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Radial Forearm Free Flap (RFFF)

The radial forearm free flap (RFFF) is the gold standard for total phallic reconstruction and a versatile option for complex urethral reconstruction, based on the radial-artery vascular pedicle providing thin, pliable, relatively hairless, and reliably innervatable tissue.[1][2][3] Originally described by Yang in 1981 for head-and-neck reconstruction and adapted for penile reconstruction by Chang and Hwang in 1984, the RFFF has the largest published series for phalloplasty (> 100 patients) and follow-up extending beyond 20 years.[1][4][5]

This page is the foundations-level deep dive on the RFFF as a cross-application reconstructive flap. Site-specific technique pages — phalloplasty, urethroplasty, GAS feminizing/masculinizing — link back here.

Flap Anatomy and Design​

The RFFF is a fasciocutaneous free flap based on the radial artery and its venae comitantes, with additional superficial venous drainage via the cephalic vein:[6][7][8]

ComponentDetail
Arterial pedicleRadial artery — large caliber (~2.5 mm), long pedicle (up to 20 cm), consistent anatomy
Venous drainageDual system — deep (radial-artery venae comitantes) and superficial (cephalic vein). Including ≥ 2 veins is critical; fewer than 2 flap veins is the only identified predictive factor for vascular complications[9]
Sensory innervationLateral antebrachial cutaneous nerve (LABCN), medial antebrachial cutaneous nerve (MABCN), and the posterior antebrachial cutaneous nerve (PABC) — coapted to recipient nerves (dorsal nerve of clitoris / penis, ilioinguinal) for sensate reconstruction[10][11][12]
SkinThin, pliable, relatively hairless (volar surface), excellent color match for genital reconstruction. The thin subcutaneous layer enables the tube-within-a-tube design for simultaneous neourethra and neophallus construction[4][8]
BoneA segment of the radius can be included (osteocutaneous variant) for rigidity, though rarely used today given the availability of penile prostheses[13][14]

Preoperative Assessment — the Allen Test​

Adequate hand perfusion via the ulnar artery must be confirmed before harvest, since the radial artery is sacrificed:[16][17][18]

TestNotes
Clinical Allen Test (CAT)Bedside test — compress both arteries, exsanguinate, release ulnar, observe reperfusion. Sufficient (< 6 s), intermediate (6–10 s), or insufficient (> 10 s)[18]
Doppler Allen Test (DAT)Total concordance with the intraoperative Surgical Allen Test (SAT), whereas CAT has only weak concordance with DAT. Vascular abnormalities severe enough to change flap choice were found in 39% of patients by DAT[16]
Practical controversyA 237-RFFF series found no acute or chronic ischemic hand complications regardless of whether the Allen test was performed; the JAMA Otolaryngology consensus is to use CAT as a screening tool and reserve Doppler for abnormal CAT[17][18]

Application 1 — Total Phallic Reconstruction (Phalloplasty)​

The primary urologic application and the most extensively studied.

Flap design techniques​

  • Chang and Hwang (1984) — original "tube-within-a-tube" design: a de-epithelialized strip separates inner tube (neourethra, ulnar portion) from outer tube (shaft, radial portion).[4][19]
  • Gottlieb and Levine (1993) — modified design with a centrally located neourethra in continuity with a neoglans, eliminating the circumferential meatal suture line that drives meatal stenosis in the Chang-Hwang design.[4][5]
  • Spennato 2022 — direct head-to-head in 45 patients: Chang-Hwang had lower rates of urologic complications (fistulas, stenosis); Gottlieb-Levine had significantly lower rates of partial flap necrosis. Urethral fistulas were the leading cause of revision in both.[19]

Combined / modified configurations​

  • Modified tube-in-tube with combined flaps (Staud 2021) — RFFF as the inner tube (neourethra) combined with a free ALT flap as the outer tube (shaft) in 21 patients: 100% flap survival at mean 4.4 yr; urethral fistula 38%, stricture 24%.[20]
  • Single-tube phalloplasty without neourethra (Miller 2022) — for patients who do not desire standing urination, with a cosmetic neomeatal pouch; reduces urologic complications while preserving aesthetic outcomes.[21]

Largest published series — Garaffa 2010 (UCL, n = 115)​

The landmark series:[1]

  • 97% flap survival (3 total losses from venous thrombosis)
  • 97% patient satisfaction with cosmesis and size
  • 86% reported phallic sensation
  • Urethral strictures 7.8%; fistulae 17.4%
  • After revision surgery, 99% voided from the tip while standing

