Radial Forearm Free Flap Phalloplasty
Radial forearm free flap (RFFF) phalloplasty is the most widely used microsurgical flap for total phallic construction in masculinizing genital gender-affirming surgery. It offers thin pliable tissue, reliable radial-artery vascular anatomy, tube-in-tube urethral construction and the potential for tactile and erogenous reinnervation. It also carries high urethral complication rates and a conspicuous forearm donor-site scar.[1][2][3][4]
For the cross-application donor-flap anatomy and non-GAS salvage uses, see Radial Forearm Free Flap. For cohort-level pathway selection, see Masculinizing Gender-Affirming Surgery.
Indications
RFFF phalloplasty is best suited for patients who prioritize phallic size, penetrative potential with a delayed prosthesis, sensory reinnervation, and standing micturition, and who accept microsurgical staging plus a visible forearm donor site.[2][3][5]
| Patient Priority | Fit for RFFF Phalloplasty |
|---|---|
| Penetrative intercourse | Strong fit after delayed erectile prosthesis |
| Standing micturition | Strong fit if urethral lengthening is included |
| Tactile / erogenous sensation | Strong fit; multiple forearm sensory nerves are available for coaptation |
| Thin, aesthetic shaft | Strong fit; forearm skin is thin and pliable |
| Avoiding visible donor-site scar | Poor fit; the forearm scar is the defining disadvantage |
| Avoiding urethral morbidity | Poor fit if tube-in-tube UL is performed |
| Avoiding microsurgery | Poor fit. Pedicled ALT or abdominal flaps can avoid microsurgery for shaft construction, but a standing-voiding plan may still require microsurgical urethral reconstruction.[25] |
The same flap is used for total phallic reconstruction in cisgender men with penile insufficiency. A retrospective single-center series of 108 patients with congenital micropenis or traumatic or surgical penile amputation (median follow-up 78.5 months) staged RFFF phalloplasty as phallic construction, glans sculpting with second-stage urethroplasty when indicated, and penile prosthesis implantation. Primary anastomotic urethroplasty was performed in 90 patients (83.4%); arterial thrombosis occurred in 4, with complete phallic loss in 2, and urethral complications occurred in 49.1%, with staged urethral reconstruction associated with urethral complications on multivariable analysis (p = 0.04).[35]
Contraindications and Caution Zones
The main preoperative questions are whether the hand can tolerate radial-artery sacrifice, whether the forearm skin is suitable for a urethral tube, and whether the patient accepts the tradeoff between aesthetics / sensation and urethral morbidity.
| Scenario | Counseling Point |
|---|---|
| Abnormal ulnar collateral circulation | Avoid radial-artery harvest or obtain vascular imaging; Doppler Allen testing is more objective than clinical Allen testing[6][7] |
| Dense forearm hair in urethral segment | Preoperative laser / electrolysis is needed to avoid intraurethral hair, stones, infection, and obstructive symptoms |
| Active smoking / nicotine use | Stop before microsurgical phalloplasty. In one series of 23 nontranssexual RFFF phalloplasties, 3 of 4 flap necroses occurred in heavy smokers, although the correlation was not statistically significant[8] |
| High BMI / thick forearm adiposity | Adjust flap width and counsel about shaft bulk / debulking |
| Diabetes, cardiovascular disease, or substantial comorbidity | Assess and optimize in multidisciplinary planning. A 2026 international Delphi panel identified diabetes and cardiovascular disease as risk factors and Charlson Comorbidity Index ≥3 as a relative phalloplasty contraindication.[48] |
| Forearm-scar intolerance | Consider pedicled ALT, abdominal, or other flap pathways |
| Standing micturition not desired | Consider shaft-only phalloplasty without UL to reduce urethral complication burden |
Historical Context
Chang and Hwang introduced the radial-forearm tube-in-tube phalloplasty concept in 1984, and Gottlieb and Levine later modified the design to improve glans / meatal configuration and vascular reliability.[2][9] Contemporary practice still revolves around these design families, with refinements in venous drainage, nerve coaptation, urethral staging, glansplasty, donor-site closure, and prosthesis anchoring.
