Superficial Circumflex Iliac Artery Perforator Flap Phalloplasty
Superficial circumflex iliac artery perforator (SCIP) flap phalloplasty uses thin groin / lower-abdominal tissue based on the superficial circumflex iliac artery system for phallic urethral reconstruction, shaft-only phalloplasty, or combined shaft-plus-urethra reconstruction in selected gender-diverse patients. It is the contemporary perforator-flap refinement of the older groin and abdominal flap family. The scar is concealed, the donor site usually closes primarily, and microsurgery is often avoided when the flap is pedicled. Shaft sensation is usually less predictable than with RFFF phalloplasty.[1][2][3]
For cross-application vascular anatomy, flap harvest concepts, vulvoperineal reconstruction, Fournier's reconstruction, vesicocutaneous fistula repair, and lymph-node transfer, see Superficial Circumflex Iliac Artery Perforator Flap. For cohort-level pathway selection, see Masculinizing Gender-Affirming Surgery.
Concept and Nomenclature
"SCIP phalloplasty" covers three operations. The same groin-perforator flap can be used in three roles, and counseling depends on the role planned.
| Role | What the SCIP Provides | Typical Use Case |
|---|---|---|
| Urethral SCIP | Dedicated thin flap for the phallic urethra | Previously used as a separate urethral flap with pedicled ALT phalloplasty when ALT was too thick for tube-in-tube reconstruction; Ghent moved away from routine SCIP–ALT pairing after urethral-flap losses and now usually suggests an RFFF urethra with ALT[1][2] |
| Shaft-only SCIP | Neophallic shaft without urethral lengthening | Patient prioritizes concealed donor scar, avoids forearm scar, and does not need standing voiding[3] |
| Bilateral / combined SCIP | One SCIP for shaft and one SCIP for urethra, or bilateral paddles for combined reconstruction | Highly selected single-stage shaft-plus-urethra strategy; urethral complications remain substantial[2] |
This page uses SCIP for the flap and SCIA for the superficial circumflex iliac artery. The term SCIAP appears in older phalloplasty literature and generally refers to the same superficial circumflex iliac artery perforator concept.
Indications
| Scenario | Fit for SCIP |
|---|---|
| ALT shaft planned but ALT urethra is too thick | A thin SCIP urethral flap has been used with an ALT shaft, but the Ghent team moved away from this pairing after complete urethral-flap losses and now usually suggests a free RFFF urethra with ALT.[2] |
| Forearm scar is unacceptable | Strong fit if SCIP anatomy and groin tissue are favorable |
| Abnormal Allen test or forearm vascular concern | Strong fit as an alternative to RFFF urethra / shaft tissue |
| Concealed donor site prioritized | Strong fit; scar lies in groin / flank region and usually closes primarily |
| Shaft-only phalloplasty without standing voiding | Reasonable fit in selected thin patients |
| Revision after failed urethral reconstruction | Useful as a second flap when local or prior flap tissue is exhausted |
| Maximal shaft sensation is the primary goal | RFFF remains stronger; SCIP candidates must accept potentially lower sensation |
Contraindications and Caution Zones
The SCIP advantage is donor-site discretion. It has no demonstrated functional superiority.
