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Oral-Lip Mucosa Graft

Oral-lip mucosa, usually the inner lower lip, is an additional donor for urethral reconstruction. Cheek and lingual mucosa have stronger contemporary comparative support. For male urethral stricture reconstruction, AUA 2023 permits buccal or lingual grafts as equivalent alternatives ; EAU 2026 recommends either when available and counseling on distinct buccal, lingual, and lower-lip donor morbidity .[1][15] Lower-lip harvest remains useful in selected patients, with particular attention to mental-nerve symptoms, donor area and lip function.[1][2]

Name the donor explicitly. “Labial” can refer to oral lip or vulvar labia, and some papers call lower-lip grafts “buccal.” Confirm the operative harvest site before applying results. An oral-lip free graft differs from a labia-majora fasciocutaneous flap.

See Grafts in GU Reconstruction, The Oral Cavity, Buccal Mucosa and Lingual Mucosa.

Anatomy and Harvest Planning​

The inner lip has nonkeratinized stratified squamous epithelium, connective tissue and minor salivary glands superficial to orbicularis oris. This resembles other oral lining mucosa, but the tissues are not histologically identical.[3][4]

The lower lip and chin receive sensation through the mental nerve, a terminal branch of the inferior alveolar nerve (V3). Upper-lip sensation comes from the infraorbital nerve (V2). The facial artery's labial branches supply the lips. Preserve the supporting muscle and avoid deep dissection around sensory branches.[14][5][6]

Cadaveric studies show variable mental-nerve branching and cross-midline communications. Won examined ten specimens: branches overlapped adjacent branches in five and anastomosed with the buccal nerve in six. Toure studied 60 mental nerves in 30 lips and described three intralabial patterns: type I without connections, type II with connections in the upper third of the lower lip, and type III with connections in the upper, middle and lower thirds. Types II and III allow recovery of labiomental sensation after nerve injury.[5][6]

Practical Sequence​

  1. Examine oral health, baseline sensation, previous graft sites, mouth opening and lip contour. Match the donor plan to the measured recipient defect and discuss alternatives.
  2. Evert the lip and mark a mucosal graft that preserves the vermilion, commissures and adequate surrounding mucosa. Avoid treating published defect lengths as fixed donor-site limits.
  3. Elevate mucosa and supporting connective tissue with controlled superficial dissection; preserve orbicularis oris and protect sensory branches.
  4. Obtain hemostasis and manage the defect without excessive tension or distortion. Closure technique depends on the defect.
  5. Prepare and inset the free graft on a vascular recipient bed. Lower-lip urethroplasty reports describe removing deep tissue to retain mucosa and lamina propria and quilting or otherwise securing the graft to its bed; small fenestrations have been used to limit hematoma.[17][18] Its blood supply must be re-established.[3][2][7]

Dessanti's 12-case historical series used upper and/or lower lip alone in seven patients and combined lip/bladder mucosa in five. The 3.5–6 cm and 6–13 cm ranges described urethral gaps, not anatomical harvest maxima. There was one fistula and four early stenoses requiring dilation.[7]

Reconstructive Evidence​

Castagnetti 2009 reviewed 115 children and adults with heterogeneous anterior urethral defects. Reported success was 66% at median 36 months; 39 patients had complications and 18 required additional surgery.[8] Tubular graft configuration was the only factor significantly associated with complications; in hypospadias-related defects the odds ratio was 5.86 (95% CI 1.5–23.4), and the authors favored an onlay configuration.[8] Complications were unrelated to age, indication, graft length or stricture level. EAU 2026 gives a Strong recommendation against tubularizing a free graft in a single-stage repair.[15] Later tubularization of a healed first-stage graft is a different reconstruction.[8]

Caldamone 1998 included 22 complex reconstructions, 18 of them after failed hypospadias repair, using cheek, lower lip or combined grafts (seven combined); 16 were tubular and six onlay. Nine developed urethral complications (two meatal stenoses, four fistulas, three strictures) that had been managed successfully at the time of the report, and two had donor-site complications.[9]

The 2025 Jena report describes 204 female “labial mucosal” graft urethroplasties. The accessible Jena abstract cannot support lower-lip selection or a lower-lip-specific 93.5% success rate without the full operative report.[10] A retrospective single-arm series explicitly used lower-lip mucosa after failed minimally invasive treatment in 17 women; 16/17 (94%) had no detected surgical failure during at least 12 months of follow-up, with cystoscopy reserved for symptomatic patients with increased residual urine or low flow.[16]

Use the specific donor and procedure described by the source; the buccal graft hub covers those applications.