Preoperative Planning
| Planning Domain | Practical Point |
|---|---|
| Readiness criteria | Follow WPATH SOC8 and ACOG guidance alongside local multidisciplinary eligibility criteria. SOC8 suggests considering genital surgery when an eligible adult is stable on the current treatment regimen, which may include at least 6 months of hormone therapy or longer if needed for the surgical result, unless hormones are undesired or contraindicated.[10][11] |
| Vascular assessment | Perform Allen assessment; Doppler Allen testing better approximates intraoperative findings than bedside clinical testing in many series[6][7] |
| Hair removal | Clear hair from the planned urethral strip before transfer |
| Urethral plan | Decide tube-in-tube, prelaminated urethra, staged urethral lengthening, or no UL |
| Vaginectomy / pars fixa | Coordinate gynecology and reconstructive urology for hysterectomy / BSO, vaginectomy, and fixed urethral lengthening when planned. When vaginectomy is performed, vascularized vestibular / bulbospongiosus tissue can cover the fixed-urethral suture line; in a retrospective mixed-flap phalloplasty-with-urethral-lengthening series, urethral complications occurred in 27% of 215 patients with vaginectomy versus 67% of 9 with vaginal preservation. The groups included RFFF and other flaps.[39] |
| Donor-site closure | Plan full-thickness graft, split-thickness graft with dermal matrix, or free groin flap coverage based on local expertise[12][13] |
| Prosthesis expectations | Penetrative function usually requires delayed erectile prosthesis, with higher revision risk than anatomic-penis implantation[14][15] |
Technique
Flap Design
The classic RFFF phalloplasty uses a tube-in-tube design: the inner skin tube forms the phallic urethra and the outer skin tube forms the shaft. The flap is usually harvested from the non-dominant forearm and includes radial artery, venae comitantes, superficial veins, and sensory nerves.[2][16]
| Component | Operative Role |
|---|---|
| Radial artery | Primary arterial pedicle; before permanent division, temporarily clamp the artery and confirm hand perfusion with intraoperative surgical Allen assessment and pulse oximetry.[6] |
| Venae comitantes | Deep venous drainage |
| Cephalic / basilic system | Superficial venous outflow; in a 25-patient retrospective series, fewer than two flap veins were associated with vascular complications.[17] |
| Lateral antebrachial cutaneous nerve | Supplies shaft skin; choose dorsal clitoral or another recipient nerve according to the sensory plan.[18][36] |
| Medial antebrachial cutaneous nerve | Its anterior branch supplies the urethral skin strip in mapped RFFF flaps. Dorsal-clitoral coaptation has been used, but distinguish recipient nerve from the skin territory expected to reinnervate.[18][36] |
| Posterior antebrachial cutaneous nerve | Additional / alternative shaft-sensation target in contemporary nerve planning[18] |
Chang-Hwang Versus Gottlieb-Levine
| Feature | Chang-Hwang | Gottlieb-Levine |
|---|---|---|
| Urethral / shaft relationship | De-epithelialized strip separates urethral and shaft skin | Urethral tube positioned at ulnar edge / modified neoglans continuity |
| Urethral complications | Lower in a comparative 45-patient series | Higher in that series |
| Partial flap necrosis | Higher | Lower |
| Practical interpretation | Lower observed urologic-complication rate; difference not statistically significant[19] | Lower partial-flap-necrosis rate; difference statistically significant[19] |
In a retrospective series of 45 patients (20 Chang-Hwang, 25 Gottlieb-Levine), Spennato et al. found the Chang-Hwang design associated with fewer urologic complications, while Gottlieb-Levine had a significantly lower rate of partial flap necrosis. In this 45-patient retrospective series, the lower observed urologic-complication rate did not reach statistical significance; flap design was not randomized.[19] The Chang-Hwang de-epithelialized strip between urethral and shaft segments has been described as approximately 1 cm wide, acting as a hinge that maintains blood supply as the phallic skin is wrapped around the neourethra.[32]
Recipient-Site Reconstruction
| Step | Technical Goal |
|---|---|
| Pars fixa urethra | Connect native urethra to phallus base using anterior vaginal-wall / labial tissue, BMG, or staged approaches depending on center practice |
| Flap transfer | Tunnel / inset the neophallus and connect the phallic urethra to the fixed urethra |
| Arterial anastomosis | Radial artery to common femoral, deep inferior epigastric, or another suitable recipient artery depending on approach. A 2026 mixed-flap meta-analysis associated femoral graft or arteriovenous-loop inflow with more arterial thrombosis than direct femoral or deep inferior epigastric anastomosis, but case complexity may confound these study-level comparisons.[43] |
| Venous anastomoses | Superficial and deep venous outflow to saphenous or femoral branches; in a 25-patient retrospective series, fewer than two flap veins were associated with vascular complications.[17] |