Outcomes by indication​

Gender-affirming surgery (FTM)​

The RFFF is considered the preferred technique for FTM phalloplasty when feasible, sitting alongside vaginoplasty in the standard reconstructive options reviewed for transgender care.[2][3][15]

StudynFlap survivalFistulaStrictureSatisfaction
Garaffa 2010[1]11597%17.4%7.8%97%
Falcone 2021[9]2596% (1 loss)———
Spennato 2022[19]45100%Leading cause of revision——
Staud 2021 (RFFF + ALT)[20]21100%38%24%—
Ascha 2018[22]149 RFFF vs. 64 ALT96.6% vs. 92.2%Lower with RFFFSimilar—

Netshiongolwe 2025 — most recent SR comparing RFFF vs. pedicled ALT in 769 patients (614 RFFF, 155 pALT):[3]

  • Flap failure: RFFF 1.9% vs. pALT 0.6% (p = 0.348)
  • Patient satisfaction: RFFF 78% vs. pALT 76.2% (NS)
  • ALT required less operative time (290 vs. 516 min)
  • Conclusion: "The RFF remains the most reliable technique for phalloplasty, with the pALT serving as a secondary option when the RFF is not feasible"

Wang 2026 offered a counterpoint — 57-patient series showed RFFF had the highest overall complication rate (80%) vs. ALT (60%) and pedicled abdominal flaps (40.9%) (p = 0.023), with significantly higher urologic complications (60%) including fistulas (48%) and strictures (44%). The authors note patients may opt for RFFF to maximize aesthetic outcomes despite higher complication risk.[23]

Penile cancer (post-penectomy)​

  • Gobbo 2025 — narrative review of post-penectomy phalloplasty (48 patients across 6 studies). RFFF and ALT are preferred techniques; RFFF offers superior tactile recovery; ALT reduces donor-site morbidity. Urethral stricture / fistula in up to 64.3%, but functional outcomes (standing micturition, sexual activity) are achievable and satisfaction remains high.[24]
  • Falcone 2016 — 10 patients with traumatic penile amputation (self-amputation, RTA, blast injury, donkey bite, Fournier's). All satisfied with size, cosmesis, and sensation at median 51 months. 6 received IPPs and engaged in penetrative sex; all with complete urethral reconstruction could void and ejaculate from the tip.[25]

Congenital penile inadequacy​

  • Spennato 2020 — 23 nontranssexual patients (DSD 34.8%, oncologic 34.8%, automutilation 8.7%, iatrogenic 8.7%, micropenis 8.7%). Total flap necrosis 8.7% (3 of 4 with any necrosis were heavy smokers). Despite high complication rates, satisfying results in experienced centers.[26]
  • Massanyi 2013 — 10 exstrophy patients with 100% graft survival; all reported protective and erogenous sensation with ability to achieve orgasm.[27]
  • Harris 2021 — pedicled ALT and RFFF phalloplasty for bladder exstrophy with comparable outcomes.[44]

Application 2 — Complex Urethral Reconstruction​

The RFFF is a salvage option for complex urethral defects when local tissue is unavailable or has failed:

  • Dabernig 2007 — 9 patients (3 post-penectomy, 6 failed GAS urethroplasty): 100% flap survival; 2 stenoses requiring revision (success 7/9 after first operation); no postoperative fistula; satisfactory uroflowmetry. RFFF is a good option "particularly when patients need extensive and long urethral reconstruction".[28]
  • Lee and Khouri 1993 — first description of RFFF for a 23 cm near-total urethral defect after trauma. Single-stage transfer enabled standing urination without strictures and maintained continence.[29]
  • Morrison 1996 — 7 patients with scarred urethras; one with hirsute forearm skin received a prefabricated hairless flap by applying a full-thickness skin graft from a non-hairy site onto the forearm fascia before flap transfer.[30]
  • Erickson 2006 — RFFF for a posterior urethral stricture with rectourethral fistula after multiple failed repairs; flap anastomosed to the inferior gluteal artery and vein, providing well-vascularized tissue outside the zone of injury.[31]

