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Figure 5. During the glansplasty, the distal flap is de-epithelized and curled onto itself to recapitulate the corona. A full thickness skin
graft is harvested from the groin and placed below. Before the return of sensation to the neophallus, this can be further refined with
tattooing if the patient so wishes once the wounds have healed

time of flap transfer, other will stage it for at least three months to allow the tissues to heal from the initial
operation [Figure 5]. The corona can be further refined before the return of sensation by tattooing in order
to match the color of the areola.

The anastomosis of the neourethra and native urethra may also vary in timing, from the time of flap
transfer to a separate stage several months later. In many cases, the need to perform a urethral anastomosis
is determined by the indication. For example, children with exstrophy may have a continent umbilical
bladder stoma and not need urethral reconstruction. In these children, the native glans can be de-
epithelialized and brought out the ventral and proximal surface of the neophallus to allow for ejaculation
from the native urethra. Without the normal peristalsis of the corpora bodies, the ejaculate may not reach
the tip of the neophallus if a full-length urethra is constructed. Furthermore, the ability to urinate standing
up may not be a priority for some transgender men, who may wish to forego urethral lengthening and
anastomosis in order to avoid the relatively high complication rates.

The final stage of RFFF phalloplasty is typically the insertion of a penile prosthesis. This is normally
performed up to one year after the index procedure in order to allow for adequate regeneration of
protective sensation. Although some surgeons have described osteocutaneous modifications to RFFF in
order to provide stiffness of the flap and avoid the need for a penile prosthesis, this procedure is associated
with an increased risk of donor site fractures and not commonly employed [24,25] . Penile prostheses are
discussed in further detail in a separate section below.

Overall, despite being the “gold standard” reconstructive technique [Figure 6], the outcomes of RFFF fall
[3]
short in many ways. A recent meta-analysis by Yao et al. included 925 RFFF phalloplasties that included
nearly 90% female-to-male gender-affirming surgeries. Although complications varied greatly based on the