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Posterior Auricular (Postauricular) Skin Graft

The posterior auricular skin graft is a full-thickness skin graft harvested from the retroauricular sulcus (the skin between the pinna and mastoid) — a niche but valuable third-line graft material in reconstructive urology, used primarily for anterior urethroplasty when both buccal mucosa and genital skin are unavailable or unsuitable. The evidence base is small, anchored on a single landmark series (Manoj 2009 — n = 35; 89% success), but the tissue's intrinsic hairlessness, rich dermal vascularity, and concealed donor scar give it a defensible role when standard graft materials are contraindicated.[1][2][3]

See the overview article for graft-selection principles: Grafts in GU Reconstruction.

Posterior auricular skin has no role in urogynecology

There is no published evidence for posterior auricular skin grafts in vaginal reconstruction, prolapse repair, or urogynecologic surgery. Vaginal reconstruction uses STSG from thigh / buttock / scalp, FTSG from abdomen, bowel segments, or local / regional flaps. The graft area available from the retroauricular sulcus is too small for any urogynecologic indication.[4][5][6]

Why the Posterior Auricular Donor Site?​

The retroauricular sulcus has several tissue properties that make it attractive for urethral grafting when buccal mucosa is off the table:

  • Inherently hairless skin — the postauricular area is naturally devoid of terminal hair follicles, eliminating the urethral-calculus, recurrent-UTI, and obstruction risk of hair-bearing skin grafts.[7][8]
  • Rich dermal vascularity — cadaveric studies (Tomita 2009) demonstrate that the postauricular dermis has significantly richer vascularity than other common skin-graft donor sites (peri-clavicle, groin, back, buttocks, thigh), comparable to the scalp and sole. The rich vascular profile supports rapid graft revascularization through dermal-dermal inosculation and angiogenesis.[9]
  • Thin, pliable tissue — closely approximates the characteristics desirable for urethral substitution.
  • Concealed donor site — the scar is hidden behind the ear with minimal cosmetic morbidity. Vancouver Scar Scale at ≥ 6 months averages 1.87 / 13, with rare mild hypertrophic scarring that resolves spontaneously or with intralesional triamcinolone.[10]
  • Low donor-site morbidity — pain is minimal and transient; no interference with eyeglasses or hearing aids; wound dehiscence and keloid formation are rare.[11]

Donor-Site Anatomy​

The retroauricular sulcus extends from the cephaloauricular angle superiorly to the lobule inferiorly. Vascular supply derives from the posterior auricular artery (posterior auricular branch of the external carotid) with anastomotic contributions from the superficial temporal and occipital systems. The skin overlies the postauricular muscle and mastoid periosteum, both of which serve as well-vascularized recipient beds for primary closure of the donor defect.

Practical harvest considerations:

  • Maximum FTSG dimensions — single-side ~5 cm long × 1.5–2 cm wide; bilateral harvest can roughly double the area but rarely exceeds 10 cm of usable graft length.[10]
  • Two-team possibility — a dedicated head-and-neck or plastics team can harvest the postauricular graft simultaneously while the urology team performs urethral dissection, shortening operative time (Manoj 2009 mean OR time 190 min).[1]
  • Donor closure — primary, with a hidden retroauricular scar.

Harvest Technique​

  1. Patient positioning — supine with the head turned to expose the retroauricular sulcus.
  2. Marking — outline the graft within the retroauricular sulcus, sized to the urethral defect plus margin. Avoid extension onto the visible posterior pinna or mastoid hairline.
  3. Local infiltration — lidocaine + epinephrine for hemostasis (general anesthesia is typically already in effect for the urologic procedure).
  4. Sharp incision through epidermis and full dermis. Elevate the FTSG in a subdermal plane, leaving the postauricular muscle and mastoid periosteum intact for donor-site closure.
  5. Defatting — meticulous removal of all subcutaneous tissue from the deep surface of the graft, as for any FTSG. Inadequate defatting is the most common preventable cause of FTSG failure.
  6. Donor-site closure — primary, with absorbable subcuticular suture; the retroauricular scar is concealed.
  7. Recipient bed preparation — quilt the graft to a vascularized recipient bed (corpus spongiosum or tunica) with interrupted absorbable sutures to ensure intimate apposition and prevent shearing.

Primary Urologic Application — Anterior Urethroplasty​

The Manoj 2009 series — the landmark dedicated urologic experience[1]​

ParameterValue
Number of patients35
Indication for postauricular graftBoth BMG and genital skin unavailable: circumcision + oral submucous fibrosis from betel-nut / tobacco chewing
Stricture etiologyLichen sclerosus 35%, unknown 29%, trauma 22%, infection 14%
Stricture locationPanurethral 43%, penile 34%, bulbar 23%
Mean stricture length8.9 cm (range 3–15 cm)
ConfigurationDorsal-onlay anterior urethroplasty
Mean operative time190 min (120–300)
Success rate89% (31 / 35)
Failure rate11% (4 / 35)
Wound infection at donor site14% (5 / 35) — managed with culture-directed antibiotics
Diverticulum / fistula / sacculation / meatal protrusionNone

Two clinical points anchor this series:

  • The success rate is comparable to BMG urethroplasty (typically 85–95%), supporting postauricular skin as a defensible alternative when BMG is contraindicated.
  • Manoj 2009 deliberately included lichen sclerosus strictures (35% of the cohort) — a setting where genital skin grafts are contraindicated because LS affects genital skin. The retroauricular site is extragenital and not affected by LS, making it a legitimate option for the LS-with-buccal-fibrosis patient who would otherwise face a long-graft problem.[1]

