testicular implants is available.

Sometimes if a metoidioplasty or phalloplasty procedure with scrotoplasty included is performed, the scrotum may end up lowering too far below the legs. This can be fixed with an outpatient monsplasty procedure, which pulls the scrotum out from between the legs and raises it to a more natural location. [14,15]

Commonly performed as a treatment for testicular cancer, orchiectomy is removal of the testicles. For gender affirmative purposes, orchiectomies are performed for multiple reasons, including but not limited to: permanently stopping testosterone production by the body, flattening the visual profile of one’s genitals and creating a more feminine appearance, and allowing preservation and continued use of the penis without testosterone production. Because a sudden reduction in testosterone can cause mild side effects it is typically recommended that patients be on hormone replacement therapy which limits testosterone so that they are used to the effects.

There may be slight variations in how orchiectomies are performed by each surgeon, but it is typically a minimally invasive and outpatient procedure involving one or two small incisions in the scrotum tissue to remove the testicles. Orchiectomies typically do not require long recovery times and patients can return to normal activities within only a few days.

If desired, the scrotal tissue may be left nearly entirely intact to allow for more tissue to work with in a future gender affirming surgery such as vaginoplasty, or the scrotal tissue can be removed entirely. [17]

Vaginoplasty commonly refers to any gender affirming surgery which aims to create a functioning vagina from existing tissue when a vagina is not already present. As more surgeons have begun performing vaginoplasties, several methods of vaginal construction have been developed, offering a variety of options in aesthetics and functionality depending on one’s needs.

Most vaginoplasties primarily construct the vagina and all its parts using penile and scrotal tissue, with some operations requiring donor tissue from elsewhere on the body if there is not enough tissue present where the vagina will be created.

Because the vagina is typically created using skin from the scrotum and penis, and the skin has hair follicles, most vaginoplasty providers strongly recommend that patients get electrolysis performed on the genital region, or laser hair removal if it is an option for the individual in order to prevent hair growth inside the vaginal canal. As with orchiectomies, the testicles are nearly always removed. Similarly, HRT to limit testosterone is recommended to avoid side effects caused by testosterone removal.

Most vaginoplasties are not able to be performed as an outpatient procedure, and a hospital stay ranging from overnight to 2 weeks is standard. With the exception of zero/minimum-depth vaginoplasties where there is no vaginal canal, post-operative dilation will be required to maintain depth and girth. Frequency of dilation can be decreased over time.

The most common methods of performing vaginoplasty include:

• Penile Inversion Vaginoplasty (PIV): So-called because the penis becomes “inverted” to construct the vagina. Penile skin is used to construct the vaginal lining, the labia majora is created using scrotal skin, and the clitoris is created skin from the tip of the penis. [2] The prostate is left alone, allowing it to aid function as a “G-spot”. [1] Most surgeons can achieve a reasonable depth using this technique, however, if the desired depth is not able to be gained some skin grafting (usually from the forearms, thighs, or buttocks) may be necessary. [3]
  • Pros:
    • Widely available procedure
    • “One-size fits most” vaginal depth results
    • Relatively low risk of complications compared to other methods
  • Cons:
    • Skin grafting may be required for additional depth if not enough tissue is present
    • End-result aesthetics can vary wildly by patient and by surgeon
• Non-Inversion “Thai Method”: A method of performing vaginoplasty developed by Dr. Suporn in Thailand. Scrotal tissue is used to create the vaginal lining, with penile tissue used to create the labia, vulva, and clitoris. Unlike PIV, this method makes use of additional membranous components from the testes to also line the vaginal cavity. Because tissue from the scrotum and testes membranes are both used, depth is not limited based on the amount of available penile tissue. [4]
  • Pros:
    • Stronger guarantee of vaginal depth without skin grafting
    • Vaginal aesthetics often preferred to PIV results
  • Cons:
    • Performed in extremely limited number of locations
    • Insurance outside Thailand unlikely to cover procedure
    • Patients experiencing post-op complications must have concerns addressed over the internet or by traveling back to Thailand
• Peritoneal Pull-Through Vaginoplasty (PPT): Peritoneum flaps are pulled through small incisions to be used to be used as part of the vaginal canal lining. The labia, clitoris, and remainder of the vaginal canal are created using methods similar to those used in PIV. Benefits of this method include but are not limited to more depth than standard PIV, some amount of self-lubrication, and reduced need for dilation and pre-op hair removal. [5]
  • Pros:
    • May allow vagina to self-lubricate as a cisgender vagina might
    • Reduced (but not eliminated) need for pre-and-post-op prep and care
    • Less likely to require skin grafting than other methods
  • Cons:
    • Performed less commonly than PIV
    • Some patients report that self-lubrication effects are overstated
• Sigmoid Colon Vaginoplasty (SCV): Performed similarly to a PIV but uses lining of the colon instead of penile skin to construct the vaginal canal. This method is performed far less commonly than other methods primarily due to it being far more invasive, having a much more difficult recovery than other methods, and complication risks can potentially be greater. This method is most commonly performed when a PIV fails. While the benefits and outcomes of this method have not been highly studied, some patients report increased depth over a standard PIV with this method, and the colon lining is able to self-lubricate. [3]
  • Pros:
    • Depth results generally agreed to be higher than other methods without skin grafting
    • Self-lubrication is an expected outcome
  • Cons:
    • Not commonly performed and may be difficult to find surgeon willing to do it
    • Not commonly offered as first choice option for vaginoplasty
    • Highest risk of complications relative to other vaginoplasty methods
    • Tough post-operative recovery

