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Buccal Mucosa Graft (BMG)

Buccal mucosa grafts (BMG) are the gold standard graft material for urethral reconstruction, preferred for their unique biological properties, versatility across multiple anatomic locations, and excellent long-term outcomes.[1][2][3][4]

See the overview article for graft selection principles: Grafts in GU Reconstruction, and the anatomy article for oral cavity harvest anatomy: The Oral Cavity.

Biological Properties​

Buccal mucosa exhibits unique regenerative characteristics that make it ideal for urethral reconstruction. The tissue demonstrates rapid re-epithelialization, minimal inflammation, and tightly controlled fibroblast activity resulting in a "scarless healing" phenotype that reflects fetal-like wound healing biology.[4] The epithelium is thick, non-keratinized, and nonhair-bearing, with a lamina propria rich in elastic fibers that tolerates secondary ischemia better than skin grafts.

Practical advantages for the reconstructive surgeon:

  • Wet epithelium compatible with the urethral microenvironment
  • High vascularity in the lamina propria — rapid neovascularization after graft take
  • Pliable and elastic — handles suture well without tearing
  • Consistently available and harvestable under the same general or locoregional anesthetic
  • Resistant to infection — salivary immunoglobulins and indigenous oral flora provide local immunity[3][5]

The AUA 2023 Urethral Stricture Guideline recommends oral mucosa as the first choice when using grafts for urethroplasty (Expert Opinion). Buccal and lingual mucosal grafts are considered equivalent alternatives (Strong Recommendation; Evidence Level: Grade A). Buccal mucosa from the inner cheeks provides the largest graft area; lingual mucosa is thinner and may offer advantages for distal urethral and meatal reconstruction.[2]

Harvest Technique​

Setup and Exposure​

The patient is positioned supine with the mouth opened and held with a self-retaining retractor (Jennings or similar). A headlight or fiberoptic illumination improves visualization. The inner cheek is palpated to identify the parotid (Stensen's) duct orifice opposite the upper second molar — this landmark defines the safe harvest corridor.

Graft Elevation​

An ovoid template is marked on the buccal mucosa, at least 5 mm from the commissures and clear of Stensen's duct. Local anesthetic with epinephrine (1% lidocaine with 1:100,000 epinephrine) is infiltrated submucosally both for analgesia and to create a hydraulic plane for dissection.

The mucosa is incised sharply with a 15-blade or scissors. The graft is elevated just superficial to the buccinator muscle fibers — harvesting into muscle increases donor morbidity without gain. The graft is kept as thin as possible while maintaining the full thickness of the epithelium and lamina propria.

Graft dimensions: A single cheek provides approximately 5–7 cm in length × 1.5–2 cm in width. For reconstructions requiring >7 cm, bilateral harvest is necessary. The inner cheeks combined can yield 12–14 cm of total graft length.[17]

Defatting​

Any residual submucous connective tissue or fat is removed on a flat surface. The graft must be uniform in thickness — irregular thickness impairs uniform imbibition and inosculation during the first 48 hours after graft inset.

Donor Site Management​

Closure versus nonclosure of the harvest site is genuinely a matter of surgeon preference. A randomized controlled trial (Soave et al.) demonstrated nonclosure is noninferior to closure for oral pain intensity and quality; leaving the harvest site open may result in less pain than primary closure (mean pain score 2.26 vs. 3.68, p < 0.001).[15][16] Most experienced surgeons leave the site open.

GU Applications​

Anterior Urethral Strictures​

BMG is the dominant graft material for bulbar, penile, and panurethral strictures. Among Society of Genitourinary Reconstructive Surgeons (GURS) members, 99% prefer buccal mucosa as their primary graft site, and 95% favor it over fasciocutaneous flaps for penile urethroplasty regardless of circumcision status. For bulbar urethroplasty, 66% favor dorsal graft placement over ventral placement (34%).[1]

Success rates for anterior urethroplasty range from 80–97%, with most surgeons reporting 80–90% success at mid-term follow-up.[1][7][8]

Posterior Urethral Strictures​

BMG is increasingly used for vesicourethral anastomotic stenosis (VUAS) and membranous urethral strictures after prostatectomy and radiation. Dorsal onlay BMG urethroplasty for post-prostatectomy, post-radiation anastomotic stenosis demonstrates 3-year stricture recurrence-free survival of 65–81%, with notably low rates of de novo stress urinary incontinence — an important advantage over conventional urethral transection techniques.[9][10]

Distal Urethral Strictures​

Transurethral ventral inlay BMG urethroplasty for fossa navicularis and distal urethral strictures demonstrates 95% patency at mean 36-month follow-up, with significant improvements in maximum flow rates and patient-reported outcomes.[11]

Hypospadias Repair​

BMG is widely used in pediatric urology for complex hypospadias repair — both as primary surgery and for salvage procedures. Staged repair using the Bracka technique with buccal mucosa demonstrates lower complication rates (20%) compared to preputial skin grafts (31%), with better cosmetic outcomes.[12] The graft shows reliable uptake within 5 days and maintains vascularization at 6-month histologic evaluation.[6]

Novel applications include tunneled buccal mucosa tube grafts for proximal hypospadias[13] and "watch-shaped" grafts for simultaneous chordee correction and urethroplasty in scrotal hypospadias.[14]

BMG Ureteroplasty​

An emerging indication. BMG with omental backing has been used for segmental ureteral defects not amenable to primary anastomosis or bowel interposition. See: Omental Flap for the backing technique.

