Gender reassignment surgery, more commonly called gender-affirming surgery, refers to a range of procedures that reshape the body to match a person’s gender identity. There is no single operation. Instead, surgical options span chest procedures, genital reconstruction, and facial reshaping, each tailored to the individual. Here’s how the major procedures work, what recovery looks like, and what outcomes to expect.
Before Surgery: Eligibility and Preparation
Most surgical programs follow international standards that require a sustained, well-documented experience of gender incongruence before any procedure. You’ll need a mental health assessment, not to prove your identity, but to confirm you understand the effects of surgery (including its impact on fertility) and that any conditions that could complicate healing have been addressed. For genital surgeries, most guidelines recommend at least six months of hormone therapy beforehand, unless hormones aren’t desired or are medically unsafe.
One preparation step that surprises many people is hair removal. For vaginoplasty, the penile and sometimes scrotal skin that will line the new vaginal canal must be permanently cleared of hair before surgery. Hair trapped inside a closed body cavity can cause infection and debris buildup. The process typically involves electrolysis or laser treatments over many months. For phalloplasty patients who will have a new urethra constructed from forearm or thigh skin, the donor site also needs to be hair-free, because hair inside a urethra can obstruct urine flow and promote stone formation.
Feminizing Bottom Surgery: Vaginoplasty
The most common technique is penile inversion vaginoplasty, first developed in the 1950s and refined considerably since. The surgeon removes the internal erectile tissue, then inverts the penile skin and advances it into a surgically created canal between the bladder and rectum. This inverted skin becomes the lining of the new vagina. The head of the penis, with its nerve supply preserved, is reshaped into a clitoris. Scrotal skin is used to form the outer and inner labia.
Penile skin alone often doesn’t provide enough tissue to line the full depth of the vaginal canal. Surgeons routinely supplement with scrotal skin grafts, and in roughly half of cases, a layer of tissue called the tunica vaginalis (a membrane surrounding the testes) is used as additional graft material. When even more lining is needed, options include skin grafts from the groin, tissue from the peritoneum (the membrane lining the abdomen), or segments of intestinal tissue. The choice depends on available tissue and surgeon preference.
The clitoral hood and inner labia are shaped from remaining penile skin. When there isn’t enough, surgeons can fashion these structures from urethral tissue. The urethra is shortened and repositioned to allow seated urination.
Masculinizing Bottom Surgery: Two Main Options
There are two fundamentally different approaches to creating a penis, and they involve real tradeoffs in size, sensation, and complexity.
Metoidioplasty works with what testosterone has already done. Hormone therapy causes significant growth of the clitoris over time, and metoidioplasty releases this enlarged tissue from surrounding structures to create a small phallus. Because it uses the clitoris itself, erogenous sensation is preserved at very high rates and the result can become erect naturally without an implant. The procedure is typically completed in a single stage, scarring is limited to the genital area, and complication rates are lower than with phalloplasty. The tradeoff is size: the resulting phallus is often too small for standing urination to work reliably and penetrative sex may not be possible.
Phalloplasty builds a full-sized penis using a flap of skin and tissue transferred from another part of the body, most commonly the forearm. The radial forearm flap is considered the standard technique. Surgeons shape the tissue into a cylindrical form, construct a new urethra within it from a rolled tube of skin, and microsurgically connect blood vessels and nerves at the recipient site. The nerve connections can restore protective and sometimes erogenous sensation over months to years. Phalloplasty produces a result closer in size to a typical penis and usually allows standing urination, but it requires multiple surgical stages, leaves a visible scar at the donor site (typically the forearm), and needs an implanted device for erections. Urethral complications are the most common issue, with fistulas (abnormal openings) occurring in 14% to 25% of cases and narrowing of the urethra in 8% to 12%.
Top Surgery: Chest Masculinization
The most common technique is double incision mastectomy, in which the surgeon makes two horizontal cuts across the chest following the natural contour of the pectoral muscles. Breast tissue is removed through these incisions, and the nipples are detached, resized, and grafted back into a position that looks natural on a masculine chest. The larger the amount of tissue being removed, the longer the incisions.
For people with very small chests, keyhole surgery is an option. The surgeon cuts along the lower edge of the areola and removes breast tissue through that small opening, leaving minimal scarring. A third option, the buttonhole technique, preserves the nipple on a stalk of tissue so that nerve connections (and therefore sensation) remain intact. The tradeoff is that a small amount of tissue bulk stays behind, so the result may not be completely flat.