| Nerve coaptation | Coapt forearm cutaneous nerves to dorsal clitoral nerve and ilioinguinal or other recipient sensory nerves |
| Clitoral management | Usually buried at the phallus base for erogenous stimulation |
| Scrotoplasty | Labia majora flaps create the neoscrotum; implants are usually delayed |
| Donor-site closure | Resurface forearm and immobilize / protect graft site |
Two clitoral-nerve strategies have been described as alternatives: coapting one dorsal clitoral nerve to a cutaneous forearm-flap nerve, or leaving the clitoral innervation intact and burying the de-epithelialized clitoris at the phallus base with erogenous stimulation preserved through base manipulation. Coapting both clitoral nerves has been described as a risk for loss of erogenous sensation if the flap nerves fail to reinnervate; no comparative sensory outcomes have been reported for either strategy.[33]
Perfusion Modifications
ICG angiography and additional arterial inflow can be used when marginal perfusion is detected. De Wolf et al. described a bipedicled radial forearm / posterior interosseous artery perforator approach for perfusion support in selected phalloplasty flaps.[20]
Staging
RFFF phalloplasty is usually staged, and urethral lengthening may precede, accompany, or follow flap transfer. In one phalloplasty-first two-stage pathway (Big Ben), the 73-patient mixed-flap cohort included 82% RFFF[41]; 71 proceeded to second-stage urethral lengthening, with stricture in 8% and urethrocutaneous fistula in 16.4% of those 71 after at least six months of follow-up.[40]
| Stage | Operation | Timing / Notes |
|---|---|---|
| Preliminary stage | Hysterectomy / BSO, vaginectomy, pars fixa urethral lengthening, or neourethral prelamination | Sequence and interval depend on the procedure and center protocol. For full-thickness forearm-graft neourethral prelamination, a 2025 German S2k guideline describes at least six months before flap transfer.[21][44] |
| Main phalloplasty | RFFF harvest, tube-in-tube construction, microsurgical transfer, urethral anastomosis, clitoral burial, scrotoplasty | Multidisciplinary plastic surgery + reconstructive urology operation |
| Refinement stage | Glansplasty / coronoplasty, debulking, urethral revisions, scrotal refinements | Performed after flap maturation and wound stabilization |
| Prosthetic stage | Testicular implants and erectile prosthesis | A 2016 international consensus describes erectile prosthesis placement after protective sensation returns, at approximately 9–12 months after phalloplasty.[14][47] Voiding and vascular-pedicle anatomy are assessed before insertion.[45] Testicular implants may be placed separately after scrotoplasty, often at least six months later, although reported practice ranges from immediate placement to one year.[45] |
A modified Norfolk technique has been described for glansplasty: a circumferential distal flap is inverted to form the coronal ridge, then covered with a non-hairy full-thickness skin graft made 1–2 cm shorter and narrower than the donor defect, which its authors describe as helping to define the coronal sulcus and pseudoglans while avoiding the ventral area to preserve a more natural frenular contour. They also propose that full-thickness skin is more durable during later prosthesis insertion.[32]
Postoperative Care
When urethral lengthening is staged, the two temporary neourethral openings can be stented with either a 16-Fr Foley catheter or a ¼-inch Penrose drain, ends sutured together; a Penrose has been preferred as a softer, more deformable wick for skin debris and secretions from the skin-lined lumen, aiding hygiene. No comparative drainage, stricture, or infection outcomes have been reported for this choice.[34]
Immediate postoperative pathways described for RFFF phalloplasty include admission to an ICU or flap-monitoring unit, hourly clinical / Doppler checks for the first 3 days, forced-air warming of the phallus during the first 24 hours, and emergent return to the operating room when examination suggests arterial insufficiency or venous congestion.[33] Schechter and Facque describe positioning the phallus perpendicular to the body during initial flap monitoring to promote venous drainage and reduce pedicle kinking, with up to a further 48 hours of bed rest depending on flap and vascular configuration. Garcia describes about 20° elevation immediately after surgery and horizontal-to-slightly-upward support for the first 3 months after discharge to reduce swelling and support ventral and urethral healing.[33][34] One description proposes that an unsupported flap can fold the proximal pars fixa neourethra, impair its subdermal perfusion, and contribute to stricture, and that support also reduces swelling and helps glans-graft healing.[34]
