42-year-old married woman, singleton (twins), with a 20-year history of repeated infections in the genital area. At the age of 22 she contracted HPV; for years she was treated with laser, without success. She suffered from Candida albicans infections at least once a month. At the age of 34 she developed genital herpes. Episodes of candidiasis worsened, alternating with herpes. Constant vaginal pain made it impossible for her to maintain regular sexual activity. At the age of 36 she underwent in vitro fertilisation (IVF) treatment, resulting in a twin pregnancy carried to term. At the age of 38, she underwent a new vaginal laser cauterisation, which evolved with repeated ulcerations, mainly in two locations, always very difficult to heal. Her vagina was permanently dry and she could not wear trousers due to constant pain. Faced with the dissatisfaction caused by conventional and unsuccessful treatments, with her intimate life at an unacceptable level, the patient was looking for an alternative.
Taking into account the knowledge acquired about wound treatment and the good evolution of chronic ulcers treated with lipoaspirate graft (which contains most of the VEFs and ADSCs (1)), we proposed an innovative solution for her case.
This proposal consisted of:
1. Resection of the vaginal areas with recurrent wounds, and coverage with local rotation flaps.

2. Lipografting of the labia majora to increase their volume and thus close the vulvar orifice and retain the natural moisture.
3. Lamellar lipograft placed under the vaginal mucosa, in all its posterior hemisphere, in order to increase the inflammatory response capacity, improve the healing power and give resistance to the tissues.
Once the proposal was accepted by the patient, the surgery was performed under general anaesthesia. Although the fat donor areas with the highest production of stem cells are those of the trunk of the body (3), in this case we opted to aspirate from the hips, using tumescent technique with physiological saline and adrenaline at 1 /500,000, following the usual practice of our group (4). We used 4 mm diameter cannulas for liposuction and 3 mm diameter cannulas for grafting. From the aspirate column (approximately 400 cc. Fig. 1), after waiting 40 minutes for sedimentation, we discarded the oil layer on the surface, resulting from the rupture of the adipocytes, and the residual liquid at the bottom, mostly the product of infiltration. We grafted 10 cc of fat in each labium majus, tunneled in layers, and 4 cc in the posterior submucosa of the vagina following the retroinjection technique, in a parallel and laminar fashion; we had previously performed resection of two vaginal ulcers and approximation of the superficial transverse muscle of the perineum, with a small posterior perineoplasty for closure. The patient was discharged from hospital the day after the operation. She removed two internal stitches of polyglycolic acid suture thread at three and four weeks.

As for recovery, she resumed her professional activities three days after surgery, her sporting activities after three weeks and, out of misgivings, did not resume sexual relations until two months after surgery. Due to restriction of the perineum, she presented a small fissure next to the posterior vaginal commissure after sexual intercourse, which healed quickly.

So far, after 9 months of follow-up, there has been no recurrence of herpes or any other type of infection; the vagina is permanently moist, something she was unaware of as she had always lived with local dryness. The vaginal introitus remains closed, the labia have a youthful and turgid appearance and the patient can wear any type of clothing. Her only complaints are related to the occasional appearance of fissures in the posterior commissure after sexual intercourse, and a small wound of 3 x 1 cm, painful, which occasionally appears at the point where an irreabsorbable stitch was placed in depth, but which does not coincide with the area where the ulcers caused by the laser therapy were previously located. These problems are caused by mechanical action and can be corrected; they are due to a small excess in the closure of the perineum and a reaction to the suture thread, and not due to a lack of resistance of the tissues, which was the main objective of the treatment and which was fully successful, as we know from MRI carried out 2 months after the surgery, that the liposuctioned material had already stabilised in its new bed (2), as well as the angiogenesis induced by the EVF, which was already fully active, allowing an improvement in the resistance of the mucosa and restoring it to normality. After this period, the critical moment for this type of surgery is considered to have passed.

