Pedicled Flaps Versus Free Radial Forearm Flap for Phalloplasty in Female to Male Gender-Confirming Surgery
Bibliographic record
Abstract
BACKGROUND: The field of gender-affirming surgery is rapidly evolving, with plastic surgery units worldwide increasingly offering these services. Phalloplasty is a critical component of female-to-male (FTM) transition, providing significant psychological and functional benefits. Although robust comparative trials are scarce, expert consensus favors the radial forearm free flap (RFF) when feasible. This systematic review directly compares outcomes of pedicle anterolateral flap (pALT) and the RFF in FTM gender-affirming surgery. METHODS: A systematic review was conducted following the PRISMA guidelines, searching PubMed/Medline, Scopus, Web of Science, ProQuest, and EBSCO for eligible studies. Two independent reviewers screened and selected studies, resolving discrepancies by consensus. Flap survival and patient satisfaction were the primary outcome measures. Secondary outcomes included standing voiding ability, penetrative sexual function, number of operative stages, surgical duration, anesthetic techniques, and donor site morbidity or acceptance. Risk of bias was assessed using ROBINS-I, and evidence quality was evaluated using GRADE. RESULTS: A total of 19 studies comprising 769 patients (614 RFF, 155 pALT) were included. Both techniques demonstrated comparable outcomes, although the ALT required significantly less operative time (RFF vs pALT, 290 vs 516 minutes). Flap failure rates were low for both groups (1.9% RFF, 0.6% pALT; P = 0.348), and patient satisfaction was high (78% RFF vs 76.2% pALT; P = 1.0). Risk of bias assessment indicated serious selection bias due to the observational nature of studies. GRADE evaluation rated the evidence as low, reflecting the absence of randomized trials in this field. CONCLUSIONS: The RFF remains the most reliable technique for phalloplasty, with the pALT serving as a secondary option when the RFF is not feasible. However, the limited number of studies and the lack of standardized outcome reporting in gender-affirming surgery make it difficult to draw definitive conclusions or establish evidence-based recommendations. Although both flap types are considered safe for female-to-male phalloplasty, the small patient cohorts and absence of randomized data contribute to the ongoing uncertainty in determining the optimal approach.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.010 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".