For phalloplasty with urethral reconstruction, both a suprapubic tube and a transurethral catheter to gravity have been described, with cystoscopy and retrograde urethrogram at about 2–4 weeks and a voiding trial by capping the suprapubic tube, following postvoid residuals to guide removal; the suprapubic tube has been removed about 4 weeks after the transurethral catheter when residuals are low. Patients who travel for surgery have been advised to remain nearby for at least 3 weeks and to arrange local urologic follow-up.[33]
Outcomes
Flap Survival
Flap survival is the most reliable part of RFFF phalloplasty. Large series and reviews generally report total flap loss in the low single digits, while partial necrosis and wound problems remain more common.[1][17]
| Study / Review | N | Key Flap Finding |
|---|---|---|
| Monstrey 2009 | 287 | Reliable creation of a normal-appearing penis and scrotum, mostly in two stages, with a high rate of initial fistulas, a forearm scar and potential long-term urologic complications.[1] |
| Falcone 2021 single-center + SR | 25 local cases | Vascular flap complications in 20%; one complete flap loss (4%); fewer than two flap veins was the only predictor of vascular complications[17] |
| Netshiongolwe 2025 SR | Total flap loss: 428 RFFF, 154 pALT; satisfaction: 91 RFFF, 21 pALT | Total flap loss was 1.9% versus 0.6% (p = 0.457 in the full-text Results), partial loss 8.2% versus 5.8% (p = 0.348), and satisfaction 78.0% versus 76.0%. The authors favor RFFF, but the contributing studies were observational with serious selection bias and low-grade evidence; comparative superiority remains unproved.[3] |
Urethral Complications
Urethral fistula and stricture are the dominant morbidity and the main driver of revisions. The rates vary because studies mix flap designs, urethral staging, prior vaginectomy, smoking status, follow-up duration, and definitions of complication.[22][23][24]
| Study / Review | N | Urethral Signal |
|---|---|---|
| Hu 2022 meta-analysis | 1,566 transgender men | Pooled rate of urethral fistula or stenosis 48.9% across phalloplasty techniques; standing voiding 91.5%[22] |
| Veerman 2020 | 63 after UL; 27 RFFF within 55 phalloplasties | Across the mixed cohort, 46/63 (73%) required fistula or stricture revision at mean 23-month follow-up. Fistulas and strictures first appeared after a mean of approximately 3 months.[23] |
| Paganelli 2023 | 89, mixed transmasculine and cisgender phalloplasty | Urethral complications in 70.9% of free-flap and 73.5% of skin-graft urethras (p = 0.911); mean follow-up 5.5 years.[24] |
| Wang 2026 | 25 RFFF of 57 patients | Overall complications: RFFF 20/25 (80%), ALT 6/10 (60%), abdominal 9/22 (40.9%); urologic complications with RFFF 15/25 (60%). Follow-up was typically 90 days (minimum 30), and urethral construction and staging differed by flap in this single-centre retrospective series.[25] |
Standing micturition is achievable for most patients after successful construction and revision, but patients should be counseled that "standing voiding" often requires staged correction of fistula, stricture, spraying, dribbling, or meatal problems. During early neophallus healing, the 2026 EAU guideline describes suprapubic catheterization as first-line for obstruction that severely affects quality of life, recurrent UTI, or retention. It recommends against endoscopic incision or urethroplasty within six months of neophalloplasty , against more than two endoscopic incisions except for palliation , and for staged urethroplasty when a stricture of the neophallic urethra needs open repair . The guideline also describes definitive perineostomy as an option for refractory stricture or when the patient declines complex reconstruction.[42]
Sensation and Sexual Function
Nerve coaptation is one reason RFFF remains favored. In a 45-patient penile-reconstruction series using the native dorsal penile nerve as recipient, innervated flaps had better distal sensation than noninnervated flaps after mean 9.1-year follow-up; this is indirect evidence for gender-affirming dorsal-clitoral coaptation, and sensory measures vary between series.[26][27][28]
| Outcome Domain | Evidence Signal |
|---|---|
| Tactile sensation | In a multimodal study of 20 patients, 14 perceived 2 or more sensory modalities at the neophallus and 2 had none.[27] |
| Erogenous sensation | Coaptation to the dorsal clitoral nerve is intended to support erogenous sensation and orgasmic function |
| Posterior antebrachial cutaneous nerve | May innervate much of the shaft territory and should be considered during harvest planning[18] |
| Sexual health outcomes | A 2025 systematic review reported erogenous sensation in 53–100% and orgasm during masturbation in 50–93%, with heterogeneous measures and no presurgical data[28] |
Erectile Prosthesis
RFFF creates a potentially sensate phallic shaft, but penetrative rigidity usually requires a delayed erectile prosthesis. Implantation is technically demanding because the neophallus lacks corpora cavernosa. Proximal fixation at the symphysis or pubis is used; partial cylinder wrapping is an option with uncertain comparative benefit, and periosteal or bony anchoring is not universally required.[14][15][29][44]
