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Radial Forearm (RF) Free Flap Phalloplasty

Radial Forearm (RF) free flap phalloplasty is considered the gold standard for patients wanting/needing a neophallus.


PREOP REQUIREMENTS for RF phalloplasty candidacy include:

  • Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor)
  • Hair removal: laser or electrolysis
  • Hysterectomy
  • Overall good health
  • No smoking, nicotine use, or inhalational products (including vaping, marijuana, and 2nd hand smoke) around 3 months before and after surgery (ideally 6 months before and after surgery). This includes chewing tobacco and nicotine free inhalational products. Use of these products can cause about a 5-fold increase in complications. Use within this 3-6 month window before surgery may prompt rescheduling of the surgery to a later time when then the patient has reliably stopped smoking.
  • Perioperative assistance (friends, family, hired help)
  • Good Allen's test (alternative blood flow to the hand)
  • No hanging mons (area of lower abdomen directly in front of the pubic bone)/pannus​ (abdominal fat and skin that is pendulous)


General information:

  • Team members: Microsurgeons, Reconstructive Urologist, associated surgical and perioperative care staff

  • Duration of surgery: 6-8 hours

  • Hospital stay: 5 days on average

  • In town stay: 4 weeks on average

Reconstructive urology portion:

  • Cystoscopy, SP tube insertion: camera that looks into bladder with placement of a catheter through the lower abdomen skin.

  • Vaginectomy: removal/fulguration of the mucosa with closure of the canal.

  • Urethral lengthening: minora tissue is used to extend the urethra from where it is currently to the head of the native phallus.

  • Nerve dissection: one of the two dorsal nerves (sensory and erotic sensation) are dissected free for future connection with the sensory nerve of the arm.

  • Transposition of native penis: the outer skin of the glans and shaft are removed and the native penis with the lengthened urethra at the tip are moved to just underneath the pubic bone. The native penis (clitoris) is buried beneath the skin at the base of the new phallus to help align the urethra and nerves.

  • Scrotoplasty: the majora tissue is dissected free and folded into a pouch that lies more anteriorly--about 10 cm away from the anus.

  • Perineal reconstruction: the perineum is the area between the anus and the back of the scrotum. This is reconstructed with inner thigh skin and neighboring genital tissue.

Microsurgeon portion:

  • Flap harvest: the rectangular RF free flap (skin and fat) is dissected free along with its nerve and blood supply. The muscles and tendons are left alone.

  • Neophallus/neourethra creation: the urethral component of the RF flap is rolled into a tube; the remainder of the RF flap is then rolled into the phallus.

  • Glansplasty: performed as long as there is sufficient blood supply.

  • Groin dissection: the groin vessels are dissected free to eventually connect with the phallus blood vessels.

  • Nerve coaptation: the dorsal nerve is microscopically connected to the RF flap sensory nerve.

  • Vessel anastomosis: the groin blood vessels are microscopically connected to the RF flap blood vessels.

Joint portion:

  • Urethral anastomosis: the tip of the native penis urethra is connected to the back of the RF flap neophallus urethra.

  • Donor site closure: the arm donor site is closed with a split thickness skin graft that is taken from the thigh.

  • Skin closure: the groin and base of phallus skin is closed with several layers of absorbable suture.

Note: This is a generalized description of the procedures, and steps vary depending on patient anatomy, medical/surgical history, and surgical goals.

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