| Scenario | Counseling Point |
|---|---|
| Thick groin / flank adiposity | The flap may be too bulky for urethra or a refined shaft |
| Need for best sensory outcome | RFFF has better-established nerve coaptation and sensory-outcomes literature[4][5] |
| Standing voiding required in one stage | SCIP can help, but urethral fistula / stricture risk remains substantial |
| Unmapped SCIA anatomy | Obtain high-resolution ultrasound, CTA, or local mapping according to center protocol |
| Prior groin surgery / lymph-node surgery / extensive scars | Map pedicle and lymphatic drainage carefully; consider alternate flap |
| Active smoking | In the Ghent series, SCIP phalloplasty for shaft or urethra was performed only in nonsmokers or after at least 3 months of smoking cessation.[2] |
Historical Context
Abdominal and groin flap phalloplasty has the longest history of phallic reconstruction. Bogoras used an abdominal tube flap in 1936, and Gillies later refined multistage tubed abdominal pedicle methods for wartime penile reconstruction.[6][7] Modern suprapubic pedicled phalloplasty was reported by Bettocchi, Ralph, and Pryor, and the Lyon group later described pre-expanded suprapubic phalloplasty to improve dimensions and donor closure.[8][9]
SCIP is the perforator-era branch of that lineage. Instead of relying on a broader random-pattern abdominal tube, it uses mapped superficial circumflex iliac perforators to harvest thinner, more reliable groin / flank tissue with low donor-site morbidity.[2][10]
Vascular and Neural Anatomy
The SCIP flap is based on the superficial circumflex iliac artery, usually arising from the femoral artery. The artery has superficial and deep systems; either may supply a usable skin paddle depending on the branch pattern, perforator location, and planned flap thickness.[10][11]
| Structure | Practical Relevance |
|---|---|
| Superficial circumflex iliac artery | Primary arterial system for the SCIP flap |
| Superficial branch | Runs in the subcutaneous plane and supports thin fasciocutaneous harvest |
| Deep branch | Courses deeper near sartorius and can support chimeric or osteocutaneous variants |
| Superficial inferior epigastric / external pudendal connections | Adjacent lower-abdominal vascular networks explain overlap with broader abdominal-flap concepts |
| Sensory nerves | In the Ghent SCIP shaft technique, lateral cutaneous T9–T11 branches are coapted to the dorsal clitoral nerve; proximal sensation was reported in 4/7 assessed shaft patients at 3–25 months, with limited longer-term measurement[2] |
| Lymphatics | Reverse lymphatic mapping should be considered if lymph-node harvest or prior groin lymphatic surgery is relevant[12] |
Preoperative high-frequency ultrasound is particularly useful because the vessels are small and branch anatomy varies. The foundations SCIP page covers the branch anatomy, mapping methods, and non-GAS SCIP applications in more detail.
Preoperative Planning
| Planning Domain | SCIP-Specific Point |
|---|---|
| Goal selection | Decide first whether SCIP is the shaft, the urethra, or an adjunct to another shaft flap |
| Standing micturition | If desired, define the entire pars fixa and phallic urethral plan before selecting the flap |
| Pinch test | Thin groin or flank tissue favors urethral and shaft refinement; the Ghent team used a pinch <1 cm as one SCIP selection criterion and generally kept to this threshold, with a documented salvage exception.[2] |
| Vascular mapping | Map SCIA branches and perforators; CTA can help when anatomy is uncertain or ALT is also being considered |
| Hair management | Remove hair from any planned urethral segment before tubularization |
| Donor scar counseling | Scar is usually concealed, but groin asymmetry, scar widening, and contour change still matter |
| Backup flap | Have an RFFF, ALT, abdominal, or staged urethral salvage plan if SCIP caliber / course is unsuitable |
Technique
Urethral SCIP With ALT Shaft
A separate SCIP urethral flap has been paired with an ALT shaft when the ALT is too thick for tube-in-tube reconstruction.[1] The later Ghent series reports moving away from this pairing after 2019 because of urethral flap loss; that center now usually suggests an RFFF urethra for an ALT shaft, reserving SCIP for selected patients.[2]
