The Oral Cavity
The oral cavity is the usual donor site for urethral substitution grafts. The AUA urethral stricture guideline states that surgeons should use oral mucosa as the first choice when a graft is used for urethroplasty and that buccal or lingual mucosa may be used as equivalent alternatives .[1] Buccal mucosa provides the largest graft area. Lingual mucosa is thinner and may restrict the lumen less in the distal urethra and meatus.[1][6]
The buccal, lingual and oral-lip graft pages cover technique and outcome evidence. Male Urethra covers recipient anatomy.
Tissue Biology
Oral lining mucosa provides hair-free, nonkeratinized squamous epithelium and a vascular connective-tissue layer. It can tolerate a wet environment, but graft survival still depends on contact with a healthy recipient bed, immobilization and revascularization. Oral tissue can scar, contract, become infected or fail.[2][3]
Two biological studies are often cited:
- Human histology: Soave studied 22 patients undergoing repeat surgery for recurrent stricture. Previously implanted buccal grafts retained stratified nonkeratinized squamous histology and were not overgrown with urothelium after a mean 22.2 months (range 4.1–76.0). This shows persistence of tissue identity.[4]
- Animal angiogenesis: Gardikis compared grafts in 22 rabbits. Buccal grafts had more vessels than penile-skin grafts at postoperative day 21 (94.3 ± 6.4 vs 61.7 ± 6.4 per ×200 field).[5]
Buccal Mucosa
The inner cheek extends from the oral commissure toward the retromolar region, between the gingivobuccal sulci. Identify the parotid duct papilla opposite the upper second molar and preserve the duct, commissure and adequate surrounding mucosa. Injury to the duct risks a salivary fistula or duct stricture.[12][13] Graft size is set by the individual mouth and the measured urethral defect.[12][13]
Buccal and other maxillary-artery branches supply the cheek. Elevate the graft superficial to buccinator, leaving donor muscle intact, then remove excess fat from the deep graft surface without over-thinning its lamina propria.[13] Sensation is supplied by the long buccal nerve, a branch of V3, distinct from the motor buccal branches of the facial nerve. Deep or extensive harvest can produce numbness, tightness and restricted mouth opening.[12]
Bilateral cheek harvest supplies additional tissue, with additional donor morbidity. In a 2024 survey of Society of Genitourinary Reconstructive Surgeons members (134 of 350 responded), 99% preferred buccal mucosa as the primary site and 56% preferred using both cheeks for long grafts. Respondents favored buccal mucosa over a fasciocutaneous flap for penile urethroplasty (95% for circumcised, 84% for uncircumcised patients), dorsal over ventral graft placement for bulbar strictures (66%), and multiple buccal grafts over a combined graft and flap for panurethral strictures (90%). Success was estimated at 80% to 90% by 53%.[7]
Lingual Mucosa
The usual donor is the ventrolateral tongue, avoiding the dorsal papillary surface, frenulum and floor-of-mouth duct openings. The submandibular ducts open beside the base of the frenulum. Plan around visible veins and the underlying lingual neurovascular structures; stay superficial to tongue muscle.[2][14]
The lingual artery and its branches supply the tongue and floor of mouth. General sensation in the anterior tongue travels through the lingual nerve (V3), with taste fibers from chorda tympani (VII). These sensory pathways explain potential numbness and altered taste after harvest; deeper tissue injury can also impair tongue movement.[14][15]