Application 3 — Combined Flap Techniques​

  • RFFF + dorsalis pedis flap (Ma 2016, n = 14) — RFFF for shaft, dorsalis pedis for glans. No urethral fistula or stenosis; high satisfaction and sensory recovery at 3–6 mo.[32]
  • RFFF + vascularized appendix (Koshima 1999) — vascularized appendix as neourethra plus RFFF osteocutaneous flap for shaft; the appendix provides natural mucosal-lined tubing with minimal stricture risk.[33]
  • Non-microsurgical RFFF (Mutaf 2001) — reverse-flow island flap technique without microvascular anastomosis: RFFF elevated as a pedicled flap, transferred as a distant flap, with pedicle division at 2–3 weeks. Enables RFFF phalloplasty in settings without microsurgical expertise.[13]

Sensory Outcomes and Nerve Coaptation​

A key advantage of the RFFF over other phalloplasty flaps:[10][11][12][34]

  • LABCN → dorsal nerve of clitoris / penis (erogenous)
  • MABCN → ilioinguinal nerve (protective)
  • PABC (posterior antebrachial cutaneous) — recently proposed as an additional / alternative nerve innervating most of the phallic shaft, where sensation is most desired[10]
StudyFinding
Ma 2011 (definitive innervation study, n = 45, mean 9.1-yr follow-up)Innervated flaps had significantly better pain, vibratory threshold, temperature, and two-point discrimination in the distal neophallus vs. non-innervated (p < 0.05)[12]
Küenzlen 2020 (multimodal sensory eval, n = 20)70% perceived ≥ 2 sensory modalities at neophallus; vibration similar between neophallus and unoperated forearm; 75% experienced orgasms at 23 months; 100% at 54 months[11]
Hu 2024 (prospective)75% regained sensation at average 73 days, with progressive improvement in pressure thresholds[34]

Penile Prosthesis Implantation​

The final stage of phalloplasty, enabling penetrative sexual function:[35][36][37][38][39]

  • Three-piece IPPs are most commonly used; cylinders are wrapped with synthetic material or allografts and bone-anchored to the pubic symphysis.[35]
  • 5-yr IPP retention 42–78% — lower than in anatomic phallus.[35]
  • Cohen 2017 — 80% functioning at last follow-up; 70% required reoperation (mean 1.4 revisions).[36]
  • Van der Sluis 2019 — 32 transgender men; 44% of all implanted prostheses (n = 45) were surgically replaced or removed; uneventful course in only 31.3%.[37]
  • Pang 2025 SR (184 AMAB patients post-phalloplasty) — complications up to 64.3% (infection ≤ 33.3%, mechanical failure ≤ 28.6%, malposition / migration ≤ 40%); explantation up to 40%; 80–100% satisfied with outcomes.[38]
  • Young 2017 — prosthesis patients scored higher in orgasmic function, intercourse satisfaction, and overall sexual satisfaction vs. phalloplasty-only patients.[39]

Donor-Site Morbidity​

The forearm is the principal disadvantage of the RFFF.

Motor function and strength​

  • Küenzlen 2022 — 20 patients: no significant difference in grip strength (36.3 kg vs. control, p = 0.629); no impairment of thumb opposition, finger ROM, or wrist mobility; pronation / supination fully preserved. Oversized RFFF harvest does not cause significant motor / strength deficits.[40]
  • Ozturk 2024 — 20 patients with DASH, POSAS, SBSES: minimal-to-no functional impairment on Quick DASH; overall scar satisfaction; worsening DASH sport / music score correlated with wound surface area (p = 0.037).[41]

Nerve morbidity​

  • Peters 2022 — 37 patients: 83.8% had minimal-mild donor-site pain (VAS 0–3); 16.2% had moderate-severe pain with significant QoL impact (sleep interference, sadness, frustration, decreased hopefulness).[42]
  • Küenzlen 2022 — superficial radial nerve irritation common: hypoesthesia 40%, neuroma 45%; dorsal ulnar nerve injury 0% hypoesthesia.[40]

Donor-site wound management​

Falcone 2023 — FTSG vs. acellular dermal matrix (Integra) + STSG for donor closure in 34 patients:[43]

  • Integra + STSG significantly better: healing time 24 vs. 30 days (p = 0.003), complete graft take 93.8% vs. 27.8% (p = 0.001), shorter operative time 310 vs. 447 min (p = 0.001), higher cosmetic satisfaction 93.8% vs. 66.7% (p = 0.048).