Surgical Techniques​

Multiple placement configurations exist depending on stricture location, length, and caliber:

TechniqueSurgeon / SourceBest Application
Dorsal onlayBarbagliBulbar strictures; most widely used
Ventral onlayVariousBulbar strictures; comparable success to dorsal
Dorsal inlay + ventral urethrotomyAsopaPenile strictures; graft inlaid through ventral urethrotomy
Dorsolateral onlayKulkarniPenile strictures; one-sided urethral dissection preserves vascularity
Two-sided dorsal + ventral onlayPalminteriObliterative bulbar strictures; circumferential augmentation
Augmented anastomotic—Short bulbar strictures with focal obliteration; EPA + onlay augmentation

For panurethral strictures requiring long grafts, 56% of GURS members prefer bilateral cheek harvest, and 90% prefer multiple BMGs over combined graft/flap techniques.[1]

Donor Site Morbidity​

Short-Term (First 3 Months)​

ComplicationIncidenceTime Course
Oral pain70–83%Peaks at 1 week; 87.5% pain-free by 3 months
Perioral numbness68% initially26% with residual numbness at 6 months
Difficulty with mouth opening67% initiallyPersistent in 9%
Delayed resumption of normal diet—90% resume liquids within 24 h; 77% resume normal diet within 1 week
Bleeding3–5%—

Data from Wood et al. (2004), Barbagli et al. (2014), Desai et al. (2025).[16][17][18]

Long-Term​

Long-term donor site complications are rare and seldom perceived as bothersome:

  • Perioral sensory deficit: Most common long-term complication (28%); more frequent in adults than children[19]
  • Mucous retention cysts requiring excision: 2%[16]
  • Altered salivation: 11%[16]
  • Overall patient satisfaction: 95–98%[17][18]

Bilateral harvest is the only significant independent predictor of patient dissatisfaction (OR 2.72, p = 0.02), which should be weighed when counseling patients requiring long grafts.[17]

Outcomes​

Success Rates​

Overall success for BMG urethroplasty ranges from 80–97% depending on stricture location, complexity, and technique.[1][7][8][20][21]

Factors Affecting Recurrence​

Surgical sequence: Initial and repeat BMG urethroplasties show comparable success rates (87.4% vs. 87.5%). Secondary procedures after other failed urethroplasty techniques show lower but acceptable success (70.6%) when performed at high-volume centers.[20]

Stricture location: Bulbar strictures show slightly higher success (86%) compared to penile strictures (72%), though differences are not statistically significant across series.[21]

Lichen sclerosus (LS): Associated with higher recurrence, particularly with one-stage repair (50% success) versus multistage repair (80% success). LS involving the graft donor site is a relative contraindication to BMG harvest.[21]

Cardiovascular and metabolic factors: Stricture recurrence is largely independent of cardiovascular and metabolic risk factors. A larger intraoperative hemoglobin drop is independently associated with better recurrence-free survival (HR 0.74, p = 0.03), potentially reflecting robust microvascular perfusion and graft neovascularization.[22]

Functional Outcomes​

Patients demonstrate significant improvements in maximum urinary flow rates, post-void residual volumes, IPSS scores, and quality-of-life domains postoperatively, with no negative impact on sexual or ejaculatory function.[7][8][10][11]

Comparison With Alternative Graft Materials​

Buccal vs. lingual mucosa: Meta-analysis of 12 studies found no difference in success rates (RR for lingual mucosa: 1.03; 95% CI: 0.96–1.10).[2] Lingual mucosa is thinner and may be advantageous for distal urethral reconstruction but carries a slightly higher risk of floor-of-mouth hematoma.

Buccal vs. penile skin grafts: Prospective randomized trials demonstrate comparable success rates between BMG (93–98%) and penile skin grafts (89–93%) for extensive anterior urethral strictures, with similar patient satisfaction, complication profiles, and no difference in sexual or ejaculatory function.[7][8] BMG remains preferred due to consistent availability and resistance to lichen sclerosus involvement.

