4 Things you Need to Know about Radial Forearm Flap Phalloplasty

Written by Giovanna D’Ambrosio. Medically reviewed by Jennifer Richman on August 19, 2025.

What is a Radial Forearm Flap (RFF) Phalloplasty?

An RFF phalloplasty is the most common of the three types of phalloplasty procedures that can construct a phallus for a patient. The RFF technique for gender-affirming bottom surgery for trans men and transmasculine patients takes a donor skin flap from the forearm to create the new penis.

This procedure is selected by patients who do not mind having a large, visible scar on their forearm; likewise, having heightened, erogenous sensation in their new penis is a major priority for them. By taking the radial artery and the nerves from the sensitive forearm tissue, it is more likely that the patient will have heightened, erogenous sensation than with other phalloplasty techniques.

Dr. Zara Ley (she/her/they) is a board certified plastic surgeon, a transgender woman of color and former patient herself who offers a full spectrum of bottom surgery and other procedures to our transgender and non-binary patients. If you have questions about RFF phalloplasty or would like to see if you qualify for the procedure, you can request a free, in-person consultation with Dr. Ley here.

1. Who Qualifies for an RFF Phalloplasty?

To be eligible for this specific type of masculinizing bottom surgery, patients must meet the following requirements:

• Age: Patients must be legal adults capable of participating in an informed consent process.
• Insurance Coverage and Supporting Documents: Due to hospital requirements, Dr. Ley is only able to perform phalloplasty on patients whose health insurance will cover this gender-affirming procedure. Providers that cover gender-affirming surgery often require patients to present a support letter with a gender dysphoria diagnosis and psychological assessment. Likewise, for many providers, you will likely need to be on continuous testosterone hormone therapy for a minimum of 12 months to obtain coverage.
• BMI: To be a candidate for an RFF phalloplasty, patients must have a BMI no greater than 30 and have adequate forearm anatomy to qualify for this procedure.
• Nicotine and tobacco: Dr. Ley will not perform nerve innervation microsurgery on patients who smoke or vape. This is because tobacco and nicotine consumption significantly increase surgical risks and impair healing.

2. Undergoing Permanent Hair Removal Before Surgery

Since an RFF phalloplasty involves taking skin grafts for the phallus and the urethra from the forearm, patients will need to undergo permanent hair removal before surgery.

Permanent hair removal with Electrolysis is only required for the section of the forearm that will be used as a graft for the urethra. The section of the forearm taken for urethral lengthening is marked in the diagram below in orange.

Many patients also wish to undergo Laser Hair Removal and/or Electrolysis treatment on the other area of their forearm, marked in purple below, to prevent hair from growing on the penis shaft.

3. Scarring

Scarring is the most notorious trade-off to this specific type of phalloplasty. Taking a radial forearm flap to construct a penis leaves a large, noticeable scar on the donor forearm. In a later surgery, a split-thickness skin graft will be taken from the thigh to cover the wound left on the forearm. Once healed, the rectangular skin graft will look like a burn mark; the tissue will be discolored and depressed compared to the surrounding skin.

After surgery, patients often accept this large, visible scar. It can be concealed with long-sleeve shirts or, 12 months after the split-thickness skin graft has healed, can be repigmented by a qualified medical tattoo artist, with varying levels of success.

4. Multiple Stages of Surgery Will be Needed to Achieve Your Desired Results

One of the most important factors that patients need to consider for a phalloplasty is that multiple stages of surgery are needed to produce the final surgical result. This means that unlike other forms of gender-affirming bottom surgery, such as a metoidioplasty, the recovery process is longer and more drawn-out. This has a significant effect on a patient’s mental health, which is why it is essential that patients have a solid support network that includes loved ones and a mental health professional.

After the phallus is created in the first stage of surgery, additional stages of surgery will be needed to accomplish the following:

• A primary urethral lengthening (PUL) surgery will allow the urethra to exit the body at the tip of the penis, making it possible to urinate while standing.
• A vaginectomy or removal of the vaginal canal. Dr. Ley requires this procedure for all of her patients who undergo a PUL due to the extremely high risk of urinary complications.
• Taking a split-thickness skin graft to cover up the skin flap taken from the forearm.
• Constructing the glans of the penis (called a glansplasty)
• Constructing scrotum (scrotoplasty), inserting tissue expanders and eventually silicone testicular implants.
• Undergoing a mons resection and panniculectomy to remove unwanted fat and/or skin overhang from above the groin, giving the penis a more apparent look on the body.
• Inserting an erectile device.

5. Erogenous Sensation

The greatest advantage of the RFF phalloplasty technique is that it innervates the sensitive forearm nerve to the clitoral nerve, meaning that the entire penis may acquire heightened, erogenous sensation once it is fully healed. Sadly, some patients will experience no nerve regeneration at all; this would leave their phallus with a normal, tactile level of sensation.

Nerves will start to regenerate as early as 3 weeks after surgery. As nerves heal, patients may experience tingling sensations in the phallus over the course of a few months. Regardless, the buried clitoral nerve should still maintain heightened sensation, meaning that the patient will be able to stimulate it after surgery.