Phalloplasty Results: Key Outcomes and Surgical Insights

Phalloplasty produces high rates of patient satisfaction, with about nine in ten patients reporting a satisfactory outcome overall, but the path to that endpoint involves significant complication rates and often multiple revision surgeries. The procedure has evolved substantially over the past three decades, and different flap types, staging approaches, and reconstructive techniques each carry distinct trade-offs in sensation, aesthetics, urinary function, and sexual outcomes. Understanding these trade-offs is essential for anyone considering or recovering from the surgery.

How Flap Choice Shapes Results

The radial forearm free flap remains the most commonly performed technique and is widely considered the reference standard, largely because the thin, pliable forearm skin produces good cosmetic results and the flap’s nerve anatomy supports tactile and erogenous sensation after reinnervation. The anterolateral thigh flap is the main alternative, drawing tissue from the outer thigh instead of the forearm. A study of over 400 patients found that secondary procedures on the penis were needed far more often with the thigh flap (about 45%) than the forearm flap (about 15%), and donor-site revisions were also more frequent with the thigh flap. On the other hand, the forearm flap had higher early fistula rates (roughly 32% versus 15%). Rates of fistulas needing surgical repair, strictures, and prosthesis-related complications did not differ significantly between the two, and patient-reported outcome measures showed no statistical difference either.¹

When it comes to sensory outcomes between these two flaps, an Iranian cohort found no significant differences in quality of life, touch sensation, temperature sensation, phallus shape, or sexual pleasure for patients and partners. One interesting exception was that the thigh-flap group reported higher rates of orgasm.² However, an earlier comparative study found that sensitivity in the forearm flap was clearly superior and described the thigh flap’s sensation as “markedly inferior,” recommending it mainly when free flaps are contraindicated.³ The disagreement likely reflects differences in surgical technique, nerve coaptation methods, and follow-up length between centers.

A third option, the latissimus dorsi flap taken from the back, offers reliable tissue volume and length without leaving a visible forearm scar. Its main drawback is poorer sensation. A review of 30 years of experience with this flap found that with reinnervation, the muscle can achieve enough contraction to potentially support rigidity without an implant, which is unique among phalloplasty techniques.⁴ Still, most surgeons consider it a secondary choice for gender-affirming surgery because the sensory trade-off is considerable.⁵

Single-Stage Versus Multi-Stage Approaches

Phalloplasty can be performed in one operation or broken into two or more stages. Intuitively, spreading the work across multiple surgeries might seem safer, but the data tells a more complicated story. A systematic review comparing the two approaches found that patients who underwent two-stage phalloplasty actually had higher rates of partial or total flap loss (about 5.9% versus 1.3%) and fistulas (roughly 21% versus 16%) compared with those who had everything done in a single stage.⁶ This may reflect the additional tissue handling and blood-supply disruption that comes with re-operating on the same area. That said, many surgeons still prefer staging certain elements, particularly urethral lengthening and implant placement, to let tissues heal between steps and reduce the risk of cascading complications.

Urethral Reconstruction and Its Challenges

Building a functional urethra through the neophallus is consistently the most complication-prone aspect of the entire procedure. A meta-analysis covering transgender men found that the pooled rate of urethral fistula or narrowing was nearly 49% across all patients studied.⁷ Another study looking at both cisgender and transgender patients who underwent phalloplasty found urethral complication rates above 70% regardless of how the urethra was built or the patient’s reason for surgery.⁸ These numbers are sobering, but it helps to understand that many fistulas and strictures are small and treatable, and the meta-analysis found that over 91% of patients were ultimately able to urinate while standing.⁷

When strictures or fistulas do require repair, staged approaches to urethroplasty tend to have lower recurrence rates than one-stage fixes, particularly for long or complex strictures. Success rates for staged repairs ranged from 75% to 100% in available studies. However, recurrence rates after urethroplasty were notably higher when the original surgery was phalloplasty compared to metoidioplasty, reflecting the greater technical complexity involved.⁹

The urethral complication rate also varies by patient population. Transgender men had an overall urethral complication rate of about 39% compared with roughly 25% in cisgender men undergoing phalloplasty for other reasons, though flap complication rates were similar between the groups.¹⁰ The difference likely relates to the longer urethral segment needed in gender-affirming cases and the additional tissue junctions involved.

