vaginal reconstruction due to agenesis , trauma , or after surgical exenteration , has undergone significant evolution since the introduction of split thickness skin graft to cover the vagina canal by abbe in 19th century 1 . the ideal reconstructive procedure should be reliable and provide normal function with no subsequent needs for dilatation . variety of procedures and techniques have been performed to achieve the mentioned goals including using different parts of gastrointestinal tract as either a graft , pedicle flap or free flap 2 , 3 . we describe our case , a 55yearold lady , who was referred to us with a narrow vagina caused by a progressive fibrosis of unknown origin over 2 years which affected her relationship . given the physical and psychological effects on the patient and after ruling out malignancy , decision has been made in multidisciplinary meeting ( mdt ) to reconstruct the vagina . hence , we decided to create the neovagina with a free jejunum flap in view to enlarge the canal , improve the lubrication along with preservation of sensation to clitoris . a 55yearold lady referred to our unit from gynecology department with a progressive vaginal fibrosis over 2 years . imaging was inconclusive and histology revealed epithelial atrophy , chronic inflammatory infiltrates , and intense focal submucosal edema with no evidence of malignancy . vaginal wall thickness reduced from 4.4 to 2.7 mm in further biopsies without showing any change in the cervix or parametrium . cervical biopsy and endocervical curettage indicated reactive benign cellular changes associated with atrophy . storage disease was then ruled out by measuring relevant immunoglobulins and antibodies in the blood . after considering all findings and patients complaint , we decided to perform the reconstruction without visible scars around perineal and thighs ( fig . mri t2wi in the sagittal plane after intravaginal gel administration depicts a lack of vaginal distention , and an abnormal homogenous diffuse high signal intensity in the vaginal walls , secondary to vaginal stenosis and fibrosis . our approach to abdomen was through the midline infraumbilical laparotomy incision from the previous cesarean section . the cesarean was done 20 years before , most probably for fetal distress . that median incision was the approach of choice for a more rapid fetal extraction in those years . we noticed an intense fibrosis of the uterosacral and parametrial ligaments as well as an atrophic uterus . after performing total hysterectomy and double adnexectomy , the fibrotic vagina wall resected via vaginal approach . hysterectomy and bilateral oophorectomy was performed because they precluded the completion of correct cervical cancer screening , due to stenosis of the introitus , to the vaginal fibrosis and to the obliteration and fusion of the vaginal sack with the cervix . segment was approximately 70 cm from the treitz ligament supplied by the third branch of the superior mesenteric artery . after transferring the segment to the pelvis , microsurgical anastomosis performed to the right inferior epigastric vessels and satisfactory flow was confirmed with an intraoperative doppler ( fig . inferior part of the jejunum sutured to the remnant of the vagina without tension with 3.0 braided sutures and then , the posterior wall of the vagina was created with the flap ( fig . flap molded as desired right after anastomosis to the deep inferior epigastric artery and vein and before insetting to reconstruct the new vagina . notice the particular design of the flap which allowed us to reconstruct the posterior wall of the vagina and at the same time\r\nelongate it . finally , surgical wound was closed over a drain and patient was transferred to the recovery with a dilator in situ which was kept for 2 weeks . patient was discharged on day 15 with a satisfactory computed tomography scan ( ctscan ) . she was reviewed in the clinic 2 months postoperatively with an aesthetically acceptable vagina measuring 4 cm in width and 14.5 cm in length ( fig . she started her sexual intercourse 3 months postoperatively and by the fourth month , secretions lessened significantly . ct in the sagittal plane after administration of iodinated contrast medium in the neovagina shows the size , shape , location , and intestinal pattern of the walls , as well as the excellent distention . our approach to abdomen was through the midline infraumbilical laparotomy incision from the previous cesarean section . the cesarean was done 20 years before , most probably for fetal distress . that median incision was the approach of choice for a more rapid fetal extraction in those years . we noticed an intense fibrosis of the uterosacral and parametrial ligaments as well as an atrophic uterus . after performing total hysterectomy and double adnexectomy , hysterectomy and bilateral oophorectomy was performed because they precluded the completion of correct cervical cancer screening , due to stenosis of the introitus , to the vaginal fibrosis and to the obliteration and fusion of the vaginal sack with the cervix . segment was approximately 70 cm from the treitz ligament supplied by the third branch of the superior mesenteric artery . after transferring the segment to the pelvis , microsurgical anastomosis performed to the right inferior epigastric vessels and satisfactory flow was confirmed with an intraoperative doppler ( fig . inferior part of the jejunum sutured to the remnant of the vagina without tension with 3.0 braided sutures and then , the posterior wall of the vagina was created with the flap ( fig . flap molded as desired right after anastomosis to the deep inferior epigastric artery and vein and before insetting to reconstruct the new vagina . notice the particular design of the flap which allowed us to reconstruct the posterior wall of the vagina and at the same time\r\nelongate it . finally , surgical wound was closed over a drain and patient was transferred to the recovery with a dilator in situ which was kept for 2 weeks . patient was discharged on day 15 with a satisfactory computed tomography scan ( ctscan ) . she was reviewed in the clinic 2 months postoperatively with an aesthetically acceptable vagina measuring 4 cm in width and 14.5 cm in length ( fig . she started her sexual intercourse 3 months postoperatively and by the fourth month , secretions lessened significantly . ct in the sagittal plane after administration of iodinated contrast medium in the neovagina shows the size , shape , location , and intestinal pattern of the walls , as well as the excellent distention . vaginal reconstruction is a complex and controversial process as it affects individuals both physically and psychologically . most frequent indication is congenital agenesis followed by neoplasm , stenosis due to radiotherapy or transsexuality problems 4 , 5 . although a wide spectrum of surgical and nonsurgical techniques being performed , from a simple graft to regional and free flaps 6 , many patients present with postoperative complications such as hypertrophic or unsightly scars , absent or excess of lubrication , receding grafts , and stenosis 7 , 8 . nonsurgical techniques like  frank  are based on progressive introitus dilatation without satisfactory results 6 . mclndoe procedure may offer good result few months postoperatively , but dyspareunia and scarring can be the limiting factors , on the other hand , different types of regional flaps mainly based on perforators of internal pudendal artery can restore shape , volume , and function of the vagina , but lacks lubrication 5 , 9 . amniotic graft can mimic characteristics of the vagina , however , fistula formation , stenosis , inadequate length , and poor lubrication can complicate the postoperative period 10 , 11 . baldwin introduced intestinal interposition , subsequently pedicled and free gastrointestinal segments such as jejunum , cecum , and colon have been employed for the reconstruction . the advantages of using intestinal segments are lowering the risk of stenosis , no molds required to ensure permeability , resistant to repetitive trauma , present natural lubrication , and prevent dyspareunia 12 . on the contrary , the presence of two surgical teams and lengthy procedure are the two limiting factors , and potential donor site morbidities can also be debilitating 13 . the other postoperative concern is hypersecretion which progressively diminishes , thus patients can usually resume their sexual relationship after 3 months 14 . numerous techniques have been described in vaginal reconstruction . vaginal fibrosis is an uncommon condition and treatment gastrointestinal ( gi ) tract flaps can be ideal as they enlarge and lengthen the vagina , provided natural lubrication , and maintain sensitivity .
key clinical messagevaginal reconstruction represents a very difficult challenge . 
 free jejunal flaps can be easily molded and adapted to solve complex cases restoring the width , length , and consistency of the  new  vagina without compromising the external genitalia and improving the lubrication while preserving sensation to clitoris .