Comparison with Other Phalloplasty Flaps​

FeatureRFFFPedicled ALTPedicled abdominalFibular osteocutaneous
Flap typeFree (microsurgical)PedicledPedicledFree (microsurgical)
Tissue thicknessThinThick (often debulked)VariableThin–moderate
Sensory potentialExcellent (3 nerves available)Moderate (LFCN)PoorModerate
NeourethraTube-in-tube (single stage)Tube-in-tube or stagedStagedTube-in-tube
Flap survival96–100%92–99%~100%~95%
Urethral complications25–60%20–33%9–32%High
Aesthetic outcomeSuperiorGood (after debulking)AcceptableGood
Donor-site morbidityConspicuous forearm scar; nerve irritationHidden thigh scar; minimalHidden abdominal scarLeg weakness; fracture risk
Microsurgery requiredYesNoNoYes
Operative time~290–516 minShorterShortestLong
Patient satisfaction78–97%76%——

Key Takeaways​

The RFFF remains the benchmark flap for total phallic reconstruction because of its unique combination of thin pliable tissue, reliable vascular anatomy, long pedicle, and exceptional sensory reinnervation potential. Its principal applications are:

  1. Phalloplasty — gender-affirming, post-penectomy, congenital penile inadequacy[1][2][3]
  2. Complex urethral reconstruction — salvage option for extensive defects (> 10 cm) when local tissue is unavailable[28][29][30]
  3. Combined reconstructions — RFFF neourethra with ALT shaft, or RFFF with dorsalis pedis glans[20][32]

The trade-offs are well-defined: superior aesthetic and sensory outcomes come at the cost of microsurgical complexity, conspicuous donor-site scarring, and the highest urologic complication rates (fistula 17–48%, stricture 8–44%) among phalloplasty flaps.[1][23] The shift toward staged approaches, optimized nerve coaptation, and improved donor-site management (Integra) continues to refine outcomes.[5][10][43]

See Also​

References​

1. Garaffa G, Christopher NA, Ralph DJ. "Total Phallic Reconstruction in Female-to-Male Transsexuals." Eur Urol. 2010;57(4):715–722. doi:10.1016/j.eururo.2009.05.018

2. Yao A, Ingargiola MJ, Lopez CD, et al. "Total Penile Reconstruction: A Systematic Review." J Plast Reconstr Aesthet Surg. 2018;71(6):788–806. doi:10.1016/j.bjps.2018.02.002

3. Netshiongolwe T, Mitchell S, Kathiravelupillai S, et al. "Pedicled Flaps Versus Free Radial Forearm Flap for Phalloplasty in Female to Male Gender-Confirming Surgery: A Systematic Review." Ann Plast Surg. 2025. doi:10.1097/SAP.0000000000004502

4. Gottlieb LJ, Levine LA. "A New Design for the Radial Forearm Free-Flap Phallic Construction." Plast Reconstr Surg. 1993;92(2):276–283.

5. Gottlieb L, Cripps C. "An Update on Gender-Affirming Phallus Construction Using the Radial Forearm Free-Flap." Neurourol Urodyn. 2023;42(5):963–972. doi:10.1002/nau.25103

6. Médard de Chardon V, Balaguer T, Chignon-Sicard B, et al. "The Radial Forearm Free Flap: A Review of Microsurgical Options." J Plast Reconstr Aesthet Surg. 2009;62(1):5–10. doi:10.1016/j.bjps.2008.06.053

7. Mühlbauer W, Herndl E, Stock W. "The Forearm Flap." Plast Reconstr Surg. 1982;70(3):336–344. doi:10.1097/00006534-198209000-00007

8. Hentz VR, Pearl RM, Grossman JA, Wood MB, Cooney WP. "The Radial Forearm Flap: A Versatile Source of Composite Tissue." Ann Plast Surg. 1987;19(6):485–498. doi:10.1097/00000637-198712000-00001

9. Falcone M, Preto M, Timpano M, et al. "The Surgical Outcomes of Radial Artery Forearm Free-Flap Phalloplasty in Transgender Men: Single-Centre Experience and Systematic Review of the Current Literature." Int J Impot Res. 2020;33(7):737–745. doi:10.1038/s41443-021-00414-x

10. Peters BR, Richards HW, Berli JU. "Optimizing Innervation in Radial Forearm Phalloplasty: Consider the Posterior Antebrachial Cutaneous Nerve." Plast Reconstr Surg. 2023;151(1):202–206. doi:10.1097/PRS.0000000000009771

11. Küenzlen L, Nasim S, van Neerven S, et al. "Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap." J Sex Med. 2020;17(5):1012–1024. doi:10.1016/j.jsxm.2020.02.014

12. Ma S, Cheng K, Liu Y. "Sensibility Following Innervated Free Radial Forearm Flap for Penile Reconstruction." Plast Reconstr Surg. 2011;127(1):235–241. doi:10.1097/PRS.0b013e3181fad371

13. Mutaf M. "Nonmicrosurgical Use of the Radial Forearm Flap for Penile Reconstruction." Plast Reconstr Surg. 2001;107(1):80–86. doi:10.1097/00006534-200101000-00013

14. Swanson E, Boyd JB, Manktelow RT. "The Radial Forearm Flap: Reconstructive Applications and Donor-Site Defects in 35 Consecutive Patients." Plast Reconstr Surg. 1990;85(2):258–266.