Top Surgery: Breast Augmentation
Feminizing chest surgery is a breast augmentation performed the same way it is for cisgender women. The surgeon creates a pocket either behind the breast tissue or beneath the chest muscle and places a gel or liquid-filled implant, centering it beneath each nipple. Hormone therapy typically produces some breast growth over one to three years, and many people wait to see how much development occurs before deciding whether augmentation is needed.
Facial Feminization Surgery
Facial feminization surgery (FFS) is a collection of bone and soft-tissue procedures that reshape features influenced by testosterone exposure during puberty. The specific combination varies from person to person, but common procedures include:
- Forehead and brow reshaping: Reducing the bony ridge above the eyes and recontouring the forehead to create a rounder, more oval face shape. The brow can be lifted through the same scalp incision.
- Hairline advancement: Moving the hairline forward to reduce forehead height.
- Rhinoplasty: Reshaping the nose to softer proportions.
- Jaw and chin contouring: Shaving or cutting the angle of the lower jaw to create a softer line, and reshaping the chin bone to a less prominent or more pointed profile.
- Tracheal shave: Reducing the cartilage at the front of the throat to minimize the appearance of an Adam’s apple.
These procedures can be done individually or combined into a single lengthy operation. Forehead work is often considered the single most impactful change because the brow ridge is one of the strongest visual cues of facial sex differences.
Recovery: What the First Year Looks Like
Recovery timelines vary by procedure, but vaginoplasty has the most demanding aftercare of any gender-affirming surgery. The first two weeks are the hardest. Activity is heavily restricted, swelling is significant, and pain during the healing incisions and early dilation sessions is expected. Mood changes, including increased anxiety and low mood, are common during this initial phase and not a sign that something has gone wrong.
By two weeks, the focus shifts to short walks and avoiding stairs and heavy lifting. By three months, most people return to their baseline activity level, including swimming, exercise, and sexual exploration. If significant limitations persist at three months, that’s unusual enough to warrant medical evaluation. Full nerve healing takes one to one and a half years, meaning sensation continues to improve well after the surgical sites look healed.
Dilation After Vaginoplasty
The body naturally tries to close the surgically created vaginal canal, so regular dilation with medical dilators is essential to maintain depth and width. The schedule is intensive at first: at least three times daily for the first several weeks, tapering to twice daily by three months, once daily by nine months, and once weekly after the first year. Most people dilate weekly for the rest of their life. Skipping days and trying to compensate later doesn’t work. Consistency matters more than duration of each session.
Some depth loss (one to two centimeters) in the first few months is normal. The goal during that period is to maintain current depth rather than trying to gain more.
Complications and Risks
Like all major surgeries, gender-affirming procedures carry real risks. For vaginoplasty, narrowing of the urinary opening occurs in 5% to 16% of cases, and vaginal stenosis (narrowing of the canal) in 7% to 14%. These are treatable but may require additional procedures.
Phalloplasty carries the highest complication burden, mostly related to the new urethra. Fistulas and strictures each affect a meaningful percentage of patients, and revision surgeries are common. Standing urination is achieved in 73% to 99% of cases depending on technique, but reaching that outcome sometimes takes more than one procedure.
Top surgery complications are generally less severe and less frequent, similar to those of standard breast surgery: hematoma, infection, changes in nipple sensation, and scarring.
Satisfaction and Regret
Research consistently shows high satisfaction rates with gender-affirming medical care. A study published in JAMA Pediatrics examining 220 patients who began care as adolescents found very high satisfaction and low regret with both puberty blockers and hormones. Nine individuals reported some regret, and of those, only four stopped all gender-affirming care entirely. The others continued treatment, illustrating that experiencing some regret doesn’t necessarily mean regretting the decision overall. The study’s authors noted that while regret was rare, understanding those experiences remains important.
For surgical procedures specifically, the pattern holds. Patient satisfaction with vaginoplasty and phalloplasty is high in most published data, with the primary sources of dissatisfaction being complications or aesthetic outcomes rather than regret about having surgery at all. Functional outcomes like the ability to reach orgasm, which surgeons typically assess at the six-month mark, are achievable for most vaginoplasty patients.