Gender affirmation surgery, previously known as sex reassignment surgery (SRS), is a series of procedures that help folks transition to their self-identified gender, and include facial, top, and bottom surgeries. These surgeries can help alleviate gender dysphoria for trans and non-binary people that choose to undergo them, but they aren’t required to validate your gender identity. In some countries, however, a trans person who wishes to change their legal gender must undergo SRS procedures, including bottom surgery.
Surgery is just one option, as not everyone who is trans or non-binary chooses to have it done. Non-surgical options include hormone therapy, voice therapy or vocal lessons, and puberty blockers.
You can opt for one or more of the above, or opt not to have any medical procedure and transition socially by changing your name and pronouns and presenting your gender identity through your clothing or hairstyle.
What’s bottom surgery?
Bottom surgery is one of many names used to refer to the plastic surgery procedures performed on the genitals to make them match in look – and in some cases perform – to match your gender identity. It can also be called gender confirmation/affirmation surgery, or gender reconstructive surgery. Having the genitalia to match your gender identity can feel liberating, as it can ease feelings of gender dysphoria and improve your sense of security particularly when having to use public toilets.
Before you make the decision, it’s advisable to seek consultation with an experienced surgeon. If possible, seek multiple consultations with as many surgeons as you can to get a better idea of all the options and recommendations. You can supplement this by talking to other folks who have gone through the surgery to get their experiences, referrals, and tips.
How should I prepare for bottom surgery?
As with any other major operation, you’ll see your surgeon before the operation. You can prepare a list of questions beforehand to clear all your doubts. Your surgeon will walk you through the procedure, pros and cons, what to expect, cost, potential risks and complications, and recovery. Take as much time as you need to decide whether or not you wish to move forward with the surgery.
If you’re a smoker (or vaper), you’ll need to stop in the weeks leading up to the operation, as nicotine can slow your recovery. Your surgeon may also request a blood test or samples.
Make sure you have adequate time off work to recover, as you won’t be able to walk or sit comfortably for at least a few weeks. For sitting comfort, you can get one of those donut butt cushions to avoid putting your sore parts in direct contact with the seat. It would be best to have someone you trust at home with you to help with tasks and bathing while you recover.
What happens in bottom surgery?
In bottom surgery, the genitalia are reconstructed to align with the identified gender. We’ll go through the basics of each type of surgery, but it is still advisable to seek professional medical advice.
The goal of trans feminine bottom surgery, or feminising genital surgery, is to reconstruct the male genitalia into female genitalia. Trans feminine bottom surgery is typically performed as a single stage procedure. There are many techniques used to perform bottom surgery, and the most common is the penile inversion vaginoplasty1, which is a single procedure.
During the vaginoplasty, your surgeon creates a vaginal vault between the rectum and urethra. Vaginal lining is created from penile skin, and the labia majora from scrotal skin. The clitoris is created from a portion of the glans. To avoid complications related to peeing, such as incontinence, your prostate will be left in place.
A stent or gauze packing is placed in the new vagina to prevent it from healing shut for about a week. Once it’s removed, your surgeon will advise you how to use a dilator, which looks like a less detailed dildo with markings.
Following the procedure, you may be kept overnight or for a few days for observation. It is advisable to avoid strenuous activity for up to six weeks, or as advised by your surgeon. A shower after the first day is generally ok – just gently pat the incision area dry. Don’t soak in a bath, though.
Some pain and swelling are to be expected while your surgical wounds heal. This can be alleviated with over-the-counter pain meds, or one prescribed by your surgeon. An ice pack can help relieve discomfort from swelling. Prop your seat with a donut cushion. Wear loose-fitting clothing for a while to let your new bottom parts breathe.
During the first 4-6 weeks post op, there may be some brownish-yellow vaginal discharge and bleeding. Washing with a gentle soap will take care of this.
Rectosigmoid vaginoplasty, aka sigmoid colon vaginoplasty, uses a section of the sigmoid colon to create the vaginal lining, resulting in self-lubricating vagina with less risk of losing depth compared to the penile inversion vaginoplasty.
Non-penile inversion is also known as the Suporn technique (after Dr. Suporn who invented it) or the Chonburi Flap. This method uses perforated scrotal tissue graft for the vaginal lining, and intact scrotal tissue for the labia majora (same as a penile inversion). The penile tissue is used for the labia minora and clitoral hood. This technique is known to result in greater vaginal depth, more sensate inner labia, and improved cosmetic appearance.
