Introduction <p>Total anorectal reconstruction (TAR) can be challenging for surgeons aiming to achieve both anatomic and functional anal reconstruction. Techniques involving coloplasties and graciloplasties have been described but have yet to become routine procedures. In this report, we present a rare case of TAR combining a coloplasty with an innervated gracilis muscle flap. This case aims to illustrate the surgical approach and emphasize the critical role of physiotherapy in postoperative functional recovery.</p> Methods <p>We report the case of a young female patient who underwent abdominoperineal resection (APER) following a low rectal carcinoma, resulting in a permanent end colostomy. Five years later, with no evidence of local or distant recurrence, the patient sought to improve her quality of life. TAR was performed by mobilizing the colon into the perineum and creating a neosphincter through an innervated gracilis muscle flap loop around the colon. Postoperatively, the patient underwent 6 months of intensive pelvic floor rehabilitation, including manometry-guided biofeedback therapy. This case report was prepared in accordance with the CARE (CAse REport) guidelines.</p> Results <p>Minor revision surgeries were needed to optimize the perineal colostomy scar, and three dilatation procedures were performed over 4 years to manage mild stenosis. The neo-anus remains functional at the 5-year postoperative visit, with fecal continence achieved within 2 months.</p> Conclusion <p>TAR is documented in the literature, though still not used systematically for various reasons, including inadequate muscle contraction, fatigability, and lack of neuroplastic adaptations in the central nervous system. Through this report, we demonstrate that an adequate surgical technique, followed by intensive pelvic floor training and manometry-assisted biofeedback to promote neuroplasticity, can provide successful outcomes.</p>