FTM Bottom Surgery
Bottom surgery is not one operation. It is two groups. The removal operations, hysterectomy and vaginectomy, take out the uterus and close the vaginal canal, and they are done laparoscopically or from below with nothing to see afterwards. The reconstruction operations build a phallus, either from the clitoris that testosterone has enlarged, which is metoidioplasty, or from skin taken from elsewhere on the body, which is phalloplasty.
Most people who have bottom surgery have some of the first group and one of the second, in stages over one to three years. Some stop after the removals. Some have a metoidioplasty and never go further. A minority go through the full phalloplasty sequence.
The decision that shapes everything else is metoidioplasty or phalloplasty, and it comes down to size against sensation, scarring, stages and risk. There is no right answer, only the one that fits what you want from it. Everything below is a version of that trade.
Who bottom surgery is for
Anyone who wants it, with the usual conditions. Two letters of support in most systems, a period on testosterone, which matters here more than for top surgery because metoidioplasty depends on the growth it produces, and general health that can take a long operation. Nicotine has to stop, and for phalloplasty in particular surgeons are strict about it because the flap's survival depends on small blood vessels.
The fertility conversation belongs here. Hysterectomy ends carrying a pregnancy, and removing the ovaries ends using your own eggs. Neither is reversible, and fertility preservation has to happen before, not after.
The other honest thing to say is that bottom surgery has more stages, more complications and a longer recovery than anything else on this site. The people I have seen do well with it are the ones who went in expecting exactly that, and the ones who struggled were usually surprised by the second stage rather than the first.
Before you go further
Write down what you actually want from the result, in plain words: to stand to pee, to have sensation, to have something a partner can feel, to look a certain way in clothes. Every one of those points to a different operation, and knowing which ones matter to you is the whole decision.
Choosing between them
The removals are rarely a hard choice. If you are having reconstruction with urethral lengthening, you need them. If you are not, it is a question of dysphoria, periods and cancer risk, and the hysterectomy page goes through it.
The choice that people agonise over is metoidioplasty or phalloplasty. Meta gives you a small, fully sensate phallus in one operation with minimal scarring. Phallo gives you a full-size one that can penetrate, over two or more operations, from a donor site that leaves a major scar, with more risk. Some people have a meta first and a phalloplasty years later. The meta vs phallo guide sets them side by side.
Before you book a consultation
Read the metoidioplasty and phalloplasty pages back to back, in that order, and notice which one you argued with. Most people know their answer before they know they know it, and the arguing is the tell.
The bottom surgery procedures
The operations below fall into two groups. Removal takes things out; reconstruction builds something new. Most people have some of each, and the removals almost always come first, because the reconstructions with a lengthened urethra run through the space the removals clear.
Metoidioplasty and phalloplasty each have their own versions and stages, which their pages cover. Scrotoplasty, erectile implants and glansplasty are add-ons to a reconstruction rather than operations on their own. Read the page for the operation your surgeon named, then the ones it depends on.
Removal
Hysterectomy
Removal of the uterus, usually with the cervix and tubes, through three or four small laparoscopic cuts. Nothing changes externally. Ends periods and uterine cancer risk, and is the first step before vaginectomy and genital surgery.
Best for: anyone with dysphoria around the uterus or periods, or planning genital surgery
- Scar
- Three or four small laparoscopic ports on the abdomen
- Sensation
- Genital sensation unaffected
- Back to work
- 2–4 weeks
- Typical cost
- $10,000–$20,000
Oophorectomy
An oophorectomy removes both ovaries, nearly always during a hysterectomy, through the same ports. Ends your own oestrogen and eggs for good and means staying on hormones for life; keeping them leaves a fallback and the option to remove later.
Best for: anyone certain they will not want their own eggs and will stay on testosterone for life
- Scar
- None of its own; uses the hysterectomy ports
- Sensation
- No change to sensation
- Back to work
- Adds nothing to a hysterectomy; about 1 week standalone
- Typical cost
- $0–$1,000 with a hysterectomy; $5,000–$10,000 standalone
Vaginectomy
The vaginal canal is closed permanently: the lining removed and the walls stitched together. Nothing changes externally. Required by nearly every surgeon before urethral lengthening, and the step that makes genital surgery irreversible.
Best for: anyone planning metoidioplasty or phalloplasty with urethral lengthening, or wanting the canal closed for its own sake
- Scar
- None visible; internal and perineal
- Sensation
- Clitoral sensation unaffected
- Back to work
- 3–4 weeks
- Typical cost
- $8,000–$15,000 standalone
Reconstruction
Metoidioplasty
A small, fully sensate phallus built from the testosterone-grown clitoris, released and shaped in one operation with minimal scarring. Typically three to six centimetres. Optional urethral lengthening lets you stand to pee at the cost of most of the complication risk.