| Step | Technical Goal |
|---|---|
| Map and mark SCIP | Identify reliable SCIA perforator(s), usually near the groin crease / inguinal region |
| Design urethral paddle | In the Ghent technique, make the hair-cleared paddle at least 4 cm wide for tension-free catheter-based tubularization and allow length for the buried pivot segment and planned phallic urethra.[2] |
| Raise pedicled SCIP | Preserve the SCIA pedicle and avoid pedicle torsion during transfer |
| Tubularize urethra | Create the phallic urethral tube over catheter / stent according to center practice |
| Transfer into shaft | Place the SCIP urethra within ALT shaft or as a separate urethral component |
| Urethral anastomoses | Connect distally to neomeatus and proximally to pars fixa urethra |
| Drainage and diversion | Use urethral catheter and suprapubic diversion according to local protocol |
D'Arpa's retrospective 93-case ALT experience over 13 years is the main comparative series cited here; 79 phalloplasties were for gender affirmation and 14 were in men with severe penile insufficiency.[1] Urethral complication rates (fistula or stricture) were 26.3% with a pedicled SCIP urethra (38 cases), 37.9% with an RFFF urethra (29 cases), 87.5% with a prelaminated ALT urethra (8 cases) and 20% with a tube-in-tube ALT urethra (5 cases).[1]
Shaft-Only SCIP
SCIP shaft construction does not itself require a phallic urethra. In De Gelder’s 10 SCIP shaft cases, five had immediate perineal urethrostomy without urethral lengthening and five had an RFFF urethra.[2] Shaft-only phalloplasty can also retain the native urethral outlet when perineal surgery is omitted, as described with other flaps.[19] This is conceptually close to shaft-only ALT or abdominal phalloplasty but with thinner groin tissue and a concealed donor site.[3]
| Step | Technical Goal |
|---|---|
| Design shaft paddle | Match length and girth goals to primary donor closure and pedicle reach |
| Harvest flap | Preserve the SCIA pedicle; keep flap thin enough for phallic contour |
| Tubularize shaft | Shape around a form without creating a urethral tube |
| Transfer / inset | Rotate or tunnel to the pubic base without pedicle compression |
| Sensory reconstruction and clitoral management | In the Ghent shaft technique, include a T9–T11 lateral cutaneous nerve branch for tension-free coaptation to a dorsal clitoral nerve; preserve erogenous clitoral anatomy according to patient goals.[2] |
| Refinement | Delay glansplasty, contouring, testicular implants, and prosthesis until wounds mature |
Bilateral or Combined SCIP
In the Ghent 10-year experience, bilateral SCIP flaps were used for combined shaft and urethral reconstruction in selected patients.[2] It can keep both donor sites concealed.[2]
Staging
SCIP staging depends on whether urethral lengthening is included.
| Pathway | Typical Sequence |
|---|---|
| SCIP urethra + ALT shaft | Genital preparation / vaginectomy / pars fixa planning -> ALT shaft plus SCIP urethra or staged urethral construction -> revisions -> prosthesis |
| Shaft-only SCIP | SCIP shaft creation -> glansplasty / contouring -> scrotoplasty / testicular implants -> erectile prosthesis if desired |
| Combined bilateral SCIP | Bilateral flap harvest and shaft-plus-urethra reconstruction -> urethral revisions as needed -> prosthetic stage |
| Urethral revision and SCIP salvage | Define fistula or stricture site, length, tissue quality, and time since phalloplasty. The 2026 EAU guideline recommends no endoscopic incision or urethroplasty within 6 months after neophalloplasty and staged urethroplasty for a neophallic-urethral stricture requiring open repair .[20] Vascularized SCIP urethral salvage has been described after failed RFFF urethra.[2] |
Patients should understand that "no microsurgery" and "concealed scar" do not mean "single operation." Urethral reconstruction, glansplasty, scrotoplasty, implant surgery, and complication management can still make the SCIP pathway multistage.
