Comments on “Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates”

We read with great interest the study by Wang et al. (2026) examining the association between flap choice and postoperative complications following gender-affirming phalloplasty. The topic is timely and clinically relevant, particularly given the expanding demand for masculinizing genital reconstruction and the need for evidence to guide shared decision-making. The authors provide valuable comparative data across commonly used flap options within a single institutional practice. Several methodological and interpretative considerations, however, merit further discussion. First, while the analysis focuses on flap type, the degree of procedural heterogeneity embedded within each flap category does not appear to be fully disentangled. Differences in urethral reconstruction strategy, timing of urethroplasty, and extent of concomitant procedures are intrinsically linked to flap choice and may act as intermediates rather than independent covariates (Yeow and Tse 2022). This approach may limit the ability to attribute observed complication profiles solely to flap selection, as opposed to the broader reconstructive pathway associated with each technique. Second, the multivariable model identifies blood thinner use and staging as predictors of complications, yet the clinical interpretation of these findings warrants caution. The odds ratio for staged phalloplasty suggests a protective association, but the wide confidence intervals and overlap across flap groups raise uncertainty regarding the stability of this estimate (Bluebond-Langner and Redett 2011). Without reporting events-per-variable or model calibration metrics, it remains unclear whether the regression adequately accounts for the complexity of surgical and patient-level factors influencing postoperative risk. Third, complication burden is treated as a binary outcome, despite the marked variability in severity, management requirements, and downstream impact on patient recovery. Grouping diverse events such as fistula formation, infection, and flap necrosis into a single composite endpoint may obscure clinically meaningful distinctions (Baracaldo-Santamaría et al. 2023). This approach may limit the applicability of the findings when counseling patients about trade-offs between aesthetic priorities, functional goals, and the likelihood of specific adverse outcomes. In addition, the reported differences in hospital length of stay across flap types deserve closer scrutiny in terms of clinical translation. Length of stay is influenced not only by surgical morbidity but also by perioperative protocols, pain management strategies, and institutional pathways that may differ by reconstructive approach (Dandurand et al. 2023). Without adjustment for these factors, its role as a surrogate for surgical burden may be overestimated. Finally, while the study emphasizes complication rates, patient-centered outcomes such as functional recovery trajectories, tolerance of staged reconstruction, and alignment with individual goals are not integrated into the analytic framework. Given that flap choice in gender-affirming surgery is inherently preference-sensitive, future research may benefit from parallel evaluation of complication profiles and patient-reported priorities to better contextualize risk. Taken together, this study contributes important observational data to a limited evidence base. Further work incorporating standardized reconstructive pathways, refined risk modeling, and patient-centered outcome measures may help clarify how flap choice and surgical strategy jointly influence both safety and meaningful clinical outcomes in gender-affirming phalloplasty. Palavardhan Peddapalegani: validation, writing – original draft, writing – review and editing. Raghav Gupta: supervision, project administration, writing – original draft, writing – review and editing. Priyanka Bansal: conceptualization, methodology, writing – original draft, writing – review and editing. Pankaj Nainwal: writing – original draft, writing – review and editing. Hariharan Srinivasan: writing – original draft, writing – review and editing. All authors reviewed and approved the manuscript. During the preparation of this work the authors used Grammarly and ChatGPT in order to refine language, grammar, and style. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.