Best for: people who want sensation and a single operation over size
- Scar
- Minimal; within the genital folds
- Sensation
- Fully kept; the tissue is not moved
- Back to work
- 3–6 weeks
- Typical cost
- $10,000–$50,000
Phalloplasty
A full-size phallus built from skin and tissue taken from the forearm, thigh, back or abdomen, over two or more operations. Can take an erectile implant for penetration. The cost is a major donor-site scar, a long staged recovery and higher complication rates.
Best for: people for whom size and penetrative sex matter enough to accept the scar, the stages and the risk
- Scar
- A large donor-site scar on the forearm, thigh, back or abdomen, plus groin scars
- Sensation
- Kept at the base; shaft feeling grows in over 1–2 years
- Back to work
- 3–8 weeks depending on flap
- Typical cost
- $50,000–$150,000+
Scrotoplasty
A scrotoplasty where the outer labia are joined into a pouch under the base of the phallus, usually during metoidioplasty or the first stage of phalloplasty. The pouch is left empty to heal; silicone implants are an optional second step months later.
Best for: anyone having meta or phallo who wants a scrotum, and anyone who wants implants later
- Scar
- A midline line in the scrotal fold, plus the fold incisions
- Sensation
- Kept; the labial skin stays on its own nerves
- Back to work
- 2–3 weeks
- Typical cost
- $5,000–$15,000 standalone
Erectile Implants
An inflatable or malleable device placed inside a healed phalloplasty to make it rigid for penetration. The step that makes the phallus work, and the one with the highest infection and failure rates of any bottom surgery stage.
Best for: anyone with a healed, sensate phalloplasty who wants to use it for penetration and accepts that the device may need replacing
- Scar
- Short incision at the base of the phallus or in the scrotum, mostly within old scars
- Sensation
- Unchanged by the implant; sensation is required before it goes in
- Back to work
- 2–3 weeks
- Typical cost
- $15,000–$35,000 plus the device
Glansplasty
A glansplasty sculpts a head on a phalloplasty phallus by cutting a ridge around the shaft and grafting a groove below it. A small, cosmetic operation usually done at a later stage; the ridge can flatten over time and may need redoing.
Best for: anyone with a healed phalloplasty who wants the tip to read as a glans rather than a tube
- Scar
- A fine line around the shaft where the ridge sits
- Sensation
- Unchanged once healed; the tip can be numb for a few weeks
- Back to work
- About 1 week
- Typical cost
- $5,000–$10,000 standalone
Bottom surgery recovery
The removals recover like abdominal surgery. A night in hospital, gas pain for a few days, desk work in two to three weeks, everything else by six to eight. Vaginectomy is a harder version of the same, with a catheter and sore sitting.
Reconstruction is a different scale. Metoidioplasty is a hospital stay, a few weeks of careful sitting and, with urethral lengthening, a catheter for two to four weeks. Phalloplasty is a week in hospital for stage one, months before the donor site and the phallus have settled, and further stages each with their own recovery. Nobody gets through phalloplasty in less than a year, and eighteen months is more typical.
Bottom surgery cost
Bottom surgery is where cost varies most, because the operation ranges from a laparoscopic hysterectomy to a multi-stage phalloplasty with implants. Hysterectomy is the most likely to be covered by insurance or a public system. Reconstruction is covered in many places once approved, and the approval usually covers the whole sequence.
Self-pay, the number to ask for is the all-in figure for the whole plan, not the first stage, and what happens to the price if a complication needs a repair. Fistula and stricture repairs are the common extras and not every quote includes them. The bottom surgery cost guide has figures by procedure and country.
Where it fits
Removals first, then reconstruction, with a gap of several months between them unless the surgeon combines them. Hysterectomy is often done alongside top surgery, which is why it tends to be the first bottom surgery people have. Vaginectomy is often done in the same operation as stage one of a metoidioplasty or phalloplasty.
Facial and body procedures fit anywhere in this. Top surgery almost always comes before any of it. See surgery order for how people tend to stack things.
Eligibility
Stricter than top surgery. Most surgeons and systems follow WPATH and want two letters of support for genital surgery, a documented period living in your gender, and usually a year or more on testosterone. Age limits are firmer. Some countries fund reconstruction only after a waiting list measured in years. The eligibility section covers the criteria and the letters.
Frequently asked questions
Do I have to have all of it?
No. Many people have a hysterectomy and stop. Many have a metoidioplasty and never go further. The sequence is modular, and each page says what it depends on. See where it fits.
Metoidioplasty or phalloplasty?
Size and penetration against sensation, scarring, stages and risk. There is no right answer. See choosing between them and the meta vs phallo guide.
Do I need a hysterectomy first?
For any reconstruction with urethral lengthening, nearly always, with a vaginectomy. For a simple release metoidioplasty, no.
How long does the whole thing take?
Removals plus metoidioplasty can be done inside a year. Phalloplasty is eighteen months to two years across its stages, sometimes longer. See recovery.
Is it covered?
Hysterectomy usually. Reconstruction often, once approved, and the approval tends to cover the whole sequence. Public systems fund it with long waits. See cost.
New to FTM surgery?
Start with the guide: every procedure, the order most people take them in, and what to expect from consultation to recovery.
start here →