Radial forearm free flap (RFFF) phalloplasty is a gender-affirming surgical procedure for creating a neophallus. This operation uses a section of skin, nerves, and blood vessels from the inner forearm, known as the radial forearm flap. Surgeons favor this technique because the forearm tissue is thin and pliable, allowing for detailed shaping. The tissue’s characteristics are well-suited for constructing a neophallus with the potential for both tactile and erogenous sensation.
The Surgical Process of Phallus Creation
The creation of the neophallus begins with harvesting the radial forearm free flap from the patient’s non-dominant arm. Surgeons map out a specific section of skin and underlying tissue on the inner forearm. This harvested flap includes the radial artery, veins, and sensory nerves like the medial and lateral antebrachial cutaneous nerves. Before surgery, the surgeon tests blood flow to the hand to ensure it will remain sufficient after the radial artery is removed.
Once harvested, the flap is shaped and tubed to form the shaft of the neophallus. A “tube-within-a-tube” technique is often used, creating two tubes from the single flap. The smaller, inner tube functions as the new urethra (urethroplasty), while the larger, outer tube forms the external body of the phallus. This design allows for the simultaneous creation of the shaft and urinary channel.
The next step is the microsurgical reattachment of the neophallus to the patient’s body. The surgeon connects the flap’s artery and veins to blood vessels in the groin, such as the femoral artery and a nearby vein. Using a high-powered microscope, these vessels are sutured together to establish blood flow, which is necessary for the tissue to survive and heal.
Finally, a procedure called nerve coaptation is performed. The sensory nerves harvested with the forearm flap are connected to existing nerves in the genital region, such as the preserved dorsal nerve of the clitoris. This nerve connection creates the potential for the neophallus to develop sensation as the nerves regenerate into the new tissue.
Staging and Additional Procedures
Phalloplasty is a series of surgeries performed in stages over two to three years or more. The sequence and number of procedures are tailored to the individual’s goals and healing. This multi-stage approach allows for recovery between major steps and manages the complexity of the reconstruction.
A vaginectomy (surgical removal of the vagina) and scrotoplasty (creation of a scrotum from labia majora tissue) are often performed. These foundational procedures can be done during the initial surgery or as a separate stage to masculinize the genital area.
After the scrotoplasty heals, testicular implants can be inserted. These are silicone or saline prostheses placed inside the scrotum to provide a typical size and appearance. This is scheduled after initial surgeries to ensure the tissue is healthy enough to hold the implants.
Glansplasty is an aesthetic procedure to create a more defined head, or glans, at the tip of the neophallus. The final surgical stage is the implantation of an erectile device. Since the neophallus cannot become erect on its own, a prosthesis—either a malleable rod or an inflatable pump system—is placed inside the shaft to allow for penetrative function.
The Recovery and Healing Timeline
The recovery from RFFF phalloplasty is a lengthy process for both the neophallus and donor arm. The immediate post-operative period involves a hospital stay of five to seven days. The medical team closely monitors the new flap, checking its color, warmth, and blood flow with a Doppler device to ensure the tissue is viable.
To allow the new urethra to heal, urine is diverted using catheters. Patients have a suprapubic catheter draining urine from the bladder via an abdominal incision, and often a Foley catheter through the neourethra. These catheters remain in place for about three weeks to ensure the urethral connection is stable before use.
Once home, the early recovery phase continues for six to eight weeks, involving activity restrictions and diligent wound care for both sites. The donor arm is covered with a skin graft, often from the thigh. Patients have weekly follow-up appointments for the first few months to monitor healing, during which the catheters are removed.
Long-term healing differs for the two surgical sites. For the donor arm, recovery focuses on the skin graft and managing the permanent scar. Physical or occupational therapy is often needed to regain wrist motion and grip strength. For the neophallus, the return of sensation is a gradual process that can take months or years as nerves regenerate, often experienced as tingling before defined touch develops.
Potential Complications and Donor Site Impact
RFFF phalloplasty carries risks and potential complications. Urethral complications are the most frequent, including a fistula (a small hole causing urine leakage) or a stricture (a narrowing from scar tissue that obstructs flow). These issues often require additional corrective surgeries to resolve.
A more serious complication is flap failure, where compromised blood supply leads to tissue death (necrosis), requiring surgical removal of the non-viable tissue. While rates of total flap loss are low, it remains a risk. General surgical risks like infection and hematoma (a collection of blood under the skin) are also present.
The donor site on the forearm also has potential long-term issues. A large and permanent scar on the forearm is an unavoidable outcome of the procedure.
Beyond scarring, there can be functional impacts on the donor arm. Some individuals experience decreased grip strength or reduced wrist mobility. Sensory changes are also possible, including permanent numbness in parts of the hand or hypersensitivity around the scar. While one review found the overall rate of donor site complications to be around 7.9%, issues like changes in strength or sensation are the most commonly reported.
Functional and Aesthetic Outcomes
One of the primary functional objectives is the ability to stand to urinate. The success of this outcome depends on the complete healing of the neourethra, free from complications like fistulas or strictures.
Sensation in the neophallus is another important outcome, aiming for both tactile (touch) and erogenous sensation. While most patients regain tactile sensation, erogenous feeling is more variable. Orgasm is typically achievable, as the nerve pathways for it are often preserved at the base of the neophallus.
Sexual function involving penetration is dependent on the successful implantation of an erectile device. A prosthetic implant is required to achieve an erection suitable for intercourse, as the neophallus cannot become rigid on its own.
Aesthetically, the results of RFFF phalloplasty can vary. The final appearance, including the size of the neophallus and scarring on the phallus and donor arm, depends on the patient’s anatomy, surgical techniques, and healing. Patient satisfaction with the cosmetic appearance is generally high, but the final look is unique to each person.