Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap

Abstract

Background: The radial artery forearm free flap (RFFF) is the workhorse technique for phallus reconstruction. The RFFF provides good cosmesis and potential sensory recovery. However, the donor site is large in comparison to other applications of the RFFF which may increase the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength. This study systematically reviewed the current literature to assess the donor site morbidity associated with RFFF phalloplasty (RFFFP). Methods: A systematic review utilizing Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines was completed of the current literature pertaining to donor site morbidity after RFFFP. Two investigators independently reviewed the literature to determine eligibility for inclusion. Two hundred sixty-seven studies were reviewed and 10 were included in the final analysis after application of exclusion criteria. Results: Nine hundred forty flap reconstructions were identified. Gender affirming surgery was the indication in 77.7% (n = 730) of patients. The overall donor site complication rate was 7.9% (n = 74). Skin graft failure occurred in 41 patients (4.5%) and was the most frequent complication. Donor site infection (n = 3, 15.8%), hematoma (n = 1, 0.8%), neuroma (n = 1, 10%), compartment syndrome (n = 1, 0.8%), decreased strength or sensation (n = 15, 4.9%), lymphedema or limb swelling (n = 10, 3.9%), and contracture (n = 2, 6.5%) were also found. Conclusions: The most common donor site complication after RFFFP is skin graft failure. Decreased forearm sensation and strength affected a significant proportion of patients within each reported cohort. Prospective studies should continue to evaluate donor site morbidity with objective measures, such as grip strength evaluation, and long-term follow-up for vascular changes following radial artery harvest.

Total phallic construction techniques in transgender men: an updated narrative review

“…Donor site morbidity includes graft failure requiring re-grafting in 2.7% of cases (9,25,28,42). Urethral c o m p l i c a t i o n s a r e t h e m o s t f r e q u e n t l y r e p o r t e d complication, ranging from 32% to 58% (36,38,43).…”

“…The main drawback of RAFFF is its donorsite morbidity because nearly two-thirds of the forearm circumference is harvested. This area requires coverage with either full or split-thickness skin grafts, which may create sizeable scarring (9,26,28). Other disadvantages include discolouration between the flap and surrounding genital skin (3,29), need for a stiffener or prosthesis to allow penetrative intercourse and relatively high rate of urethral complications (2,14,16,24,29).…”

Median Nerve Neuropathy following Radial Forearm Free Flap Phalloplasty: A Case Report

“…Although current literature has addressed patient-reported loss of function and skin grafting complications, 6 this is the first reported case known to the authors of a median nerve injury following RFFF phalloplasty. Impairment suggested a high median nerve injury without a Tinel’s sign, with the source likely at the tourniquet application site, 7 thus suggesting a tourniquet-related injury.…”

Genital Gender Affirming Surgery

“…Disadvantages of the RFFF are visible donor site, sacrifice of vasculature to the hand, and potential for complications involving the hand or arm. 14,15 In select patients, anterolateral thigh flap (ALT; pedicled or free) can be used for phalloplasty. The major advantages of an ALT flap are a scar that is easier to conceal (compared to radial forearm donor site) and absence of complications involving the hand.…”