15. Safer JD, Tangpricha V. "Care of Transgender Persons." N Engl J Med. 2019;381(25):2451–2460. doi:10.1056/NEJMcp1903650

16. Tousidonis M, Escobar JIS, Caicoya SO, et al. "Preoperative Doppler Ultrasonography Allen Test for Radial Forearm Free Flap in Oral Cancer Reconstruction: Implications in Clinical Practice." J Clin Med. 2021;10(15):3328. doi:10.3390/jcm10153328

17. Bula D, Opyrchał J, Walczak D, Krakowczyk Ł, Maciejewski A. "Does the Use of the Allen Test Is an Absolute Myth? A Novel Look at the Preoperative Evaluation of the Routine Procedure Before Harvesting Radial Forearm Free Flap." J Craniofac Surg. 2025;36(4):1124–1126. doi:10.1097/SCS.0000000000010979

18. Wood JW, Broussard KC, Burkey B. "Preoperative Testing for Radial Forearm Free Flaps to Reduce Donor Site Morbidity." JAMA Otolaryngol Head Neck Surg. 2013;139(2):183–186. doi:10.1001/jamaoto.2013.1357

19. Spennato S, Ederer IA, Borisov K, et al. "Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals — A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique." J Sex Med. 2022;19(4):661–668. doi:10.1016/j.jsxm.2022.01.004

20. Staud CJ, Zaussinger M, Duscher D, et al. "A Modified Microvascular 'Tube-in-Tube' Concept for Penile Construction in Female-to-Male Transsexuals: Combined Radial Forearm Free Flap With Anterolateral Thigh Flap." J Plast Reconstr Aesthet Surg. 2021;74(9):2364–2371. doi:10.1016/j.bjps.2021.01.016

21. Miller TJ, Saberski ER, Safa B, Watt AJ. "Modification of the Single-Tube Radial Forearm Phalloplasty Technique to Allow for Urinary Meatal Reconstruction: A Report of Two Cases." Microsurgery. 2022;42(7):728–731. doi:10.1002/micr.30950

22. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. "Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap Versus Radial Forearm Free Flap in Gender Confirming Surgery." J Urol. 2018;199(1):206–214. doi:10.1016/j.juro.2017.07.084

23. Wang E, Cleff B, Basta A, et al. "Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates." Microsurgery. 2026;46(1):e70154. doi:10.1002/micr.70154

24. Gobbo A, Christopher AN, di Giovanni A, et al. "Sexual and Urological Reconstruction Following Penectomy for Penile Cancer: Phalloplasty." Int J Impot Res. 2025. doi:10.1038/s41443-025-01161-z

25. Falcone M, Garaffa G, Raheem A, Christopher NA, Ralph DJ. "Total Phallic Reconstruction Using the Radial Artery Based Forearm Free Flap After Traumatic Penile Amputation." J Sex Med. 2016;13(7):1119–1124. doi:10.1016/j.jsxm.2016.05.003

26. Spennato S, Burger AE, Schlosshauer T, et al. "Microsurgical Phalloplasty in Nontranssexual Patients — Considerations After a Retrospective Single-Center Analysis of 23 Cases." Urology. 2020;141:154–161. doi:10.1016/j.urology.2020.03.038

27. Massanyi EZ, Gupta A, Goel S, et al. "Radial Forearm Free Flap Phalloplasty for Penile Inadequacy in Patients With Exstrophy." J Urol. 2013;190(4 Suppl):1577–1582. doi:10.1016/j.juro.2012.12.050

28. Dabernig J, Shelley OP, Cuccia G, Schaff J. "Urethral Reconstruction Using the Radial Forearm Free Flap: Experience in Oncologic Cases and Gender Reassignment." Eur Urol. 2007;52(2):547–553. doi:10.1016/j.eururo.2007.01.004

