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Posterior Auricular (Postauricular) Skin Graft

Postauricular full-thickness skin is a selected alternative donor for anterior urethroplasty when oral mucosa and penile skin are unavailable, unsuitable or declined; it has also been combined with oral mucosa for lengthy strictures.[14] It offers a concealed donor scar and potentially suitable thin skin, but its clinical evidence is limited.[1] In a retrospective series of 35 selected patients undergoing postauricular skin-graft anterior urethroplasty, 31 (89%) were treatment successes.[1]

The AUA favors oral mucosa as the first graft choice by expert opinion and considers buccal and lingual mucosa equivalent alternatives .[3] The EAU discusses postauricular and other less-used donors when oral mucosa and penile skin are unavailable, unsuitable or declined. Neither guideline assigns a formal universal “third-line” rank to this donor.[3][14]

See Grafts in GU Reconstruction.

Why the Posterior Auricular Donor Site?​

  • Concealed scar: useful when the required graft can be harvested without distorting the ear or placing the closure under tension.
  • Donor selection: inspect the exact area for terminal hair, scars and skin disease. Intraluminal hair can cause obstruction, infection and calculi.[4]
  • Dermal vascularity: Tomita's cadaveric work found a rich vascular network in postauricular dermis.[5]
  • Available area: measure the recipient requirement and donor laxity directly.

Donor-Site Anatomy and Harvest​

The usual donor is the skin behind the ear near the retroauricular sulcus. Keep the planned graft within suitable skin and account for the hairline, existing scars, ear position, glasses or hearing aids. For a full-thickness graft, the entire dermis is taken and subcutaneous fat is removed carefully; avoid injuring the dermis while preparing a thin, pliable graft.

Primary closure depends on donor laxity and tension. The donor wound is closed by approximating its edges; its underlying muscle or periosteum should not be described as a “recipient bed for primary closure.” Protect local structures and assess closure before committing to the harvest. A free graft subsequently depends on revascularization from its urethral recipient bed.

A second team can perform simultaneous harvest, as in the Manoj report, but there is no evidence that a particular specialty or two-team arrangement is mandatory. Coordinate head positioning, airway access, separate preparation and tissue handling with the operative team.[1]

For graft preparation and fixation principles, see FTSG and Urethral Reconstruction Principles.

Practical Sequence​

  1. Position the patient supine with the head turned to expose the retroauricular sulcus, and confirm that the other team can work at the perineum or penis.
  2. Mark a graft within the retroauricular skin sized to the urethral defect plus a margin. Avoid extending onto the visible posterior pinna or the hairline.
  3. Infiltrate for hemostasis if desired. Incise through the epidermis and full dermis and elevate the graft in a subdermal plane.
  4. Remove all subcutaneous fat from the deep surface without damaging the dermis.
  5. Close the donor site primarily if tension allows.
  6. Quilt the graft to a vascularized recipient bed with interrupted absorbable sutures, avoiding folding, hematoma and shear.

These steps follow general full-thickness graft principles.

Primary Urologic Application — Anterior Urethroplasty​

The Manoj 2009 Series​

ParameterReported finding
Patients35 patients, mean age 34 years (range 20–64); oral mucosa and genital skin were unsuitable, and the authors concluded that postauricular skin is a good substitute in circumcised patients with submucosal fibrosis of the cheek mucosa and also in patients with lichen sclerosus [1]
EtiologyLichen sclerosus 12; unknown 10; trauma eight; infection five
LocationPanurethral 15; penile 12; bulbar eight
Stricture lengthMean 8.9 cm, range 3–15 cm
Operative timeMean 190 minutes (range 120–300), with one team harvesting the graft while the other reconstructed the urethra
Result31/35 successful (89%); four failures [1]
Follow-upEAU summary table: 22 months (range 3–48)[14]
MorbidityFive wound infections; no reported diverticulum, fistula, sacculation or graft protrusion at the meatus

The cohort supports feasibility in selected patients, including some with LS. Stricture length differs from donor graft length; the cohort's 15-cm upper range provides no 10-cm exclusion threshold.[1][14]

LS-associated strictures are a reason to avoid genital skin. Examine the donor and assess the entire reconstructive plan.[14]

Donor Morbidity: Match the Study to the Graft​

Hexsel's 39-patient dermatologic study assessed postauricular STSG harvest, not full-thickness urethral graft harvest. Erba studied posterior-conchal perichondral cutaneous grafts in 16 patients; two developed wound dehiscence and one a keloid. These are related but different donor operations.[6][7]

Discuss infection, wound separation, pain, sensory symptoms, scarring and possible contour distortion.

