MTF bottom surgery, also called vaginoplasty, reconstructs the genitalia by repurposing existing tissue to create a vulva, clitoris, and typically a vaginal canal. Several techniques exist, but they all follow the same core principle: the nerves, skin, and mucosal tissue already present are carefully dissected, reshaped, and repositioned into female-typical anatomy. The most common approach, penile inversion vaginoplasty, has been refined over decades and produces functional results with relatively low complication rates.
Penile Inversion Vaginoplasty
This is the most widely performed technique. The surgeon begins by degloving the penis, separating the skin from the deeper structures to create a tube of skin that will eventually line the vaginal canal. The erectile tissue (the corpora) is removed, while the nerves and blood vessels that run along the top of the shaft are carefully preserved. These nerve bundles are critical for sexual sensation afterward.
The testicles are removed, and the scrotal skin is harvested as a graft. The surgeon meticulously cleans this graft, removing fatty tissue and cauterizing hair follicles so hair won’t grow inside the canal. This scrotal skin is then shaped into a tube over a dilator. If the person was circumcised or simply doesn’t have enough penile and scrotal skin to achieve adequate depth (surgeons generally aim for around 12 cm or 5 inches), additional grafts can be taken from the hip, lower abdomen, or inner thigh.
To create the vaginal space, the surgeon dissects a canal between the rectum and the urethra, the same anatomical location where the vagina sits in cisgender women. This dissection is done carefully using a combination of sharp instruments and dilators to open the space between the pelvic floor muscles. The skin tube is then placed into this canal to line it.
How the Clitoris Is Created
A small flap of tissue, roughly 2 by 0.5 cm, is taken from the head of the penis (the glans). The glans is densely packed with sensory nerve endings, and the dorsal nerve bundle that runs along the top of the shaft is preserved and kept attached to this tissue. Because nerve density is highest along the top of the shaft and minimal along the underside, surgeons make their incisions ventrally (along the bottom) to avoid cutting through the most nerve-rich areas. The preserved nerve bundle is carefully monitored throughout the procedure to prevent kinking or compression.
A separate piece of penile skin, about 2 by 3 cm, is kept attached to the edge of this clitoral tissue and used to form the inner lining of the clitoral hood. The result is a clitoris positioned anatomically where you’d expect it, with intact nerve supply for erogenous sensation.
Reshaping the Urethra and Vulva
The native urethra is shortened and split open (spatulated) at its new end, then fixed into position at the base of the vestibule between the clitoris and the vaginal opening. This mimics the typical female urinary anatomy and allows a downward-directed stream. Spatulating the urethra also reduces the risk of urinary retention and narrowing at the opening.
The labia majora are sculpted from scrotal skin, while the labia minora are formed from penile skin. The prostate is left in place during the procedure, since removing it would risk incontinence and urethral complications.
Zero-Depth Vulvoplasty
Not everyone wants or needs a vaginal canal. Vulvoplasty creates the external anatomy (clitoris, labia, urethral opening) without constructing an internal canal. The surgical steps for the outer structures are largely the same, but because no skin is needed to line a vaginal canal, all available penile skin goes toward building fuller, more detailed labia minora. Recovery is generally shorter, and the procedure eliminates the need for long-term dilation. This option suits people who don’t plan on receptive penetrative sex or who have health conditions that make a longer surgery risky.
Peritoneal and Bowel-Based Techniques
For patients who lack sufficient skin for a standard penile inversion, or who want to avoid some of its limitations, surgeons can line the vaginal canal with tissue from inside the abdomen instead.
In peritoneal pull-through vaginoplasty, a rectangular sheet of the peritoneum (the thin membrane lining the abdominal cavity) is harvested and rolled into a pouch over a dilator. The peritoneum has a mucosal surface similar to natural vaginal lining. It’s smooth, moist, and capable of absorption and secretion, which gives it a degree of self-lubrication that skin grafts lack. The tissue is abundantly available and the donor site heals well. Unlike bowel-based approaches, this technique carries no risk of complications from reconnecting intestinal segments.
Sigmoid colon vaginoplasty uses a 12 to 15 cm segment of the lower colon, performed laparoscopically alongside a colorectal surgeon. The segment is detached with its blood supply intact, brought down through the vaginal space, and connected to the external opening. This approach is more commonly used as a revision after a previous vaginoplasty has failed or resulted in significant narrowing, though some centers offer it as a primary procedure for patients with a phallus length under about 11.4 cm, where skin-based techniques would likely fall short on depth.
Requirements Before Surgery
Current standards of care call for a single assessment from a qualified professional confirming that the person meets criteria for surgery. For adults, a minimum of 6 months of hormone therapy is recommended before any procedure involving removal of the gonads, unless hormones are medically contraindicated or not desired. Some surgical results depend on hormonal changes to tissue (skin softening, for instance), so surgeons may require a longer period to achieve the best outcome. For adolescents, the recommended minimum is 12 months of hormone therapy.
Recovery and Dilation
Hospital stays typically last several days. For the first weeks, activity is significantly limited. Most surgical centers instruct patients to keep walking under 2,000 steps per day until wounds are fully healed, because overactivity can cause wound separation at the vaginal opening and compromise both function and appearance.
Returning to work and baseline daily activities generally happens around two to three months. If significant limitations persist past three months, that’s considered atypical and worth a medical evaluation. Gentle sensory exploration of the surgical area can begin within the first four weeks, with more active self-stimulation at eight weeks and full sexual activity at twelve weeks.
Dilation is the defining feature of recovery after full-depth vaginoplasty. The body treats the new vaginal canal as a wound and will try to close it, so patients must insert medical dilators on a regular schedule to maintain depth and width. The frequency is highest in the early months and gradually decreases over the first year, though some level of ongoing dilation or regular penetrative activity remains necessary long-term. This is the single biggest commitment of the recovery process, and it’s the main reason some patients opt for zero-depth vulvoplasty instead.
Complication Rates
A systematic review and meta-analysis of vaginoplasty outcomes found that the most common complication is narrowing (stenosis) of the vaginal canal, occurring in about 14% of patients. This is often manageable with consistent dilation or minor revision procedures. Other complications are less frequent: vaginal or rectal fistulas (abnormal connections between internal structures) occur in roughly 2% of cases, tissue prolapse in about 4%, and tissue death (necrosis) in around 1%. The same review concluded that multiple techniques demonstrate safe and reliable results, with significant improvement in patients’ quality of life across the board.