The Oral Cavity
The mouth is a donor site whose sensory, salivary and functional anatomy matters during graft harvest. Oral mucosa is the AUA's preferred graft material for urethroplasty; cheek and lingual mucosa are accepted alternatives.[6] The recipient bed must support revascularization after transfer.[1]
This page covers donor anatomy and selection. See the buccal, lingual and oral-lip graft pages for technique and outcome evidence, and Male Urethra for 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; descriptions of rapid oral healing do not establish “scarless” urethral reconstruction.[2][3]
Two frequently cited biological studies require careful interpretation:
- Human histology: Soave studied 22 patients undergoing repeat surgery for recurrent stricture. Previously implanted buccal grafts retained squamous histology after a mean 22.2 months. This supports persistence of tissue identity, not a comparative patency advantage or a stricture-free outcome.[4]
- Animal angiogenesis: Gardikis compared grafts in 22 rabbits. Greater vessel counts in buccal than penile-skin grafts at postoperative day 21 are experimental findings; they do not quantify human graft take or clinical superiority.[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. Graft size is determined by the individual mouth and measured urethral defect; a published harvest length is not an anatomical maximum.[12][13]
Buccal and other maxillary-artery branches supply the cheek; preserve the graft's lamina propria while removing excess deep fat. 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 can supply additional tissue, with additional donor morbidity. In a 2024 GURS survey, 134 of 350 invited members responded and 99% of respondents selected cheek mucosa first. This describes surveyed practice, not comparative evidence or the preference of every reconstructive urologist.[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. The vascular anatomy does not guarantee that unilateral dissection is risk-free.[14][15]
Long strips, separate bilateral strips or combined cheek/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/buccal grafts. The reported 8–20 cm range described stricture length, not a universal single-site harvest limit.[8]
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. These are prepared surgical specimens, not normal-anatomy reference values or a trial of graft success.[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% |
| Adipose tissue, median | 10% | 2% |
The cheek samples had thicker epithelium/submucosa and more fat. Total thickness and vascular measurements did not differ significantly; that is not proof of histological equivalence. The often-quoted 1,599 µm value is the pooled median, not the median for each donor. Residual muscle in a histological specimen is not a recommendation to harvest muscle. 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. Dessanti's 3.5–6 cm figure described the urethral gaps treated with lip alone, not the maximum lip graft length.[9]
Use an explicit donor name. “Labial” in a publication can be ambiguous; confirm whether the authors mean oral lip or vulvar labia before transferring its findings to a donor-specific page.
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 |
AUA supports cheek and lingual grafts as equivalent clinical alternatives. It does not establish identical outcomes for every stricture location, length, etiology or reconstruction.[1]
Keep complication estimates tied to the study and time point. In Lumen's prospective 29-cheek/29-lingual comparison, day 3 speech difficulty was reported by 93.1% after lingual versus 55.2% after cheek harvest; eating/drinking difficulty was 62.1% versus 24.1%. At six months, sensory symptoms persisted in 31% versus 44.8%, respectively, without a statistically significant difference. These are small-cohort estimates, not fixed patient-specific risks; the six-month figures must not be labeled twelve-month outcomes.[10]
For cheek donor closure, the 135-patient Soave randomized trial reported nonclosure noninferior for pain intensity and affective pain quality. Choose closure according to tension, hemostasis and defect geometry; this does not establish noninferiority for every complication or for tongue/lip harvest. 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;S0090-4295(26)00169-X. 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