Long strips, separate bilateral strips or combined cheek or lingual harvests have been reported. Xu's 81-patient long-stricture series included 52 patients with a 9–12 cm lingual strip, 17 with a longer strip and 12 with combined lingual and buccal grafts. The 8–20 cm range is the stricture length. In this retrospective series, success was 82.7% at a mean 41 months (range 15–86), and 5 patients (6.2%) reported minimal difficulty with fine tongue movement at 12 months.[8] A meta-analysis cited by the AUA guideline (12 studies) found no difference in success between buccal and lingual grafts (RR 1.03; 95% CI 0.96–1.10) and no difference in stricture or fistula complications.[1] Buccal donor sites carried more swelling, numbness and difficulty opening the mouth, and lingual donor sites more difficulty with speech and tongue protrusion.[1]
What the Histology Actually Shows
Campos-Juanatey analyzed 52 graft specimens from a 33-patient series: 30 buccal and 22 lingual specimens after five samples were unavailable. Mean graft size was 5.8 × 1.7 cm; lingual grafts were significantly longer and narrower than buccal grafts.[2]
| Measurement | Buccal | Lingual |
|---|---|---|
| Total thickness, median | 1,693 µm | 1,347 µm |
| Epithelial thickness, mean | 577 µm | 415 µm |
| Submucosal thickness, median | 824 µm | 438 µm |
| Vascular area, median | 5% | 5% |
| Muscular layer, median | 325 µm | 573 µm |
| Adipose tissue, median | 10% | 2% |
The cheek samples had thicker epithelium and submucosa and more fat, and the lingual samples a thicker muscular layer. Total thickness and vascular measurements did not differ significantly. The pooled median thickness of both graft types was 1,599 µm. The study did not correlate these measurements with clinical outcomes.[2]
Oral-Lip Mucosa
The upper and lower lips have nonkeratinized mucosal lining with minor salivary glands. Facial-artery labial branches provide arterial supply. Lower-lip sensation is supplied by the mental nerve (V3); upper-lip sensation is supplied by the infraorbital nerve (V2). Preserve orbicularis oris and avoid deep injury to sensory branches.[16]
Oral-lip tissue is an additional donor option when cheek or tongue harvest is unsuitable. Historical pediatric repairs used upper and/or lower lip alone or in combination with bladder mucosa. In Dessanti's series of 12 children, 7 had lip mucosa alone for urethral gaps of 3.5–6 cm and 5 with posterior hypospadias had combined lip and bladder mucosa for gaps of 6–13 cm.[9]
“Labial” in a publication can mean oral lip or vulvar labia. Confirm which before applying its findings to a donor site.
Selection and Counseling
| Donor | Useful features | Main counseling and planning issues |
|---|---|---|
| Cheek | Familiar harvest; useful width; additional tissue from the opposite cheek | Parotid duct, commissure, numbness, tightness and mouth opening |
| Ventrolateral tongue | Thin graft; long narrow strips or an additional donor source | Speech, eating, tongue movement, taste and sensory change |
| Oral lip | Additional accessible mucosa in selected cases | Mental-nerve symptoms, lip contour/tightness and limited individual donor area; a review of retrospective series cited by EAU reports greater donor-site morbidity with lower-lip than lingual grafts, including potentially permanent discomfort, sensory or salivary-flow changes, and aesthetic sequelae.[17] |
Before recommending oral grafting, examine the head and neck and intended oral donor mucosa for disease that could be transferred to the recipient site.[2] The AUA guideline treats cheek and lingual grafts as equivalent alternatives; that statement is not specific to stricture location, length, etiology or reconstruction.[1]