Some individuals who undergo vaginoplasty may request some optional features, or go in for another stage to make aesthetic enhancements to their post-operative vagina. For example, if a patient does not have a desire to have vaginal penetration, some surgeons offer a “zero-depth” or “minimum depth” vaginoplasty. This is performed the same as a PIV but no or an extremely minimal vaginal canal is created in order to create an aesthetically appealing vagina without the need for post-op dilation. Other patients may go in for labiaplasty, clitoroplasty, or a similar second stage to improve the cosmetics of their vagina. A second stage generally results in improved cosmetics. Each surgeon may offer different options for vaginoplasty patients, so it is important to discuss these options with your surgeon during your consultation.

Sometimes referred to simply as genital nullification, this surgery aims to create a smooth appearance in the groin area by removing any external genitalia and leaving an opening for the urethra for urination. The processes for this surgery differ between those who are Assigned Male At Birth (AMAB) and those who are Assigned Female At Birth (AFAB).

A full, comprehensive description of these surgeries can be obtained from a medical professional during a surgical consultation.

Penile-preserving vaginoplasty (PPV) is a procedure intended to create a functioning vagina without requiring the removal of the penis nor any urethral shortening or relocation.

Most commonly, PPV is performed by removing the testicles and utilizing the remaining scrotal tissue to construct the vaginal cavity in the location of the testicles. For additional depth, or for specific aesthetic requirements (labia, clitoral hood, etc.), skin grafting may be necessary if the scrotal tissue alone is not enough.

A second, newer type of PPV uses tissue grafted from the lining inside the patient’s abdomen (peritoneal pull-through or PPT). This procedure is most akin to a feminizing PPT vaginoplasty, and many of the steps will be similar in execution to that method of vaginoplasty.

Finally, some clinics perform PPV using a “hybrid” approach where the outer portion of the vagina uses scrotal or penile shaft skin, and the inner portion uses peritoneal tissue.

Some surgeons are able to perform PPV without requiring the removal of the scrotum or the testicles, though if depth is desired for the resulting vagina, tissue grafting will probably be necessary. Depending on the technique used, the graft may come from skin or peritoneal tissue.

Most steps can be done within one surgery, but clinicians may recommend planning a second surgery within 6-12 months depending on patient specifics. Like other methods of vaginoplasty where depth is an expected result, dilation will be required to strengthen kegel muscles and maintain vaginal depth. Other personal care steps may be required as well. Of course, each technique will have its advantages and disadvantages, and should be discussed with clinicians to help you make the right decision for your goals.

[1] University of California, San Francisco: Vaginoplasty procedures, complications and aftercare

[2] Crane Center for Transgender Surgery: Vaginoplasty

[3] Healthline: Vaginoplasty: Gender Confirmation Surgery

[4] Dr. Suporn’s Clinic: Suporn’s Non-Penile Inversion SRS Technique

[5] MTFsurgery.net: Old Approach, New Application: Peritoneal Pull-Through Vaginoplasty

[6] Steven Teitelbaum, M.D.: Transgender Breast Augmentation

[7] Cleveland Clinic – Voice Feminization Surgery

[8] Mayo Clinic: Transgender voice therapy and surgery

[9] Healthline: What is a Tracheal Shave?

[10] 2pass Clinic: Hip augmentation

[11] Visage Clinic: Hip Augmentation

[12] Eppley Plastic Surgery: Shoulder Reshaping Surgery (Narrowing and Widening)

[13] Healthline: Metoidioplasty

[14] Cleveland Clinic: Phalloplasty

[15] Plastic and Aesthetic Research: Phalloplasty: understanding the chaos

[16] Richard Troy: Voice masculinization surgery for FtM transgender

[17] Healthline: What You Should Know About Orchiectomy for Transgender Women

[18] Crane Center for Transgender Surgery: Facial Feminization Surgery (FFS)

[19] Crane Center for Transgender Surgery: FTM Top Surgery

[20] FTMsurgery.net: FTM Body Masculinization Surgery Explained

• The Crane Center for Transgender Surgery: Non-Binary Surgery
• Align Surgical Associates: Procedures for People Who Identify as Non-Binary
• Davis Plastic Surgery: Gender Nullification
• Metoidioplasty.net: Non-Binary Options for Metoidioplasty
• MTFSurgery.net: Non-Binary Options for Bottom Surgery