Outcomes
Donor Site and Flap Survival
SCIP's most consistent advantage is donor-site morbidity. Across SCIP reconstructive series, primary closure is common and the scar is concealed in the groin or flank.[2][10][13] In the 55-person Ghent cohort, 36 required additional plastic-surgery interventions and 25 required additional urologic interventions during mean 26-month follow-up (range 1–97 months).[2]
| Study | SCIP Use | Key Finding |
|---|---|---|
| De Gelder 2025 | 55 patients/procedures (47 unilateral and 8 bilateral SCIP cases), 2012–2022 | Primary donor closure in all 55; no complete failures among 10 SCIP shaft reconstructions (5 shaft-only and 5 with an RFFF urethra)[2] |
| de Haseth 2025 | 47 men, shaft-only SCIA perforator phalloplasty, 2017–2023 | Successful reconstruction with a unilateral pedicled flap in 45 (96%); one total and one partial flap necrosis; primary donor closure in all; wound dehiscence at the phallus and scrotum junction in 17[3] |
| Goh 2015 | 210 SCIP flaps across reconstructive indications | Described SCIP as a thin flap with low donor-site morbidity[13] |
Urethral Outcomes
| Study / Strategy | Urethral Signal |
|---|---|
| D'Arpa 2019 ALT urethral reconstruction | Fistula or stricture occurred in 10/38 (26.3%) SCIP-urethra cases and 7/8 (87.5%) prelaminated ALT-urethra cases in unmatched subgroups.[1] |
| De Gelder 2025 SCIP urethra (unilateral and bilateral) | Among 37 unilateral SCIP urethras (33 with ALT shafts and four salvage flaps after failed RFFF urethras), 14/37 (38%) had fistula or stricture requiring surgery and 6/37 (16%) were lost completely. Across all 45 SCIP urethras, 8/45 (18%) were lost completely and 37/45 (82%) voided standing after interventions.[2] |
| De Gelder 2025 bilateral SCIP shaft-plus-urethra | Fistula or stricture in 3 of 8 patients (38%) with bilateral combined reconstruction[2] |
| Al-Tamimi 2020 labia minora urethra with ALT or SCIP shaft | The local labia minora flap provided the urethra without forearm harvest; among 16 transgender men, 4 had fistulas, 6 strictures, and 9 voided standing.[14] |
| Wu 2022 ALT plus SCIAP urethra (non-GAS penile reconstruction) | Among 49 patients with micropenis or acquired penile defects, 12/26 (46.2%) SCIAP urethras had necrosis, fistula, or stricture; all 49 eventually voided standing after 13 revisions across techniques.[15] |
SCIP has been used as a urethral adjunct when the main shaft flap is too thick or the forearm is unavailable. The phallic urethra remains the highest-risk component of the operation.
Sensation and Sexual Function
Sensation is the main tradeoff versus RFFF. De Gelder et al. reported urethral complication rates similar to those of RFFF and ALT phalloplasty but potentially lower shaft sensation with SCIP.[2] A 2026 systematic review found that neurorrhaphy consistently improved phallic sensation, with heterogeneous techniques and outcome reporting.[4][5]
The Ghent group considers preservation of the clitoris beneath the neophallus essential for orgasm after phalloplasty (Selvaggi 2007, RFFF series).[18] Penetrative intercourse generally requires a delayed erectile prosthesis, as with other soft-tissue phalloplasty flaps.[16]
Comparison With Other Phalloplasty Flaps
| Feature | SCIP | RFFF | Pedicled ALT | Pedicled Abdominal |
|---|---|---|---|---|
| Typical role | Urethral adjunct or shaft-only / selected shaft-plus-urethra | Benchmark full shaft + tube-in-tube urethra | Concealed-donor shaft flap | Nonmicrosurgical shaft flap |
| Microsurgery | Usually no if pedicled; yes if free | Yes | Usually no if pedicled | No |
| Donor scar | Concealed groin / flank | Visible forearm | Concealed thigh | Concealed lower abdomen |
| Primary donor closure | Usually yes | No; graft / dermal matrix | Depends on width / thigh size | Often yes if pre-expanded |
| Tissue thickness | Thin if favorable pinch test | Thin | Often bulky | Variable; often thicker |
| Sensation potential | Limited / evolving | Strongest | Variable | Limited |
| Urethral use | Selected separate urethral flap; substantial loss and revision risk[2] | Strong tube-in-tube or separate urethral flap | Difficult unless thin or staged | Usually separate / staged |
| Best fit | Forearm avoidance + thin groin tissue + need for urethral adjunct | Aesthetic + sensory priority | Forearm avoidance + acceptable thigh | Pedicled shaft reconstruction without microsurgery at the index operation; Wang's abdominal cohort used a later RFFF for urethral reconstruction[17] |
In the 57-patient Wang 2026 cohort, pedicled abdominal flaps had the lowest overall complication rate among RFFF, ALT and abdominal groups. SCIP evidence comes from single-center series and urethral-reconstruction cohorts, and no large comparative shaft-phalloplasty trials exist.[17]
Advantages
- Concealed groin / flank donor scar.
