Background: Constructing a sensitive phallus is a key objective in sex affirmation surgery, but still there is a major lack of evidence in outcome analysis of postoperative sensibility of the newly constructed body part. Aim: To evaluate the innervation and sensibility of a forearm free-flap neophallus with nerve coaptation by a broad-spectrum follow-up. Methods: The phallic sensibility of 20 transgender individuals who underwent phalloplasty with a free radial forearm flap was evaluated by a standardized multimodal approach, examining 5 main sensory modalities. Measurements were performed in defined areas at the phallus and at the unoperated forearm as a control area. Additionally, all patients were asked to complete a questionnaire about their subjective quality of life and ability to orgasm. Outcome: This study evaluated the following parameters: perception of pressure (Semmes-Weinstein monofilaments) and vibration (C64 Hz tuning fork), static two-point discrimination, sharp-blunt and hot-cold discrimination at the phallus and the forearm, sum score of calculated life satisfaction, and ability to orgasm. Results: Most of the patients (n = 14) were able to perceive 2 or more sensory modalities tested at the newly constructed phallus. 2 patients did not develop any sensibility. Interestingly, the median values for vibration perception were similar for the phallus and the unoperated forearm. Pressure sensibility was present at the phallus, but less than at the forearm. Moreover, sharp-blunt sensibility was present in 11 patients. In contrast, clear cold-warm discrimination could not be achieved, although the majority of patients detected the cold stimulus. A two-point discrimination of up to 23 mm could not be detected in either body part. 15 patients experienced orgasms without difficulty after 23 months (n = 20 after 54 months). Clinical Implications: We observed successful recovery of sensibility at the phalli for the majority of patients, including the preservation of orgasm. Strengths & Limitations: Our institution is one of the few centers regularly performing phalloplasties in transgender patients, especially preferring the technique of Gottlieb and Levine. This study contributes to the few studies that perform sensory testing at the phallus and is unique in its kind in that it uses a multimodal approach. A limitation of this study is the limited number of cases and the limited validity of vibratory testing. Conclusion: Confirming a promising tactile sensibility after phalloplasty with a neurovascular radial forearm flap, the next step would be to identify whether this reinnervation effectively develops due to nerve coaptation or spontaneous sprouting.

Background: The radial forearm flap remains the gold standard in phalloplasty in gender-affirming surgery due to its versatility and functional outcome, but the significant donor site morbidity and its impact on daily functioning and aesthetic perception remains understudied. This study provides valuable insights into the mid-term functional and aesthetic outcomes of the forearm in transgender individuals following radial forearm flap phalloplasty using widespread instruments for assessment scoring systems and for the evaluation of postoperative wound healing of surgical interventions in general. Methods: Between January 2013 and March 2018, a total of 47 patients underwent radial phalloplasty at AGAPLESION Markus Hospital, and 20 consented to participate in this cross-sectional, retrospective study evaluating functional and aesthetic outcomes post-radial forearm flap phalloplasty using standardized questionnaires (DASH, POSAS, and SBSES). A univariate median regression of each score was performed to determine the associations with selected variables, and correlation analyses between scores was performed using a nonparametric Spearman rank correlation. Results: Among the 20 participants, the median Quick DASH, DASH functionality, DASH sport and music, and DASH work scores indicated minimal to no functional impairment. Scar evaluations using the PSAS, OSAS, and SBSES scales showed overall patient satisfaction with minimal concerns regarding pigmentation and scar texture. Notably, an increase of 0.27 cm² in wound surface area added one point to the DASH sport and music score (p = 0.037). Statistical analysis also demonstrated a significant correlation between functional and aesthetic assessment scores. Conclusions: The radial forearm phalloplasty donor site, evaluated by the PSAS, OSAS, and SBSES scales, leads to minimal or no functional impairment; however, the worsening of the DASH sport and music score with increasing wound surface reflects a direct relation between wound size and functional impairment.