What can I do with my new genitalia?
You can pee sitting down with your new vagina. For penile inversion vaginoplasty, you’ll have to use lubrication for sex.
In trans masculine bottom surgery, male genitalia is constructed through one of two ways. In phalloplasty2,a penis and urethra are constructed using tissue from another part of your body (forearm, thigh, or side), allowing you to pee while standing. Phalloplasty is a customised process involving multiple procedures which are selected based on your desired outcome.
There are three approaches to crafting a penis in phalloplasty, depending on which part of your body you are taking tissue from. A radial forearm free flap (RFFF) involves taking the skin, fat, nerves, arteries and veins from your wrist and forearm (of your non-dominant arm) to create the penis.
There are three stages to the RFFF. In stage 1, a penis is crafted using tissue from your forearm or other part. The part where the tissue is taken from will require a skin graft. This can be done at the same time as the initial phalloplasty surgery, or 3-5 weeks afterward. If it occurs later, you will have a temporary skin covering to help the wound heal.
In stage 2, about 5-6 months later, your urethra will be lengthened to allow you to pee from your new penis. The vagina will be removed and a scrotum will be created.
In stage 3, about a year after stage 2, your surgeon will place testicle implants and an erectile device to help you achieve an erection.
This is a long process and you’ll need ample recovery time after each stage. For stage 1, you’ll be required to stay in the hospital for anything from a few days to a week. Your surgical team will monitor the blood supply to the tissue that has been used to create your new penis and ensure you are able to use the bathroom and walk around after surgery. You will also have a catheter inserted, which will be removed before you go home.
For the latter stages, hospitalisation is optional. If you decide not to have urethral lengthening as part of stage 2, you will have a Foley catheter placed in the operating room and removed before you go home. If you decide to have urethral lengthening, you will go home with a Foley catheter in the new urethra and a suprapubic tube (SPT) to allow urine to drain from your bladder. A clamp ensures that the urethra does not leak urine. The SPT will stay in for several weeks. Before it is removed, a urologist will perform a retrograde urethrogram, where dye is put in your bladder through your new urethra and tracked to make sure you can pee.
The anterolateral thigh flap (ALT) uses skin, fat, nerves, arteries and veins from the leg to create a penis. The process is similar to the RFFF.
A musculocutaneous latissimus dorsi skin flap (MLD) involves the skin, fat, nerves, arteries and veins from the side of your back to create a penis. It’s much like the RFFF, except the area from which the back tissue is taken usually does not require a skin graft and can be closed in a straight line.
A simpler and more cost-effective method compared to a phalloplasty is metoidioplasty3. In metoidioplasty, your existing genital tissue (clitoris and vaginal) is made longer, turning it into a more defined penis. The urethra can be lengthened and incorporated into the new penis.
Metoidioplasty requires that the patient undergo hormone therapy to enlarge the clitoris and achieve maximum growth (about 2-3 years). The ligaments holding the erectile tissue (clitoris) in place under the pubic bone are cut. Some of the surrounding tissue is cut, releasing the erectile tissue (clitoris) and creating a penis. Your urethra may be extended and incorporated into your penis. Fat may be removed from the pubis and skin may be pulled upward to bring your penis forward. A flap of skin is removed from the external genitals (labia or outer labia) and grafted around the penis to add bulk. The internal genital (vagina) may be removed or closed (if desired). The external genitals (major labia) may be shaped into a scrotum (if desired). Testicular implants may be put in the scrotum at a later stage (if desired).
How BIG can your new penis be? Unfortunately, we can’t just pick a girthy 9-incher from a catalogue of penises and say “That one”. How big yours ends up being depends on several factors, including the skin flap that is harvested. Thinner patients with less fat on the skin flap will have a penis with less girth. Alternatively, patients with a greater amount of fat will have a thicker penis.
Scrotum size is specific to the patient and depends on the amount of skin in the genital area before phalloplasty. The more genital tissue there is, the larger the scrotum and the testicular implants can be.
Penis function is determined by your surgical plan. If your main goal is standing to pee, then urethral lengthening may be a good choice for you. If sensation is most important, your team will focus on a donor site with good nerve innervation. If penetrative sex is most important, and you would like to maintain an erection, then implanting an erectile prosthetic can be part of your surgery plan.
