Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates

BACKGROUND: Phalloplasty plays an important role in female-to-male (FTM) gender affirmation surgery to create a neophallus that prioritizes aesthetic and functional outcomes. Patients have a variety of flap choices for phalloplasty, but they can often come with complications. This study aimed to evaluate the impact of flap choice on the rate of complications in phalloplasty. METHODS: This retrospective cohort study was conducted at a single institution of adult patients who underwent either phalloplasty with radial forearm (RFFF), anterolateral thigh (ALT) pedicled flaps, or pedicled abdominal flaps. Complications of urethral stricture, urethral fistula, necrosis of neophallus, infection, wound dehiscence, and flap loss were analyzed. RESULTS: A total of 57 patients underwent phalloplasty. RFFF was used in 25 (43.9%) patients, ALT flaps in 10 (17.5%) patients, and pedicled abdominal flaps in 22 (38.6%) patients. The overall complication rate was 61.4%. RFFF had the highest complication rate (80%), followed by ALT (60%) and pedicled abdominal flaps (40.9%) (p = 0.023). RFFF had the highest rate of urological complications (60%) (p = 0.013), including fistulas (48%) compared to ALT (20%) and pedicled abdominal flaps (9.1%) (p = 0.011), and urethral strictures (44%) compared to ALT (20%) and pedicled abdominal flaps (22.7%) (p = 0.24). RFFF required more reoperations (64%) compared to ALT (40%) and pedicled abdominal flaps (31.8%) (p = 0.082). On multivariate analysis, patients experiencing complications were more likely to have blood thinners (OR = 1.85, 95% CI: 1.05-3.25, p = 0.039) and less likely to undergo staged phalloplasty (OR = 0.91, 95% CI: 0.32-2.61). DISCUSSION: Flap choice for phalloplasty requires careful consideration between patients and providers. Pedicled abdominal flaps were associated with fewer complications, such as fistulas, urethral strictures, and reoperations. However, patients may opt for RFFF to maximize aesthetic outcomes despite such risks. Insight into clinical outcomes is vital to both surgeons and their patients to enhance the shared decision-making process.