Complication estimates depend on the study and time point. In Lumen's prospective comparison of 29 cheek and 29 lingual grafts, urethroplasty success was 82.8% (cheek) and 89.7% (lingual) at a mean 30 months (p = 0.306). On day 3, lingual harvest was followed by more speech difficulty (93.1% vs 55.2%, p = 0.001), severe eating and drinking difficulty (62.1% vs 24.1%, p = 0.004) and dysgeusia (48.3% vs 13.8%, p = 0.01). At 2 weeks, speech impairment remained more frequent after lingual harvest (55.2% vs 13.8%, p = 0.002) and oral tightness after cheek harvest (41.4% vs 6.9%, p = 0.005). Median pain scores (0–10) at day 3, 2 weeks and 6 months were 4, 2 and 0 after cheek and 6, 3 and 0 after lingual harvest, without significant differences. At 6 months, sensory symptoms persisted in 44.8% after cheek and 31% after lingual harvest (p = 0.279).[10]
For cheek donor closure, the 135-patient Soave randomized trial reported nonclosure noninferior for pain intensity and affective pain quality. Closure is chosen by tension, hemostasis and defect geometry. Graft length also affected oral pain and morbidity in this trial. The buccal graft page discusses the broader evidence.[11]
References
1. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482
2. Campos-Juanatey F, Azueta Etxebarria A, Calleja Hermosa P, et al. "Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply?" J Clin Med. 2022;11(7):2064. doi:10.3390/jcm11072064
3. Sterling J, Hecksher D, Hayden C, et al. "Buccal Mucosa — A Narrative Review: How Does It Work, How Is It Used, What Is Coming Next." Urology. 2026;211:113–119. doi:10.1016/j.urology.2026.03.015
4. Soave A, Steurer S, Dahlem R, et al. "Histopathological Characteristics of Buccal Mucosa Transplants in Humans After Engraftment to the Urethra: A Prospective Study." J Urol. 2014;192(6):1725–9. doi:10.1016/j.juro.2014.06.089
5. Gardikis S, Giatromanolaki A, Ypsilantis P, et al. "Comparison of Angiogenic Activities After Urethral Reconstruction Using Free Grafts in Rabbits." Eur Urol. 2005;47(3):417–21. doi:10.1016/j.eururo.2004.10.014
6. Horiguchi A. "Substitution Urethroplasty Using Oral Mucosa Graft for Male Anterior Urethral Stricture Disease: Current Topics and Reviews." Int J Urol. 2017;24(7):493–503. doi:10.1111/iju.13356
7. Berg C, Singh A, Hu P, et al. "Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019
8. Xu YM, Li C, Xie H, et al. "Intermediate-Term Outcomes and Complications of Long-Segment Urethroplasty With Lingual Mucosa Grafts." J Urol. 2017;198(2):401–406. doi:10.1016/j.juro.2017.03.045
9. Dessanti A, Porcu A, Scanu AM, Dettori G, Caccia G. "Labial Mucosa and Combined Labial/Bladder Mucosa Free Graft for Urethral Reconstruction." J Pediatr Surg. 1995;30(11):1554–6. doi:10.1016/0022-3468(95)90155-8
10. Lumen N, Vierstraete-Verlinde S, Oosterlinck W, et al. "Buccal Versus Lingual Mucosa Graft in Anterior Urethroplasty: A Prospective Comparison of Surgical Outcome and Donor Site Morbidity." J Urol. 2016;195(1):112–7. doi:10.1016/j.juro.2015.07.098
11. Soave A, Dahlem R, Pinnschmidt HO, et al. "Substitution Urethroplasty With Closure Versus Nonclosure of the Buccal Mucosa Graft Harvest Site: A Randomized Controlled Trial With a Detailed Analysis of Oral Pain and Morbidity." Eur Urol. 2018;73(6):910–922. doi:10.1016/j.eururo.2017.11.014
12. University of Iowa. Buccal mucosa and masticator space anatomy. Iowa Head and Neck Protocols. Anatomy. Accessed September12,2026.
13. University of Iowa. Buccal mucosa graft for urethral reconstruction. Iowa Head and Neck Protocols. Harvest protocol. Accessed September12,2026.
14. Rusu MC, Nimigean V, Podoleanu L, et al. Details of the intralingual topography and morphology of the lingual nerve. Int J Oral Maxillofac Surg. 2008;37:835–839. doi:10.1016/j.ijom.2008.05.014
15. Lopez R, Lauwers F, Paoli JR, et al. Vascular territories of the tongue: anatomical study and clinical applications. Surg Radiol Anat. 2007;29:239–244. doi:10.1007/s00276-007-0202-8
16. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg. 2008;22:269–280. doi:10.1055/s-0028-1095886
17. European Association of Urology. EAU Guidelines on Urethral Strictures, tissue transfer §9.3. 2026. Guideline.