Which Surgery First?

By Nick Peplow·Founder and editor

Last reviewed 13 September 2026· How this site is researched

Most people who want more than one surgery have to do them in some order. Nobody hands you a schedule. This page is the sequence most people end up following, why it tends to go that way, and the situations where a different order makes more sense.

The typical sequence

For the majority of people who want several procedures:

1. Top surgery first
2. Hysterectomy, with or without oophorectomy, second
3. Genital surgery (vaginectomy, metoidioplasty or phalloplasty) third, often with the hysto folded into the first stage
4. Facial and body work whenever it fits, before or between the others

That is a pattern, not a rule. Plenty of people stop after step one. Plenty never want steps two or three. And some do it in a completely different order for good reasons covered below.

Why top surgery usually comes first

• It changes daily life most. Binding stops, clothes fit, being read correctly gets easier. For most people this is the highest impact per hour of surgery.
• It is the most accessible. Widely available, comparatively cheap, shortest recovery, lowest eligibility bar. Many systems require only one letter of support, and some surgeons work on informed consent alone.
• It does not depend on anything else. You do not need to be on testosterone, you do not need a hysterectomy first, and it does not affect any later surgery.
• It is a good first anaesthetic. You learn how you handle surgery and recovery with a relatively small operation before committing to something bigger. See recovery timeline.

Why hysterectomy tends to come before or with genital surgery

• It is required by many bottom surgery teams. If you want vaginectomy, you almost always need the uterus and cervix out first or at the same time. Vaginectomy is what allows urethral lengthening to be done with lower fistula risk, so the chain is hysto, then vaginectomy, then urethral lengthening.
• Some surgeons want it done separately, months before. They prefer a healed pelvis to operate in. Others combine it with the first stage of meta or phallo to save a recovery. Ask which model your team uses; see combined procedures.
• It has its own reasons. Some people want a hysto for cramping, bleeding on T, or cancer risk reduction, regardless of any genital surgery. It is a common second surgery even for people who never go further.
• Fertility closes here. If you might want biological children, fertility preservation has to happen before the ovaries come out.

Meta versus phallo and how that affects order

If you are deciding between metoidioplasty and phalloplasty, the order question looks different:

• Metoidioplasty is often a single operation, sometimes with a later stage for testicular implants. Hysto and vaginectomy are commonly done in the same session.
• Phalloplasty is always staged. Typically the flap and (sometimes) urethral lengthening first, then glansplasty and scrotoplasty, then erectile implants a year or more later. Hysto and vaginectomy are usually stage one or done beforehand. See phalloplasty for how the stages fit.
• Some people have meta first and later convert to phallo. It is possible; it is not the cheapest path.

Time on testosterone matters here. Most meta surgeons want at least a year, often two, of T for growth. That alone can put meta after top surgery on the calendar.

Facial and body procedures

These float. Facial masculinization and body masculinization do not interact with chest or genital surgery, so people slot them in wherever money and time allow. Two things to consider:

• Testosterone reshapes the face and body over the first two to three years. Many surgeons suggest waiting until those changes have settled before facial work, so you are not correcting something T would have done anyway.
• Liposuction of flanks or hips is often cheapest as an add-on to top surgery. See combined procedures.

Common exceptions

• Hysto first. If you are not on T and have heavy periods, or if the public system has a shorter wait for gynaecology than for chest surgery, hysto may come first. It also comes first for anyone whose priority is stopping periods over chest.
• Bottom surgery before top. Rare, but happens when bottom dysphoria dominates, or when a bottom surgery date comes up through a waiting list you have been on for years.
• Everything at once. A few teams offer top surgery plus hysto plus first-stage bottom in one long operation. Most do not, because of operating time and clot risk. See combined procedures.
• Waiting lists dictate. In the NHS and some Canadian and Australian pathways, you go in the order the system gives you dates, not the order you would choose.

How staging interacts with funding

• Insurance. Each procedure often needs its own approval and letters. Some plans cap the number of surgeries per year or require a gap. Doing top and hysto in the same calendar year can hit an annual out-of-pocket maximum once, which can save real money. Read insurance.
• Public systems. Usually one procedure per referral. Getting top and bottom surgery through the same pathway can mean years between them. Some people go private for top surgery precisely so they are not waiting for it while queued for bottom.
• Paying privately. Staging spreads cost, which is why most self-funded people do one thing at a time. Financing options are covered under financing.

How staging interacts with time off

Each surgery is its own block of leave. Rough totals: two to four weeks for top, two to six for hysto, four to eight for meta, eight to twelve or more for each major phallo stage. See time off work. Employers tolerate one block far more easily than three in eighteen months, which is another reason to combine where you safely can.

Whatever order you choose, write it down with dates and dependencies. Then take it to a consultation and ask the surgeon what they would change.