Gender affirming bottom surgery is a collection of surgical procedures that are carefully designed to align a person’s physical genitalia with their deeply held gender identity. This process is a pivotal step in the journey of many transgender and non-binary individuals towards achieving a more congruent and authentic self. The specific surgical techniques employed can vary based on an individual’s unique preferences, medical requirements, and personal goals.

Vaginoplasty: This procedure is primarily performed for transgender women, also known as male-to-female (MTF) individuals. Vaginoplasty is the surgical construction of a neo-vagina. The process involves the removal of the existing genital tissue and the creation of a new vaginal canal using the patient’s own tissues. Additionally, surgeons will often craft labia and clitoral structures to provide a more natural appearance and enhanced sensation.

There are three main methods of vaginoplasty performed today:

• penile inversion

• rectosigmoid or colon graft

• non-penile inversion vaginoplasty

In all three surgery methods, the clitoris is sculpted from the head of the penis.

Phalloplasty: Phalloplasty is a surgical procedure commonly chosen by trans men, or female-to-male (FTM) individuals. It involves the creation of a neo-phallus, which can be constructed using various techniques, including tissue grafts from the patient’s arm, thigh, or other donor sites. Additionally, this surgery may involve the connection of a urinary device for urination, allowing for a more natural experience.

Metoidioplasty: During this procedure, the clitoris, which has been extended to 3-8 centimeters due to HRT, is detached from adjacent tissues and relocated to resemble the placement of a penis.

A suitable candidate for gender affirming bottom surgery is typically an adult with a clear and unwavering gender identity that is incongruent with their physical genitalia. They should have undergone a period of living in their desired gender role (Real-Life Experience) and passed a mental health evaluation to assess psychological readiness and emotional well-being. Candidates should be in good overall health, with any pre-existing medical conditions well-managed, and if using hormone therapy, it should be stable and medically supervised. Realistic expectations about surgery outcomes and a commitment to post-operative care and follow-up appointments are also key factors in determining suitability for these procedures.

The length of gender affirming bottom surgery can vary depending on the specific procedures chosen and the surgeon’s technique. Typically, these surgeries can take anywhere from 4 to 8 hours or more. The surgeon will discuss the estimated procedure length during the consultation.

Penile Inversion: This method uses penile skin to create the neovagina, with the labia crafted from scrotal tissue. It offers sensation but lacks natural lubrication. Some variations provide added depth and partial self-lubrication.

Rectosigmoid Vaginoplasty: Intestinal tissue is used to form the vaginal lining, often combined with penile inversion when tissue is limited. Ideal for transgender women who started hormones early, it offers self-lubrication and is also used for cisgender women with short vaginal canals.

Non-penile Inversion (Suporn Technique/Chonburi Flap): This technique uses perforated scrotal grafts for the vaginal lining and penile tissue for the inner labia. It promises greater depth, enhanced sensation, and improved aesthetics.

Phalloplasty: This surgery uses a skin graft, typically from the forearm, thigh, abdomen, or back, to extend the neopenis to 5-8 inches. Forearm and thigh grafts offer better sensation, while back grafts leave subtler scars. Urethral extension uses graft tissue. A later surgery can add a penile implant for full erections.

Metoidioplasty: A simpler alternative to phalloplasty, this procedure repositions the HRT-elongated clitoris to resemble a penis. Optional enhancements include urethral extension using cheek or vaginal tissue and the Centurion procedure for added girth. Vaginal removal is optional. The resulting neopenis may have limited erectile and penetrative abilities.

The standard recovery time for gender affirming bottom surgery is approximately 6 to 8 weeks. However, recovery experiences can vary from person to person, and it may take several months for individuals to fully resume normal activities. During the recovery period, patients should avoid strenuous activities, heavy lifting, and sexual intercourse as per their surgeon’s guidance. Smoking and alcohol should also be avoided, as they can impede the healing process. Patients should strictly adhere to post-operative care instructions to minimize complications.

• Immediate Post-Operative Period: After the surgery, patients will experience some immediate changes to their genitalia. It’s crucial to keep in mind that these early changes are temporary and may not accurately reflect the final aesthetic or functional outcomes.

• Swelling and Discomfort: Swelling can make it challenging to assess the results in the early days and weeks following the surgery. It’s important to understand that swelling is a natural part of the healing process, and it will subside gradually.

• Healing and Tissue Maturation: As the body heals and tissues settle, the appearance of the surgical site will continue to evolve. Over the next several weeks and months, the swelling will progressively decrease, and the genitalia will take on a more natural appearance. Tissues may also continue to mature, becoming softer and more pliable over time.

• Sensory Changes: Sensory changes, including improved tactile sensations, can develop gradually over time. It may take several months before patients experience the full range of tactile sensations in their reconstructed genitalia.

• Full Results: The full results of Gender Affirming Bottom Surgery, including the cosmetic and functional aspects, may become more evident and stabilized over the course of several months. The outcome may take up to a year or more to fully manifest.

The average cost of gender affirming bottom surgery in Canada varies based on the specific procedures chosen, the surgeon’s experience, and the geographical location of the surgery center. Costs typically range from $5,000 to $25,000+. It is essential to consult with a surgeon or clinic to obtain an accurate cost estimate.

Like any surgical procedure, Gender Affirming Bottom Surgery carries certain risks, including:

• Infection

• Poor Wound Healing

• Nerve Damage

• Urinary Complications

• Fistula Formation

• Hematomas

The decision to undergo gender affirming bottom surgery is deeply personal and varies from individual to individual. Many people find the surgery to be life-changing and affirming of their gender identity, greatly improving their quality of life:

28/33 people who have undergone MTF vaginoplasty have rated the procedure “Worth It” (85%)

4/5 people who have undergone FTM Phalloplasty have rated the procedure “Worth It” (80%)

• Source – Realself.com