Donor-Site Morbidity​

StudyPopulation and findingLimit
Kamp 200524 patients; 12 lower-lip or combined lip/cheek harvests versus 12 cheek harvests. Mean pain duration 5.9 versus 1 month (p = 0.022) and perioral numbness 10.3 versus 0.85 months (p = 0.0027); 6/12 versus 11/12 patients satisfied. The authors changed to cheek harvest whenever possible, attributing the difference to mental-nerve neuropathySmall nonrandomized study; the first group was not exclusively lower lip. Mouth opening and food intake did not differ significantly [2]
Jang 200540 men: 17 lip, 19 cheek, four combined. More persistent discomfort, sensory deficit and salivary change after lip harvestContractures were noted in 1/17 lip and 5/19 cheek patients. Overall quality-of-life scores did not differ significantly (1.35 versus 0.66, p = 0.079) [11]
Castagnetti 200878 children/adults with mixed oral donors; perioral sensory deficits were found in 28% of cases formally examined by an oral surgeon after median 7.6 yearsObjective findings and perceived bother differed [12]
Tekin 202553 eligible pediatric patients, 21 available for objective testing; tested sensory measures were similar to controlsSelective participation and small sample

Sources:[2][11][12][13]

Counsel about bleeding, pain, potentially persistent numbness or discomfort, altered salivary flow and oral function, tightness, and possible lasting lip contour change.[15] Discuss the patient's need for speech, eating and other oral activities. Avoid promising “scarless” healing, infection immunity or sensory recovery by a fixed date.[3][2] It is not established as the preferred graft for female urethral reconstruction.[3][2]

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. Kamp S, Knoll T, Osman M, et al. Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek? BJU Int. 2005;96(4):619–23. doi:10.1111/j.1464-410X.2005.05695.x

3. Markiewicz MR, DeSantis JL, Margarone JE, Pogrel MA, Chuang SK. Morbidity associated with oral mucosa harvest for urological reconstruction: an overview. J Oral Maxillofac Surg. 2008;66(4):739–44. doi:10.1016/j.joms.2007.11.023

4. 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

5. Won SY, Yang HM, Woo HS, et al. Neuroanastomosis and the innervation territory of the mental nerve. Clin Anat. 2014;27(4):598–602. doi:10.1002/ca.22310

6. Toure G. Mental nerves in the lower lip: anatomical basis for the recovery of sensation following inferior alveolar nerve damage. Plast Reconstr Surg. 2023;152(2):413–20. doi:10.1097/PRS.0000000000010241

7. 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

8. Castagnetti M, Rigamonti W. Aptness and complications of labial mucosa grafts for the repair of anterior urethral defects in children and adults: single centre experience with 115 cases. World J Urol. 2009;27(6):799–803. doi:10.1007/s00345-009-0401-5

9. Caldamone AA, Edstrom LE, Koyle MA, Rabinowitz R, Hulbert WC. Buccal mucosal grafts for urethral reconstruction. Urology. 1998;51(5A Suppl):15–9. doi:10.1016/s0090-4295(98)00088-0

10. Jena AK, Jena R, Madhavan M, Madhavan K. Dorsal onlay labial mucosal graft urethroplasty in female urethral stricture: outcomes of over 200 cases from a single surgeon. Urology. 2025;204:216–223. doi:10.1016/j.urology.2025.05.040

11. Jang TL, Erickson B, Medendorp A, Gonzalez CM. Comparison of donor site intraoral morbidity after mucosal graft harvesting for urethral reconstruction. Urology. 2005;66(4):716–20. doi:10.1016/j.urology.2005.04.045

12. Castagnetti M, Ghirardo V, Capizzi A, Andretta M, Rigamonti W. Donor site outcome after oral mucosa harvest for urethroplasty in children and adults. J Urol. 2008;180(6):2624–8. doi:10.1016/j.juro.2008.08.053

13. Tekin A, Tiryaki S, Avcı D, Ulman İ. Lower lip complications: myth or reality? A case-control study on sensory outcomes after buccal mucosa grafting. Urology. 2025;published online. doi:10.1016/j.urology.2025.06.061

14. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg. 2008;22:269–280. doi:10.1055/s-0028-1095886

15. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Tissue Transfer. Guideline

16. Emami M, Shadpour P, Kamali K, Narimani N, Hosseini J. "Female anterior wall onlay urethroplasty with lower lip buccal mucosal graft: Importance of the laterally extended incision." Asian J Urol. 2023;10(1):33-38. doi:10.1016/j.ajur.2022.04.002

17. Hongyong J, Shuzhu C, Min W, Weijing Y, Yidong L. "Comparison of lingual mucosa and buccal mucosa grafts used in inlay urethroplasty in failed hypospadias of pre-pubertal boys in a Chinese group." PLoS One. 2017;12(8):e0182803. doi:10.1371/journal.pone.0182803

18. Appiah KAA, Gyasi-Sarpong CK, Yenli EMT, et al. "Dorsal Onlay Oral Mucosa Graft Urethroplasty: A Case Report and Review of Literature." Case Rep Urol. 2020;2020:8822007. doi:10.1155/2020/8822007