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Metoidioplasty represents a viable option for female-to-male transsexual patients seeking gender reassignment surgery. The aim of this procedure is to create a microphallus with lengthening of the urethra to the tip of the hypertrophied and released clitoris. However, fistula formation and urethral obstruction might occur in the long term and reconstruction represents a challenging problem in this setting. In this report, we present the tubed superficial inferior epigastric artery perforator island flap as an option for urethral reconstruction after failed metoidioplasty in a female-to-male transsexual patient. In a 26-year-old transsexual patient a combination of urethral fistula, urethral stenosis, and disintegrated distal neourethra had developed as a consequence of postoperative hematoma formation. Metoidioplasty was reconstructed by means of a tubed, pedicled superficial inferior epigastric artery perforator flap from the left lower abdomen. The long-term result was stable with pleasing genital appearance, adequate functional outcome, and satisfactory donor site morbidity. In our opinion, this procedure may represent a viable alternative for urethral reconstruction in thin patients. © 2014 Wiley Periodicals, Inc. Microsurgery 35:403–406, 2015.