Future Directions​

Emerging technologies include tissue-engineered oral mucosal substitutes, extracellular vesicles, and organoid systems that may expand reconstructive options for patients requiring large or complex reconstructions. Clinical translation requires manufacturing standardization and cost reduction before widespread adoption. The applications of BMG continue to expand across the genitourinary tract — from renal pelvis to external genitalia — in contexts where a pliable, wet-environment-compatible autograft is required.[4]

References​

1. 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

2. 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

3. 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

4. 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

5. Dessanti A, Iannuccelli M, Ginesu G, Feo C. "Reconstruction of Hypospadias and Epispadias With Buccal Mucosa Free Graft as Primary Surgery: More Than 10 Years of Experience." J Urol. 2003;170(4 Pt 2):1600–1602. doi:10.1097/01.ju.0000083925.07074.32

6. Mokhless IA, Kader MA, Fahmy N, Youssef M. "The Multistage Use of Buccal Mucosa Grafts for Complex Hypospadias: Histological Changes." J Urol. 2007;177(4):1496–1500. doi:10.1016/j.juro.2006.11.079

7. Alrefaey A, Anwar MA, Abdelmagid ME, et al. "Comparative Outcomes of Penile Skin Grafts Versus Buccal Mucosal Grafts in Urethroplasty for the Treatment of Extensive Anterior Urethral Strictures." Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w

8. Tyagi S, Parmar KM, Singh SK, et al. "'Pee'BuSt Trial: A Single-Centre Prospective Randomized Study Comparing Functional and Anatomic Outcomes After Augmentation Urethroplasty With Penile Skin Graft Versus Buccal Mucosa Graft for Anterior Urethral Stricture Disease." World J Urol. 2022;40(2):475–481. doi:10.1007/s00345-021-03843-x

9. Doležel J, Hrabec R, Uher M, et al. "Substitution Urethroplasty With Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-Institution Long-Term Experience With Perineal Approach and Endourethroplasty." Urology. 2024;192:126–132. doi:10.1016/j.urology.2024.05.034

10. Sterling J, Simhan J, Flynn BJ, et al. "Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis." J Urol. 2024;211(4):596–604. doi:10.1097/JU.0000000000003848

11. Sterling J, Daneshvar M, Nikolavsky D. "Transurethral Ventral Inlay Buccal Mucosa Graft Urethroplasty: Technique and Intermediate Outcomes." BJU Int. 2023;132(1):109–111. doi:10.1111/bju.16007

12. Manasherova D, Kozyrev G, Nikolaev V, et al. "Bracka's Method of Proximal Hypospadias Repair: Preputial Skin or Buccal Mucosa?" Urology. 2020;138:138–143. doi:10.1016/j.urology.2019.12.027

13. Fine R, Reda EF, Zelkovic P, et al. "Tunneled Buccal Mucosa Tube Grafts for Repair of Proximal Hypospadias." J Urol. 2015;193(5 Suppl):1813–1817. doi:10.1016/j.juro.2014.10.093

14. Djordjevic M, Simsek A, Bizic M, et al. "'Watch' Shaped Buccal Mucosa Graft for Simultaneous Correction of Severe Chordee and Urethroplasty as a One-Stage Repair of Scrotal Hypospadias." Urology. 2020;137:205. doi:10.1016/j.urology.2019.12.016

15. 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

16. Wood DN, Allen SE, Andrich DE, Greenwell TJ, Mundy AR. "The Morbidity of Buccal Mucosal Graft Harvest for Urethroplasty and the Effect of Nonclosure of the Graft Harvest Site on Postoperative Pain." J Urol. 2004;172(2):580–583. doi:10.1097/01.ju.0000132846.01144.9f

17. Barbagli G, Fossati N, Sansalone S, et al. "Prediction of Early and Late Complications After Oral Mucosal Graft Harvesting: Multivariable Analysis From a Cohort of 553 Consecutive Patients." J Urol. 2014;191(3):688–693. doi:10.1016/j.juro.2013.09.006

18. Desai D, Joshi S, Ravichandran K, et al. "Donor Site Morbidity and Impact on Oral Health Following Buccal Mucosal Graft Harvesting for Urethroplasty: A Prospective Study." World J Urol. 2025;43(1):531. doi:10.1007/s00345-025-05898-6

19. 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):2624–2628. doi:10.1016/j.juro.2008.08.053

20. Vetterlein MW, Stahlberg J, Zumstein V, et al. "The Impact of Surgical Sequence on Stricture Recurrence After Anterior 1-Stage Buccal Mucosal Graft Urethroplasty: Comparative Effectiveness of Initial, Repeat and Secondary Procedures." J Urol. 2018;200(6):1308–1314. doi:10.1016/j.juro.2018.06.067

21. Levine LA, Strom KH, Lux MM. "Buccal Mucosa Graft Urethroplasty for Anterior Urethral Stricture Repair: Evaluation of the Impact of Stricture Location and Lichen Sclerosus on Surgical Outcome." J Urol. 2007;178(5):2011–2015. doi:10.1016/j.juro.2007.07.034

22. Meyer CP, Lamp J, Vetterlein MW, et al. "Impact of Cardiovascular and Metabolic Risk Factors on Stricture Recurrence After Anterior One-Stage Buccal Mucosal Graft Urethroplasty." Urology. 2020;146:253–259. doi:10.1016/j.urology.2020.07.073