Comparison with Other Graft Materials​

AlternativeDecision-relevant distinction
Buccal/lingual mucosaGuideline-preferred donors with substantially more clinical experience. Assess the actual remaining oral tissue.[3]
Penile/preputial skinRequires adequate healthy tissue; avoid genital skin in LS. Circumcision removes prepuce but does not automatically make all penile skin unusable.[14]
Abdominal FTSGCan supply more surface area, but hair-bearing donor selection caused problems in the published series (14.5% hair rate).[8]
Rectal mucosaSelected salvage option with separate colorectal harvest expertise and limited cohorts; different morbidity from skin harvest.[9][10]
SISPorcine small-intestinal submucosa is a cell-free xenograft. In a propensity-matched bulbar cohort (25 per arm), modeled freedom from further treatment at 156 months was 68% with SIS versus 83.4% with buccal mucosa.[13] AUA 2023 advises against xenograft substitution outside experimental protocols ; EAU 2026 weakly advises against cell-free grafts with extensive spongiofibrosis, after failed urethroplasty, or for strictures >4 cm.[3][14]

A GURS survey described surgeon preference.[2]

When Postauricular Skin Is Considered​

SituationRationale
Oral mucosa unusable, for example submucosal fibrosis of the cheek mucosaThe Manoj series enrolled patients with oral mucosal changes.[1]
Genital skin unusable because of lichen sclerosus or insufficient healthy penile skinEAU 2026 advises against genital skin grafts in lichen sclerosus ; assess remaining penile skin directly after circumcision.[14]
Lichen sclerosus stricture with unsuitable oral mucosaThe donor is extragenital. The Manoj series included 12 patients with lichen sclerosus.[1]

Postauricular skin is a poor fit when the required graft exceeds available donor skin or when a suitable, accepted oral or penile graft meets the reconstructive need.[14]

Limitations and Selection​

The dedicated series is small, retrospective and has limited follow-up.[11][12] Animal comparisons of buccal mucosa, bladder mucosa and skin suggest differences in inflammation and contraction.[11][12]

Consider postauricular skin when the recipient configuration, donor skin and available area are suitable and more established options are inappropriate. A free postauricular graft requires a vascularized urethral bed. For poor bed vascularization, EAU 2026 weakly recommends a vascularized flap; it strongly recommends against a tubularized free graft in a single-stage repair.[14] Ongoing disease remains relevant to donor and recipient selection.

There is no established routine urogynecologic indication supported by the urethral series discussed here.

See Also​

References​

1. Manoj B, Sanjeev N, Pandurang PN, Jaideep M, Ravi M. Postauricular skin as an alternative to oral mucosa for anterior onlay graft urethroplasty: a preliminary experience in patients with oral mucosa changes. Urology. 2009;74(2):345–8. doi:10.1016/j.urology.2009.02.065

2. 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;191:139–43. doi:10.1016/j.urology.2024.06.019

3. 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

4. Finkelstein LH, Blatstein LM. Epilation of hair-bearing urethral grafts using the neodymium:YAG surgical laser. J Urol. 1991;146(3):840–2. doi:10.1016/s0022-5347(17)37937-5

5. Tomita K, Hosokawa K, Yano K, et al. Dermal vascularity of the auricle: implications for novel composite grafts. J Plast Reconstr Aesthet Surg. 2009;62(12):1609–15. doi:10.1016/j.bjps.2008.06.073

6. Hexsel CL, Loosemore M, Goldberg LH, Awadalla F, Morales-Burgos A. Postauricular skin: an excellent donor site for split-thickness skin grafts for the head, neck, and upper chest. Dermatol Surg. 2015;41(1):48–52. doi:10.1097/DSS.0000000000000218

7. Erba P, Wettstein R, D'Arpa S, Kalbermatten DF. Donor site morbidity of the posterior conchal region. Dermatol Surg. 2009;35(6):960–4. doi:10.1111/j.1524-4725.2009.01163.x

8. Meeks JJ, Erickson BA, Fetchev P, et al. Urethroplasty with abdominal skin grafts for long segment urethral strictures. J Urol. 2010;183(5):1880–4. doi:10.1016/j.juro.2010.01.029

9. Granieri MA, Zhao LC, Breyer BN, et al. Multi-institutional outcomes of minimally invasive harvest of rectal mucosa graft for anterior urethral reconstruction. J Urol. 2019;201(6):1164–70. doi:10.1097/JU.0000000000000087

10. Palmer DA, Marcello PW, Zinman LN, Vanni AJ. Urethral reconstruction with rectal mucosa graft onlay: a novel, minimally invasive technique. J Urol. 2016;196(3):782–6. doi:10.1016/j.juro.2016.03.002

11. Filipas D, Fisch M, Fichtner J, et al. The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine. BJU Int. 1999;84(1):108–11. doi:10.1046/j.1464-410x.1999.00079.x

12. El-Sherbiny MT, Abol-Enein H, Dawaba MS, Ghoneim MA. Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol. 2002;167(5):2225–8. PubMed. doi:10.1016/s0022-5347(05)65133-6

13. Palminteri E, Toso S, Preto M, et al. Small intestinal submucosa graft bulbar urethroplasty is a viable technique: results compared to buccal mucosa graft urethroplasty after propensity score matching. World J Urol. 2024;42(1):123. doi:10.1007/s00345-024-04795-8

14. European Association of Urology. Urethral Strictures: Tissue Transfer. 2026. Guideline chapter.