Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature

Abstract

Radial artery forearm free-flap (RAFFF) phalloplasty is considered by most authors as the gold-standard technique for genital gender-affirming surgery (GGAS). RAFFF surgical complications have rarely been investigated, and the aim of this study and literature review is to analyse and focus on the surgical technique and its postoperative vascular complications. From May 2016 to January 2020, a consecutive series of 25 transgender men who underwent GGAS were enrolled in the present study. Age, BMI and smoking habits were recorded for all patients. Overall, vascular flap complications occurred in 20% of cases. Complete flap loss due to acute arterial thrombosis was recorded in a single case (4%). In 8% of cases, limited ventro-proximal arterial ischaemia was detected, while in the remaining 8% of cases, venous ventral ischaemia was reported. These results were compared with the current literature results. Indeed, from our analysis, the number of flap veins (<2) was the only predictive factor for vascular complications. In conclusion, RAFFF represents a reliable option for total phallic construction, leading to satisfactory results in terms of flap survival. To optimize the surgical outcomes, venous vascular drainage should be recommended.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Steps of total phallic construction.
Fig. 2: Steps of total phallic costruction.
Fig. 3: Vascular complications.

Similar content being viewed by others

References

  1. Rieger UM, Majenka P, Wirthmann A, Sohn M, Bozkurt A, Djedovic G. Comparative study of the free microvascular groin flap: optimizing the donor site after free radial forearm flap phalloplasty. Urology. 2016;95:192–6.

    Article  Google Scholar 

  2. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510–8.

    Article  CAS  Google Scholar 

  3. Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty: a review of techniques and outcomes. Plast Reconstr Surg. 2016;138:594–615.

    Article  CAS  Google Scholar 

  4. Hage JJ, Bouman FG, de Graaf FH, Bloem JJ. Construction of the neophallus in female-to-male transsexuals: The Amsterdam experience. J Urol. 1993;149:1463–8.

    Article  CAS  Google Scholar 

  5. Hage JJ, Bloem JJ. Review of the literature on construction of a neourethra in female-to-male transsexuals. Ann Plast Surg. 1993;30:278–86.

    Article  CAS  Google Scholar 

  6. Song C, Wong M, Wong CH, Ong YS. Modifications of the radial forearm flap phalloplasty for female-to-male gender reassignment. J Reconstr Microsurg. 2011;27:115–20.

    Article  Google Scholar 

  7. Rashid M, Tamimy MS. Phalloplasty: the dream and the reality. Indian J Plast Surg. 2013;46:283–93.

    Article  Google Scholar 

  8. Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: a systematic review. Turk J Urol. 2017;43:229–36.

    Article  Google Scholar 

  9. Van Caenegem E, Verhaeghe E, Taes Y, Wierckx K, Toye K, Goemaere S, et al. Long-term evaluation of donor-site morbidity after radial forearm flap phalloplasty for transsexual men. J Sex Med. 2013;10:1644–51.

    Article  Google Scholar 

  10. Monstrey S, Hoebeke P, Dont M, Selvaggi G, Hamdi M, Van Landuyt K, et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005;28:206–12.

    Article  Google Scholar 

  11. Wirthmann AE, Majenka P, Kaufmann MC, Wellenbrock SV, Kasper L, Hüttinger S, et al. Phalloplasty in female-to-male transsexuals by Gottlieb and Levine’s free radial forearm flap technique—a long-term single-center experience over more than two decades. J Reconstr Microsurg. 2018;34:235–41.

    Article  Google Scholar 

  12. Selvaggi G, Monstrey S, Hoebeke P, Ceulemans P, Van Landuyt K, Hamdi M, et al. Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder. Plast Reconstr Surg. 2006;118:1171–7. Oct.

    Article  CAS  Google Scholar 

  13. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery inthe female-to-male transsexual. Semin Plast Surg. 2011;25:229–44.

    Article  Google Scholar 

  14. Doornaert M, Hoebeke P, Ceulemans P, T’Sjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: an update. Handchir Mikrochir Plast Chir. 2011;43:208–14.

    Article  CAS  Google Scholar 

  15. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57:715–22.

    Article  Google Scholar 

  16. Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 2008;101:1297–300.

    Article  Google Scholar 

  17. Selvaggi G, Dhejne C, Landen M, Elander A. The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Adv Urol. 2012;2012:581712.

    Article  Google Scholar 

  18. Chang LD, Buncke G, Slezak S, Buncke HJ. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12:467–74.

    Article  CAS  Google Scholar 

  19. Müller-Richter UD, Driemel O, Mörtl M, Schwarz S, Zorger N, Wagener H, et al. The value of Allen’s test in harvesting a radial forearm flap: correlation of ex-vivo angiography and histopathological findings. Int J Oral Maxillofac Surg. 2008;37:672–4.

    Article  Google Scholar 

  20. Hage JJ, de Graaf FH, Bouman FG, Bloem JJ. Sculpturing the glans in phalloplasty. Plast Reconstr Surg. 1993;92:157–61. Discussion 162.

    Article  CAS  Google Scholar 

  21. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1.

    Article  Google Scholar 

  22. Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg. 1982;9:21–6.

    Article  CAS  Google Scholar 

  23. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–8.

    Article  CAS  Google Scholar 

  24. Gilbert DA, Schlossberg SM, Jordan GH. Ulnar forearm phallic reconstruction and penile reconstruction. Microsurgery. 1995;16:314–21.

    Article  CAS  Google Scholar 

  25. Dabernig J, Shelley OP, Cuccia G, Schaff J. Urethral reconstruction using the forearm free flap: experience in oncologic cases and gender reassignment. Eur Urol. 2007;52:547–54.

    Article  Google Scholar 

  26. Gottlieb LJ, Levine LA. A new design for the radial forearm freeflap phallic construction. Plast Reconstr Surg. 1993;92:276. Discussion 284.

    Article  CAS  Google Scholar 

  27. Cheng KX, Hwang WY, Eid AE, Wang SL, Chang TS, Fu KD. Analysis of 136 cases of reconstructed penis using various methods. Plast Reconstr Surg. 1995;95:1070–80. Discussion 1081–4.

  28. Hage JJ, Bloem JJ, Suliman HM. Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol. 1993;150:1093–8.

    Article  CAS  Google Scholar 

  29. De Wolf E, Claes K, Sommeling CE, Opsomer D, Cherubino M, Vieni S, et al. Free bipedicled radial forearm and posterior interosseous artery perforator flap phalloplasty. J Sex Med. 2019;16:1111–7.

    Article  Google Scholar 

Download references

Acknowledgements

We would like to express our great appreciation to all physicians involved in this study for the great interest demonstrated towards this ambitious project and the accuracy demonstrated in collecting data.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marco Falcone.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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 33, 737–745 (2021). https://doi.org/10.1038/s41443-021-00414-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41443-021-00414-x

This article is cited by

Search

Quick links