A 24-year-old male-to-female transgender adult with a body mass index of 25.8 kg/m2 who underwent gender reassignment surgery through penoscrotal flap vaginoplasty  in an external center was admitted to our clinic with the complaint of fecal incontinence through the vagina.
His medical history revealed no comorbidities or previous surgery, and he was using psychiatric drugs. After the initial surgery, neovaginal dilatation was performed using specifically designed dilators to prevent neovaginal stenosis, and fecal incontinence through the vagina occurred three months after the initial surgery. The patient was followed for a couple of months; however, no spontaneous closure of the fistula was noted.
In our clinic, physical examination was performed in the lithotomy position under the supervision of a gynecologist, and methylene blue dye was given via the transanal route, which was fistulized to the vagina through the anterior wall. The fecal diversion was decided to prevent fecal contamination of the fistula tract and to provide secondary healing. Transverse end colostomy was performed. After three months of surgery, the patient was reexamined in the lithotomy position. However, the methylene blue dye, which was given via the transanal route was found to be fistulized to the vagina through the anterior wall. As a result, restorative perineal graciloplasty was planned. Written informed consent was obtained from the patient.
The gracilis muscle is a long and slender muscle located in the adductor compartment of the thigh. Its transposition is a viable option for repairing fistulas between the neovagina and rectum . The operation was performed under general anesthesia in the lithotomy position (Figure 1).