How do complication and revision rates compare between radial forearm, anterolateral thigh, and suprapubic phalloplasty in micropenis patients?

1. Big picture: phalloplasty complications are common and dominated by urethral problems

Systematic reviews and meta‑analyses conclude phalloplasty has a high overall complication rate — one pooled estimate reached 76.5% — and identify urethral fistula and urethral stricture/stenosis as the single most frequent problems, with reported ranges across studies of roughly 22–75% for fistula and 25–58% for stricture ^{[1] [4]}. Population datasets echo the clinical series: a California cohort found 55.3% of patients with record linkage had subsequent presentations for phalloplasty‑related complications ^[5].

2. RFFF (radial forearm free flap): higher donor‑site morbidity but reliable sensation and variable urethral rates

RFFF remains the most commonly used technique in many series and offers advantages in thin, pliable skin and potential for direct nerve coaptation, supporting tactile/erogenous recovery in several reports ^{[6] [7]}. Published series and reviews report wide ranges for urethral complications after RFFF — e.g., fistula 22–68% and overall urethral complication rates in the low‑to‑mid 30% range in comparative cohorts ^{[3] [2]}. RFFF’s conspicuous forearm donor scar and need for skin grafting increase donor‑site morbidity compared with thigh or suprapubic options ^{[4] [7]}.

3. ALT (anterolateral thigh): fewer visible donor‑site issues but sometimes more secondary procedures

ALT phalloplasty avoids an obvious forearm scar and can be performed as pedicled or free flap; it yields a thicker, bulkier neophallus that some series report requires secondary refinements. Comparative work finds overall outcomes similar to RFFF in many respects, though some single‑center data showed higher odds of urethral and other complications at 6 months for pedicled ALT versus RFFF ^{[8] [9]}. One multicenter/large‑series comparison reported urethral complication rates of 31.5% (RFFF) and 32.8% (ALT) and higher partial/total neophallus loss with ALT (7.8% vs 3.4% for RFFF) ^[2].

4. Suprapubic/pedicled abdominal phalloplasty: easier technique but worse urethral fistula rates reported

Reviews highlight suprapubic pedicled phalloplasty as technically simpler and with a hidden donor area, but with notably high urethral fistula rates — one broad review cited ~55% for suprapubic flaps — which limits its attractiveness when urethral lengthening and standing micturition are priorities ^[3]. Comparative outcome data specifically limited to micropenis populations are sparse in the provided material; aggregate reviews remain the main evidence base ^[3].

5. Micropenis indication: data limited and mixed; many series pool heterogeneous indications

Several sources state micropenis is an accepted indication for phalloplasty but note that published cohorts mix etiologies (gender‑affirming, oncologic penectomy, congenital micropenis, trauma), making direct inference to micropenis patients difficult ^{[10] [11]}. Review authors caution that complication rates vary by indication: reconstructions after exstrophy, prior surgery, or cancer can be more challenging and carry higher complication rates than primary gender‑affirming phalloplasty ^{[10] [12]}.

6. Revisions and prosthesis complications: frequent and technique‑dependent

Reoperation is common: NSQIP‑based work identified unplanned reoperation as the most common short‑term complication and linked longer operative time to major complications ^[13]. Penile prosthesis after phalloplasty has its own high complication/revision profile — one series of 130 implantations reported 53% complications and 60 revision surgeries — reminding clinicians that implant outcomes are a major driver of later reoperations ^{[14] [15]}.

7. What the sources do not settle — and what clinicians should convey to patients

Available sources do not provide a randomized head‑to‑head trial isolating micropenis patients only, nor a definitive, pooled comparison restricted specifically to micropenis‑indication phalloplasty; most large pooled estimates pool mixed indications and variable follow‑up ^{[1] [2]}. Surgeons must therefore present individualized risk estimates reflecting technique, prior surgeries, urethral plans, and implant intentions; the literature shows tradeoffs between donor‑site visibility, tactile recovery (RFFF advantage), bulk and need for refinement (ALT), and high fistula risk for suprapubic approaches ^{[7] [3] [4]}.

Sources: systematic reviews, cohort studies and narrative reviews cited above ^{[1] [4] [5] [10] [2] [8] [9] [3] [14] [13]}.