- Usually permits primary donor-site closure.
- Thin pliable tissue when the pinch test is favorable.
- Avoids radial-artery sacrifice and visible forearm graft morbidity.
- Pedicled SCIP can avoid vascular microsurgery, but 3 of 45 urethral SCIP flaps in the Ghent series required free-flap conversion because pedicle reach was insufficient.[2]
- Can serve as a dedicated urethral flap with ALT in selected cases; the Ghent team now usually suggests RFFF urethra with ALT after SCIP urethral-flap losses.[1][2]
- Can serve as a second flap in revision / salvage urethral reconstruction.
Limitations
- Lower sensory potential than innervated RFFF.
- Smaller vessel caliber and variable branch anatomy require careful mapping.
- Pedicle length and arc of rotation can limit inset.
- Thick groin / flank adiposity can defeat the flap's thin-tissue advantage.
- Urethral complications remain common when standing voiding is pursued.
- Evidence base remains smaller than RFFF and ALT.
Patient Selection
SCIP phalloplasty is best suited for patients who:
- Prioritize a concealed donor site over maximal sensory outcomes.
- Have a favorable groin / flank pinch test.
- Cannot or do not want to use the forearm donor site.
- Need a thin separate urethral flap for selected revision cases; SCIP has also been used with ALT, though Ghent now usually suggests RFFF urethra with ALT after SCIP urethral-flap losses.[1][2]
- Accept staged revisions if standing micturition is a goal.
- Understand that shaft sensation may be lower than RFFF.
It is a weaker fit when the patient prioritizes the most predictable shaft sensation, has thick groin tissue, needs a large single-stage tube-in-tube reconstruction, or has prior groin surgery that compromises SCIA anatomy or lymphatic drainage.
Operative Pearls
- Decide whether SCIP is the urethra, the shaft, or both before designing the flap.
- Do a pinch test before promising a thin SCIP urethra.
- Map the SCIA branch pattern; small perforators are unforgiving.
- Clear hair from any urethral segment before transfer.
- Keep the tunnel generous; a pedicled SCIP can still fail from kinking or compression.
- Keep an alternate urethral strategy ready if SCIP caliber, length, or tissue quality is poor.
See Also
- Masculinizing Gender-Affirming Surgery
- ALT Phalloplasty
- RFFF Phalloplasty
- Superficial Circumflex Iliac Artery Perforator Flap
- Anterolateral Thigh Flap
- Radial Forearm Free Flap
- Buccal Mucosa Graft
References
1. D'Arpa S, Claes K, Lumen N, Oieni S, Hoebeke P, Monstrey S. Urethral reconstruction in anterolateral thigh flap phalloplasty: a 93-case experience. Plast Reconstr Surg. 2019;143(2):382e-392e. doi:10.1097/PRS.0000000000005278
2. De Gelder A, Young-Afat D, Claes K, et al. Use of the superficial circumflex iliac artery perforator flap for urethra and/or shaft reconstruction in gender-diverse persons: 10-year single-center experience. Plast Reconstr Surg. 2025;155(6):1036e-1044e. doi:10.1097/PRS.0000000000011830
3. de Haseth KB, Young-Afat DA, Mokken SE, et al. Superficial circumflex iliac artery (SCIA) perforator flap for shaft-only phalloplasty: surgical technique and outcomes. Int J Transgend Health. 2025;26(4):1377-1387. doi:10.1080/26895269.2024.2440854