Comparison with Other Graft Materials​

Graft materialSuccess rateHairlessMax graft lengthKey limitation
Buccal mucosa (BMG)89–98%Yes~7 cm / cheek (~14 cm bilateral)Oral submucous fibrosis, prior harvest, limited mouth opening
Lingual mucosa (LMG)82.7–89.7%Yes9–12 cm unilateral; 16–20 cm bilateralEarly speech / eating difficulty
Labial mucosa (LaMG)66–93%Yes3.5–6 cmMental-nerve injury risk; smaller graft area
Postauricular skin (this page)89% (Manoj 2009)Yes~5–10 cmVery limited evidence base; small graft area
Penile / preputial skin85–93%Yes (inner prepuce)VariableCircumcision; lichen sclerosus
Abdominal skin (FTSG)81%Must select non-hair-bearingLargeHair growth in 14.5%; keratinization
Rectal mucosa85%YesUp to 16 cmRequires TEM expertise; limited data
STSG (extragenital)93% (penile resurfacing)Site-dependentLargeContraction; chronic inflammation under urine
Small intestinal submucosa (SIS)68% at 13 yrN / A (acellular)VariableInferior to BMG for strictures ≥ 3 cm

The AUA Urethral Stricture Disease Guideline (2023) recommends oral mucosa as the first choice for substitution urethroplasty (Expert Opinion), with buccal and lingual mucosa as equivalent alternatives (Strong Recommendation, Grade A). Postauricular skin is not specifically named in the AUA guideline, reflecting its third-line status.[12] Among GURS members, 99% prefer buccal mucosa as the primary graft site.[2]

Advantages Over Other Alternatives​

When BMG is unavailable, postauricular skin offers specific advantages over other extragenital skin sources:

  1. vs abdominal FTSG — postauricular skin is inherently hairless, whereas abdominal FTSG carries a 14.5% risk of intraurethral hair growth if harvested from hair-bearing areas.[13]
  2. vs thigh / buttock STSG — superior dermal vascularity, supporting graft take. Standard STSG donor sites have poorer vascular profiles.[9]
  3. vs rectal mucosa — technically simpler harvest; no TEM expertise or specialized transanal endoscopic equipment required.[14][15]
  4. vs SIS / synthetic biologics — autologous tissue with no rejection / extrusion risk and longer track record at low cost.

Limitations​

  • Very limited evidence base — essentially a single retrospective 35-patient series with relatively short follow-up. No randomized trials, no long-term (> 5 yr) outcome data, and no head-to-head comparisons against BMG exist.[1]
  • Limited graft area — single-side harvest yields ~5 cm; bilateral harvest typically caps at ~10 cm. Insufficient for very long panurethral strictures unless combined with another graft source.[10]
  • Skin-graft-vs-mucosal-graft biology — animal-model histology and immunohistochemistry (Filipas 1999, El-Sherbiny 2002) demonstrate that skin grafts exposed to urine show more inflammation, fibrosis, and 20–40% shrinkage vs mucosa grafts.[16][17] The clinical significance of this for postauricular skin specifically is unclear, but it is consistent with the broader principle that mucosa outperforms skin in the urethral microenvironment.
  • Requires a non-urologist for two-team harvest — most efficient when a head-and-neck or plastics team is available.
  • Not part of mainstream practice — outside the GURS-survey consensus on BMG-first; few reconstructive urologists are familiar with the harvest.[2]

When to Choose Posterior Auricular Skin​

Postauricular skin is a defensible third-line option specifically when:

IndicationRationale
BMG contraindicatedOral submucous fibrosis (betel nut / tobacco), prior bilateral buccal harvest, oral radiation, limited mouth opening, oral leukoplakia[1][18]
Genital skin contraindicatedPrior circumcision; lichen sclerosus; scarred penile shaft
Stricture length ≤ ~10 cmWithin the limits of single-side or bilateral postauricular harvest
Lichen sclerosus stricture with concurrent oral submucous fibrosisBoth BMG and genital-skin grafts contraindicated; the postauricular site is extragenital and unaffected by LS[1]

When to avoid​

  • Long-segment / panurethral stricture exceeding ~10 cm — graft area insufficient; consider lingual mucosa (up to 12 cm unilateral, 20 cm bilateral) or combined-source reconstruction.
  • BMG and genital skin both available — these are the evidence-supported first-line options.
  • No two-team capability — the harvest is most efficient with a dedicated head-and-neck or plastics team.

Key Takeaways​

The posterior auricular skin graft occupies a narrow but legitimate clinical niche as a third-line graft for anterior urethroplasty, specifically indicated when buccal mucosa is contraindicated by oral submucous fibrosis (e.g., from betel-nut / tobacco chewing — common in South Asian populations) and genital skin is unavailable (circumcision, lichen sclerosus, scarred shaft). The 89% success rate from the Manoj 2009 35-patient series is encouraging and comparable to mainstream graft materials, but the evidence remains preliminary — a single retrospective series with no long-term or comparative data.[1] The tissue's intrinsic hairlessness, rich dermal vascularity, and concealed donor site with minimal morbidity are compelling biological advantages, and the postauricular site is extragenital — making it a particularly useful option for lichen-sclerosus strictures in patients who also cannot accept BMG.[1][9] Posterior auricular skin has no role in urogynecologic reconstruction.

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. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

5. Lesavoy MA. Vaginal reconstruction. Urol Clin North Am. 1985;12(2):369–79.

6. Höckel M, Menke H, Germann G. Vaginoplasty with split skin grafts from the scalp: optimization of the surgical treatment for vaginal agenesis. Am J Obstet Gynecol. 2003;188(4):1100–2. doi:10.1067/mob.2003.25

7. 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

8. Finkelstein LH, Blatstein LM. Epilation of hair-bearing urethral grafts utilizing the neodymium:YAG surgical laser. Lasers Surg Med. 1990;10(2):189–93. doi:10.1002/lsm.1900100213

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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