Depending on the type of constructed wetlands, the wastewater passes through a gravel and more rarely sand medium on which plants are rooted. A gravel medium (generally limestone or volcanic rock lavastone) can be used as well (the use of lavastone will allow for a surface reduction of about 20% over limestone) is mainly deployed in horizontal flow systems though it does not work as efficiently as sand (but sand will clog more readily).
Constructed subsurface flow wetlands are meant as secondary treatment systems which means that the effluent needs to first pass a primary treatment which effectively removes solids. Such a primary treatment can consist of sand and grit removal, grease trap, compost filter, septic tank, Imhoff tank, anaerobic baffled reactor or upflow anaerobic sludge blanket  (UASB) reactor. The following treatment is based on different biological and physical processes like filtration, adsorption or nitrification. Most important is the biological filtration through a biofilm of aerobic or facultative bacteria. Coarse sand in the filter bed provides a surfaces for microbial growth and supports the adsorption and filtration processes. For those microorganisms the oxygen supply needs to be sufficient.
Especially in warm and dry climates the effects of evapotranspiration and precipitation are significant. In cases of water loss, a vertical flow constructed wetland is preferable to a horizontal because of an unsaturated upper layer and a shorter retention time, although vertical flow systems are more dependent on an external energy source. Evapotranspiration (as is rainfall) is taken into account in designing a horizontal flow system.
The effluent can have a yellowish or brownish colour if domestic wastewater or blackwater is treated. Treated greywater usually does not tend to have a colour. Concerning pathogen levels, treated greywater meets the standards of pathogen levels for safe discharge to surface water. Treated domestic wastewater might need a tertiary treatment, depending on the intended reuse application.
Plantings of reedbeds are popular in European constructed subsurface flow wetlands, although at least twenty other plant species are usable. Many fast growing timer plants can be used, as well for example as Musa spp., Juncus spp., cattails (Typha spp.) and sedges.