How Sensation Develops After Surgery

Nerve recovery is one of the most common questions people have about phalloplasty, and the answer is genuinely encouraging even if the timeline is long. In the radial forearm technique, surgeons typically connect the nerves of the clitoris and the groin area to the nerves that originally served the forearm skin. The goal is to create two kinds of sensation: tactile (feeling touch and pressure) and erogenous (sexually pleasurable feeling).¹¹

A study measuring both objective and self-reported sensitivity found that over 92% of participants experienced some degree of tactile sensitivity in their neophallus, and about 89% reported erogenous sensation, at a median follow-up of just under two years. Objective testing showed that the base of the neophallus was more sensitive than the tip, and measured sensitivity improved significantly with longer follow-up, suggesting nerves continue regenerating well beyond the first year.¹² One quirk in the data was that how sensitive patients said they felt did not closely correlate with how sensitive objective instruments measured them to be. People who tested poorly on monofilament testing sometimes reported strong subjective sensation, and vice versa. This disconnect hints that erogenous sensation may involve neural pathways and psychological factors that simple pressure testing does not capture.

Researchers have also been refining nerve coaptation choices based on axon counts. By matching donor and recipient nerves with favorable axon ratios, surgeons can potentially optimize how many nerve fibers successfully regenerate across the repair site.¹³ Some centers are also incorporating postoperative nerve re-education protocols, structured programs of graduated sensory exercises designed to help the brain reinterpret signals from the transplanted tissue.¹¹

Erectile Implants and Their Complication Profile

Because the neophallus lacks the natural erectile tissue of a natal penis, a prosthetic implant is needed for penetrative intercourse. Both inflatable and semi-rigid (malleable) devices are used, and implant placement is typically delayed until the phalloplasty has fully healed, often a year or more after the initial surgery. A meta-analysis found overall complication rates of about 38% for inflatable implants and 37% for malleable ones, with no statistically significant difference between the two types. Explantation (removal of the device) occurred in roughly 19% of inflatable and 13% of malleable cases.¹⁴

The types of complications differ slightly by device. Infection was the leading problem with inflatable implants (about 15%), followed by device dysfunction (about 13%). For malleable implants, dislocation was most common (about 15%), followed by infection (about 11%).¹⁴ A retrospective cohort analysis found that late complications including dysfunction, malposition, and erosion affected over half of patients with either device type. Patients who needed a secondary implant (replacing a failed device) had 3.5 times the odds of complications compared to those receiving their first implant, and those who had undergone urethral lengthening also faced a higher risk of late complications.¹⁵

Looking at the very long term, a study of gender-affirming penile prostheses found that mechanical failure occurred in about 30% of one manufacturer’s devices and 12% of another’s. The 15-year cumulative incidence of mechanical failure was around 31%, while the overall revision incidence reached 65%.¹⁶ These numbers mean that most patients with implants should expect at least one revision surgery over the lifetime of the device. This is not unique to phalloplasty patients; prosthetic devices placed in any surgical context have finite lifespans, but it is an important expectation to set early.

Sexual Function and Orgasm

A systematic review of sexual health outcomes found that the ability to orgasm ranged widely across studies: 50% to 93% during masturbation, 58% to 75% during intercourse with a partner, and 29% to 100% when asked about orgasm in general terms. The ability to engage in penetrative intercourse ranged from 19% to 100%, and that range included patients who had not yet received penile implants.¹⁷ The wide ranges partly reflect differences in follow-up timing, implant status, and how individual studies defined their outcome measures. What stands out is that most patients do experience orgasm after phalloplasty, and the pathway to orgasm often involves stimulation of the buried clitoris at the base of the neophallus, which retains its original nerve supply even while new nerve connections develop in the transplanted tissue.

Aesthetic Refinements

The appearance of the neophallus matters deeply to patients, and glans reconstruction (creating a realistic-appearing head) is a common refinement procedure. A comparative study of two coronaplasty techniques found meaningful differences in lasting cosmetic results. At one year after surgery, 80% of patients who received a newer tissue-sculpting technique rated their results as acceptable, compared to only 40% in the group that received the standard Norfolk method. Independent assessors rated 90% of the newer technique’s results as acceptable versus 55% for the Norfolk group.¹⁸ The decline in satisfaction over time in the older technique reflects a known challenge: sculpted tissue tends to flatten and lose definition as it heals, so techniques that create more durable structural contours perform better in the long run.