| Prosthesis Issue | Counseling Point |
|---|---|
| Timing | Delay until flap vascularity, sensation, wound stability, and voiding are reliable |
| Device choice | Inflatable and malleable devices are both used; a nine-study meta-analysis found no significant difference in overall complications (38% vs 37%) or explantation (19% vs 13%), with imprecise estimates. Transgender-specific devices may be used by selected centers.[49] |
| Fixation | Locate and protect the neophallus vascular pedicle and urethra during cylinder placement; prior operative records and Doppler can guide incision planning. Proximal pubic or symphyseal fixation is used to resist migration, and some centers add proximal graft wrapping, although its comparative benefit is uncertain.[45] |
| Durability | Reported five-year inflatable prosthesis retention is 42–78% in flap phalloplasty, lower than in anatomic-penis implantation[14] |
| Revisions and erosion warning | Infection, erosion, malposition, migration, and mechanical failure are common enough that revision should be expected over a lifetime. Persistent discoloration or skin change over a distal cylinder tip signals impending erosion and warrants prompt surgical assessment; cylinder shortening or proximal repositioning may be required.[45] |
Donor-Site Morbidity
The donor site is the main non-urologic drawback. Function is often acceptable, but scar visibility, sensory disturbance, cold intolerance, pain, and graft aesthetics matter to patients.[12][13][30][31]
| Domain | Evidence Signal |
|---|---|
| Motor function | Grip strength, wrist mobility, finger motion, and thumb opposition are usually preserved in modern series[30] |
| Nerve morbidity | In a 20-patient donor-site study, superficial radial nerve hypoesthesia occurred in 8/20 (40%) and neuroma in 9/20 (45%).[30] |
| Daily function | DASH / QuickDASH scores often show mild or minimal impairment[31] |
| Closure innovation | In a retrospective series of 34 patients, dermal matrix plus split-thickness graft was associated with a higher proportion of patients achieving complete graft take (15/16, 93.8%, vs 5/18, 27.8%), faster healing, shorter operative time and higher cosmetic satisfaction than full-thickness grafting[12] |
| Free groin flap coverage | Can improve donor-site aesthetics / function at the cost of additional microsurgical time[13] |
Comparison With ALT and Abdominal Flaps
| Feature | RFFF | Pedicled ALT | Pedicled Abdominal |
|---|---|---|---|
| Microsurgery | Required | Usually not required | Not required |
| Tissue thickness | Thin, pliable | Often bulky; may need debulking | Variable |
| Tube-in-tube urethra | Reliable single-flap option | Feasible only in selected thin thighs; often staged or separate-flap | Usually staged / separate urethral plan |
| Sensation potential | Shaft nerve coaptation is feasible; comparative superiority is unproven.[37][38] | Sensory recovery is also reported; direct comparisons are limited. | Comparative sensory data are sparse. |
| Aesthetic shaft | Thin, pliable forearm skin | Thicker tissue may need debulking | Variable |
| Donor site | Visible forearm scar | Concealed thigh scar | Concealed abdominal scar |
| Complication profile | High urethral burden | Bulk / debulking and urethral strategy issues | Abdominal flaps had fewer urologic complications than RFFF in one retrospective series, but the groups differed in urethral construction and staging.[25] |
RFFF is often selected when the patient accepts the forearm donor site and prioritizes thin shaft tissue, a tube-in-tube urethral option, and sensory nerve coaptation. ALT is attractive when forearm scarring is unacceptable or RFFF is contraindicated.[3] Abdominal flaps may reduce microsurgical complexity and donor-site visibility and preserve tactile potential through ilioinguinal input; direct sensory comparisons with RFFF remain uncertain.[3][25][46] A free musculocutaneous latissimus dorsi flap is a further microsurgical option that gives a larger phallus and a concealed back scar but little tactile sensation; see MLD Phalloplasty.
Operative Pearls
- Plan the urethral strip first; hair-bearing skin in the urethra is a preventable lifelong problem.
- Use objective vascular testing when the Allen exam is equivocal or local protocol requires it; consider Doppler Allen testing even after a normal bedside exam. In an 87-patient oral-cancer RFFF series, 13 clinically negative tests were positive by Doppler.[6]
- Take enough venous outflow; insufficient venous drainage is a major avoidable flap-risk point.
- Counsel that standing micturition often requires revisions even when the flap survives perfectly.
- Delay erectile prosthesis until the flap, urethra, and perineal wounds have fully declared themselves.
- Coordinate urology, plastic surgery, and gynecology sequencing before committing to one-stage versus staged UL.
Videos
References
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