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Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates.

Ellen Wang¹, Bennett Cleff¹, Anthony Basta¹

¹Division of Plastic and Reconstructive Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA.

|January 6, 2026

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Pedicled abdominal flaps in phalloplasty had fewer complications than radial forearm (RFFF) or anterolateral thigh (ALT) flaps. Careful flap selection is crucial for female-to-male (FTM) gender affirmation surgery outcomes.

Area of Science:

Reconstructive surgery
Gender affirmation surgery
Urology

Background:

Phalloplasty is key in female-to-male (FTM) gender affirmation surgery, aiming for aesthetic and functional neophallus creation.
Various flap options exist, but complications are a concern.
This study evaluates how flap choice impacts phalloplasty complication rates.

Purpose of the Study:

To compare complication rates associated with different flap choices in phalloplasty.
To identify specific complications linked to radial forearm (RFFF), anterolateral thigh (ALT), and pedicled abdominal flaps.
To inform shared decision-making between surgeons and patients regarding flap selection.

Main Methods:

Retrospective cohort study at a single institution.

Keywords:

female to male free flap gender affirming surgery phalloplasty plastic surgery urethroplasty

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Included adult patients undergoing phalloplasty using RFFF, ALT, or pedicled abdominal flaps.

Analyzed complications including urethral stricture, fistula, necrosis, infection, dehiscence, and flap loss.

Main Results:

Overall complication rate was 61.4%.
RFFF had the highest complication rate (80%), followed by ALT (60%) and pedicled abdominal flaps (40.9%).
RFFF showed significantly higher rates of urological complications (fistulas, strictures) and reoperations compared to other flaps.

Conclusions:

Pedicled abdominal flaps are associated with fewer phalloplasty complications, including fistulas, urethral strictures, and reoperations.
RFFF may be chosen for aesthetic reasons despite higher risks, highlighting the need for careful patient-provider discussion.
Understanding clinical outcomes is vital for optimizing shared decision-making in phalloplasty.