What Happens to the Donor Site

For radial forearm phalloplasty, the forearm where tissue is harvested is a source of real concern for patients. The good news is that long-term follow-up consistently shows minimal functional impact. A study with a median follow-up of seven years found no limitations on daily activities, a pain-free scar, and unaffected bone health. Over three-quarters of patients were satisfied or neutral about the scar’s appearance.¹⁹ A more recent study of 20 patients using standardized disability scores confirmed minimal to no functional impairment in everyday tasks, with generally positive scar satisfaction.²⁰

Surgeons have explored different wound-closure materials for the forearm donor site, including dermal regeneration matrices and traditional skin grafts. A small comparative study found no statistically significant differences in disability scores or patient-reported scar quality between these methods, though a blinded clinician’s assessment suggested dermal matrices may produce slightly better-looking results, and biodegradable matrices tended to leave less volume loss in the forearm.²¹ The sample sizes are still too small to draw firm conclusions, but the trend toward newer closure techniques is promising for minimizing the visible footprint of surgery.

Preoperative Hair Removal

One practical step that receives less attention than it deserves is depilation of the donor skin before surgery. When hair-bearing skin is used to construct the urethra, hair can grow inside the urinary channel and cause blockages, infections, or stone formation.²² Preoperative laser hair removal significantly reduces hair density on the donor site. A study found that an average of six laser sessions achieved a meaningful reduction, with hair density scores dropping by about one grade on a standard scale.²³ Most surgical centers now require or strongly recommend completing a course of laser or electrolysis treatments before phalloplasty, which adds months to the preoperative timeline but reduces the risk of intraurethral hair-related complications after surgery.

Vascular Complications and Flap Salvage

Because radial forearm phalloplasty involves microsurgical reconnection of blood vessels, vascular problems can threaten the flap in the early postoperative period. These are relatively uncommon but require urgent intervention when they occur. Case reports illustrate the range of salvage techniques available. In one case, a patient developed ischemia of the neophallus three weeks after surgery. The surgical team performed a thrombectomy and infused a clot-dissolving agent directly into the flap’s blood supply, successfully restoring circulation and preserving the flap with intact sensation at six months.²⁴ In another instance, impaired venous drainage on the first postoperative day was rescued by creating a small connection between an artery and a vein at the tip of the flap, converting a sluggish blood flow pattern into a higher-flow system that kept the tissue alive.²⁵ These cases are reassuring in that total flap loss, while devastating, is not inevitable even when vascular compromise occurs, provided it is caught and treated quickly.

Quality of Life and Psychological Outcomes

Across the complication statistics and revision rates, it is easy to lose sight of why people pursue this surgery. A study of quality of life after gender-affirming surgery in trans men found significant improvements in self-image, social life, and dating life. Patients also reported less difficulty with employment. Among those who had experienced psychiatric conditions before surgery, self-reported rates of depression, anxiety, substance use, suicidal thoughts, panic disorder, social phobia, and obsessive-compulsive symptoms all improved significantly afterward.²⁶ These findings align with the broader literature on gender-affirming surgery showing that congruence between body and identity is a powerful predictor of psychological well-being. The meta-analysis figure of roughly 90% patient-reported satisfaction captures a real pattern: even patients who experience complications tend to report that the surgery was worthwhile.⁷

Urinary Outcomes After Complication Repair

For patients who do develop urethral strictures or fistulas, the repair process adds another layer of surgical recovery. A study specifically looking at patient-reported outcomes after one-stage reconstruction for phalloplasty-related strictures and fistulas found that patients generally rated their overall urinary satisfaction highly after repair, with mean satisfaction scores of about 8.6 out of 10.²⁷ Lower urinary tract symptom scores indicated relatively mild residual bother. In other words, while the road to a stable, functional urethra is often bumpy, most patients eventually arrive at a result they are comfortable with. The key is going in with realistic expectations about the likelihood of revision procedures and the patience required for a process that can stretch over two or more years from the initial surgery to final stability.