29. Lee GW, Khouri RK. "Reconstruction of a Near Total Male Urethral Defect With a Microvascular Free Flap." J Urol. 1993;149(6):1548–1550. doi:10.1016/s0022-5347(17)36444-3

30. Morrison WA, Webster HR, Kumta S. "Urethral Reconstruction Using the Radial Artery Forearm Free Flap: Conventional and Prefabricated." Plast Reconstr Surg. 1996;97(2):413–419. doi:10.1097/00006534-199602000-00021

31. Erickson BA, Dumanian GA, Sisco M, et al. "Rectourethral Fistula Associated With Two Short Segment Urethral Strictures in the Anterior and Posterior Urethra: Single-Stage Reconstruction Using Buccal Mucosa and a Radial Forearm Fasciocutaneous Free Flap." Urology. 2006;67(1):195–198. doi:10.1016/j.urology.2005.08.002

32. Ma S, Cheng K, Liu Y, Chen F. "A New Surgical Procedure for Penile Reconstruction by Combined Free Radial Forearm Flap and Dorsalis Pedis Flap." Urology. 2016;97:232–237. doi:10.1016/j.urology.2016.03.076

33. Koshima I, Inagawa K, Okuyama N, Moriguchi T. "Free Vascularized Appendix Transfer for Reconstruction of Penile Urethras With Severe Fibrosis." Plast Reconstr Surg. 1999;103(3):964–969. doi:10.1097/00006534-199903000-00030

34. Hu S, Oles N, Reiche E, et al. "Early Penile and Donor Site Sensory Outcomes After Innervated Radial Forearm Free Flap Phalloplasty: A Pilot Prospective Study." Microsurgery. 2024;44(6):e31228. doi:10.1002/micr.31228

35. Kocjancic E, Jaunarena JH, Schechter L, Acar Ö. "Inflatable Penile Prosthesis Implantation After Gender Affirming Phalloplasty With Radial Forearm Free Flap." Int J Impot Res. 2020;32(1):99–106. doi:10.1038/s41443-019-0153-8

36. Cohen AJ, Bhanvadia RR, Pariser JJ, et al. "Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus." Urology. 2017;105:2–5. doi:10.1016/j.urology.2017.01.016

37. van der Sluis WB, Pigot GLS, Al-Tamimi M, et al. "A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty." Urology. 2019;132:195–201. doi:10.1016/j.urology.2019.06.010

38. Pang KH, Christopher N, Ralph DJ, Lee WG. "Insertion of Erectile Device Following Phalloplasty in Individuals Assigned Male at Birth: A Systematic Review." J Sex Med. 2025. doi:10.1093/jsxmed/qdaf019

39. Young EE, Friedlander D, Lue K, et al. "Sexual Function and Quality of Life Before and After Penile Prosthesis Implantation Following Radial Forearm Flap Phalloplasty." Urology. 2017;104:204–208. doi:10.1016/j.urology.2017.01.031

40. Küenzlen L, Nasim S, Neerven SV, et al. "Multimodal Evaluation of Donor Site Morbidity in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap: A Case-Control Study." J Plast Reconstr Aesthet Surg. 2022;75(1):25–32. doi:10.1016/j.bjps.2021.05.068

41. Ozturk M, Wellenbrock S, Wiebringhaus P, et al. "Functionality and Scar Evaluation of the Donor Site in Extended Radial Forearm Flap Phalloplasty: How Affected Is the Arm in Day-to-Day Life?" J Clin Med. 2024;13(19):6004. doi:10.3390/jcm13196004

42. Peters BR, Sikora Z, Timmins BH, Berli JU. "Nerve Morbidity at the Radial Forearm Donor Site Following Gender-Affirming Phalloplasty." J Plast Reconstr Aesthet Surg. 2022;75(10):3836–3844. doi:10.1016/j.bjps.2022.06.075

43. Falcone M, Preto M, Ciclamini D, et al. "Bioengineered Dermal Matrix (Integra®) Reduces Donor Site Morbidity in Total Phallic Construction With Radial Artery Forearm Free-Flap." Int J Impot Res. 2023. doi:10.1038/s41443-023-00775-5

44. Harris TGW, Manyevitch R, Wu WJ, et al. "Pedicled Anterolateral Thigh and Radial Forearm Free Flap Phalloplasty for Penile Reconstruction in Patients With Bladder Exstrophy." J Urol. 2021;205(3):880–887. doi:10.1097/JU.0000000000001404