4. Calotta NA, Kuzon W, Dellon AL, Monstrey S, Coon D. Sensibility, sensation, and nerve regeneration after reconstructive genital surgery: evolving concepts in neurobiology. Plast Reconstr Surg. 2021;147(6):995e-1003e. doi:10.1097/PRS.0000000000007969
5. Ferrin PC, Burghardt E, Xu J, Peters BR. Optimizing neurorrhaphy to improve sensation in phalloplasty: a systematic review. Int J Impot Res. 2026;38(4):324-332. doi:10.1038/s41443-025-01021-w
6. Yao A, Ingargiola MJ, Lopez CD, et al. Total penile reconstruction: a systematic review. J Plast Reconstr Aesthet Surg. 2018;71(6):788-806. doi:10.1016/j.bjps.2018.02.002
7. Cripps C. Thinking outside the box: alternative techniques for gender affirming phalloplasty. Neurourol Urodyn. 2023;42(5):973-978. doi:10.1002/nau.25104
8. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;95(1):120-124. doi:10.1111/j.1464-410X.2004.05262.x
9. Terrier JE, Courtois F, Ruffion A, Morel Journel N. Surgical outcomes and patients' satisfaction with suprapubic phalloplasty. J Sex Med. 2014;11(1):288-298. doi:10.1111/jsm.12297
10. Gandolfi S, Postel F, Auquit-Auckbur I, et al. Vascularization of the superficial circumflex iliac perforator flap (SCIP flap): an anatomical study. Surg Radiol Anat. 2020;42(4):473-481. doi:10.1007/s00276-019-02402-9
11. Schiltz D, Lenhard J, Klein S, et al. Do-it-yourself preoperative high-resolution ultrasound-guided flap design of the superficial circumflex iliac artery perforator flap (SCIP). J Clin Med. 2021;10(11):2427. doi:10.3390/jcm10112427
12. Broyles JM, Smith JM, Wong FC, et al. Single-photon emission computed tomographic reverse lymphatic mapping for groin vascularized lymph node transplant planning. Plast Reconstr Surg. 2022;150(4):869e-879e. doi:10.1097/PRS.0000000000009557
13. Goh TLH, Park SW, Cho JY, Choi JW, Hong JP. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap - a review of 210 cases. Plast Reconstr Surg. 2015;135(2):592-601. doi:10.1097/PRS.0000000000000951
14. Al-Tamimi M, Pigot GL, Ronkes B, et al. The first experience of using the pedicled labia minora flap for urethral lengthening in transgender men undergoing anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty: a multicenter study on clinical outcomes. Urology. 2020;138:179-187. doi:10.1016/j.urology.2019.10.041
15. Wu Q, Yang Z, Ma N, Wang W, Li Y. Urethra reconstruction and revision urethroplasty in pedicled anterolateral thigh flap penile reconstruction. Ann Plast Surg. 2022;89(2):201-206. doi:10.1097/SAP.0000000000003100
16. Neuville P, Morel-Journel N, Maucourt-Boulch D, et al. Surgical outcomes of erectile implants after phalloplasty: retrospective analysis of 95 procedures. J Sex Med. 2016;13(11):1758-1764. doi:10.1016/j.jsxm.2016.09.013
17. Wang E, Cleff B, Basta A, et al. Flap choice in gender-affirming phalloplasty affects postoperative complication rates. Microsurgery. 2026;46(1):e70154. doi:10.1002/micr.70154
18. Selvaggi G, Monstrey S, Ceulemans P, T'Sjoen G, De Cuypere G, Hoebeke P. Genital sensitivity after sex reassignment surgery in transsexual patients. Ann Plast Surg. 2007;58(4):427-433. doi:10.1097/01.sap.0000238428.91834.be
19. Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. "Phalloplasty: techniques and outcomes." Transl Androl Urol. 2019;8(3):254-265. doi:10.21037/tau.2019.05.05
20. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Transgender Patients." EAU Guidelines. 2026. Online chapter.