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Published on: August 1, 2022
Postoperative circumferential and volumetric dynamics following gender-affirming radial forearm free flap
Ines Ana Ederer1,2, Andrej Wehle1, Carolin Wachtel1
1Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany.
Background:
The radial forearm free flap (RFFF) is the standard technique for gender-affirming tube-in-tube phalloplasty owing to its reliably vascular anatomy and pliable tissue. However, postoperative circumferential and volumetric changes, and their potential role in complications such as excessive phallic turgor, remain poorly characterized.
Aim:
To quantify early postoperative circumferential and volumetric changes following RFFF phalloplasty in patients with an uneventful postoperative course.
Methods:
A consecutive series of trans men who underwent RFFF phalloplasty between 04/2024 and 07/2025 were analyzed. Phallic circumference was measured intraoperatively and on postoperative days (PODs) 1, 3, 5, 10, and 14 at three levels (base, midshaft, tip). Volumes were modeled from these measurements using geometric formulas (two-frustum method). Patients requiring emergent reintervention (eg, operative revision) were excluded.
Outcomes:
Primary outcomes were temporal changes in circumference and estimated volume relative to intraoperative values within 14 days.
Results:
Twenty-two patients with a mean age of 32 years (SD 11) met inclusion criteria. Mean flap length was 12.3 cm (SD 0.9). In most patients (54.5%) three venous anastomoses were performed. Phallic circumference increased most prominently within the first 24 h and peaked at POD 3, with mean increases of 6.2 mm at the base, 8.1 mm at the midshaft, and 7.5 mm at the tip compared with intraoperative values. Circumferences then declined gradually but remained above baseline on POD 14 (residual mean increase: 3.7 mm at the base, 4.8 mm at the midshaft, and 5.3 mm at the tip). Estimated phallic volume rose from a mean of 111.3 cm3 (SD 21.7) intraoperatively to 131.2 cm3 (SD 24.5) on POD 3, before declining to a mean volume of 120.8 cm3 (SD 21.3) by POD 14. These changes corresponded to a mean relative increase of 16.0 % (SD 15.9) on POD 1 and 19.0 % (SD 15.9) on POD 3. Persistent edema was present in 81.8% of patients at POD 14.
Clinical Implications:
Vigilant monitoring during the first 72 h is critical for timely decompression. Individualized flap planning, particularly at proximal and midshaft levels, remains essential to avoid tension-related complications.
Strengths And Limitations:
This represents the first quantitative assessment of early postoperative swelling in phalloplasty based on multi-level measurements and volumetric modeling. Limitations include the single-center design and short follow-up.
Conclusions:
RFFF phalloplasty demonstrates predictable swelling dynamics: rapid increase within 24 h, a peak on POD 3, and gradual decline thereafter, with persistent edema in most cases by POD 14.
