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Lingual Mucosa Graft (LMG)

Lingual mucosa from the ventrolateral tongue is an established alternative to cheek mucosa for substitution urethroplasty. AUA 2023 statement 19b permits buccal or lingual grafts as equivalent alternatives (strong recommendation, Grade A). This is a clinical tissue-selection recommendation, not proof of identical results across all indications. The thinner lingual profile may be useful in distal reconstruction; a specific meatal patency advantage is not established.[1]

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

Anatomy and Graft Preparation​

Harvest lining mucosa from the ventrolateral tongue. Preserve the frenulum, floor-of-mouth duct openings and underlying muscle; identify visible veins. General sensation travels in the lingual nerve (V3), with chorda tympani taste fibers (VII). Vascular supply comes from the lingual arterial system. Cadaver studies describe variable intralingual branching; their branch counts are not universal operative landmarks or assurances against nerve/vascular injury.[2][3][4][5]

Campos-Juanatey's histological series analyzed 30 buccal and 22 lingual graft specimens from 33 patients. Median thickness was 1,693 µm for cheek and 1,347 µm for tongue; the 1,599 µm figure was pooled across donors. Lingual samples had thinner epithelium/submucosa and less fat, without a significant difference in vascular measurements. There was no clinical-outcome correlation. Preserve viable lamina propria during preparation; microscopic residual muscle does not justify deliberate deep muscle harvest.[6]

Harvest Principles​

  1. Assess oral health, mouth opening, prior donor surgery, baseline speech/taste and the patient's functional priorities. Coordinate airway placement and oral access with anesthesia; nasotracheal intubation is one described approach, not a requirement for every patient.
  2. Measure the recipient defect before final donor marking. Retract the tongue and expose the ventrolateral mucosa. Protect the frenulum and submandibular duct openings.
  3. Mark a strip that can be harvested without excessive tension or deep dissection. Published techniques differ: separate bilateral strips can preserve the tip/frenulum; an across-tip strip is not a mandatory step or an unlimited source of tissue.
  4. Elevate mucosa with its lamina propria, staying superficial to tongue muscle and protecting the neurovascular structures. Remove excess deep tissue without making the graft excessively thin or damaging its supporting layer.
  5. Obtain meticulous hemostasis and manage the donor defect according to its size and tension. Reported suture choices, feeding schedules and mouth-care regimens are technique-specific, not universal protocols.
  6. Keep the graft moist, orient the epithelium toward the lumen and secure it to a vascular recipient bed according to the chosen urethroplasty.[7][6][8]

The original Simonato 2006 pilot included eight patients. It established feasibility; it was not a head-to-head demonstration of less pain than cheek harvest.[9]

Comparative Evidence​

The 2021 Wang meta-analysis included 632 patients in 12 comparative studies (four randomized, eight nonrandomized). Reported urethroplasty outcomes around one year were similar, while donor effects differed: lingual harvest produced more early speech/tongue-protrusion difficulty, and cheek harvest more swelling and numbness. These findings support shared selection, not universal lingual superiority or lifelong equivalence.[10]

The earlier Abrate 2019 review pooled six comparative studies for success: OR 1.65 (95% CI 0.95–2.87). Its random-effects estimate for late oral complications was OR 0.18 (0.03–1.26), with substantial heterogeneity. Both confidence intervals crossed 1; the paper's favorable narrative must not be presented as statistically established superiority.[8]

Clinical settingDirectly relevant evidencePractical interpretation
Anterior stricture, cheek versus tongueLumen 2016: 29 per group; 24/29 cheek and 26/29 lingual successes, mean 30-month follow-upSmall prospective nonrandomized comparison; no significant difference, not an equivalence trial
Long anterior stricturesXu 2017: 81 men; 82.7% overall success, mean 41 months; 12 received combined cheek/lingual graftsSupports feasibility in selected complex disease; cannot attribute all outcomes to isolated LMG
Lichen sclerosusAldaqadossi 2020: 36 enrolled, 34 assessed; 88.2% success, median 66.5 monthsSelected single-arm evidence; does not establish immunity to recurrent LS or superiority over cheek

Sources:[11][12][13]

For long strictures, Xu reported 9–12 cm strips in 52 patients, longer strips in 17 and combined lingual/buccal harvest in 12. The 8–20 cm range was stricture length, not a guaranteed unilateral harvest length. Choose graft width and total donor burden as carefully as length.[12]

Failed Hypospadias and Female Reconstruction​

Failed hypospadias: Li 2016 retrospectively selected 56 of 110 patients for one-stage LMG repair: 42 total-onlay and 14 modified Snodgrass/inlay procedures. Initial success was 44/56 (78.6%); 12 developed fistula or stricture. The abstract and main report give inconsistent follow-up summaries, so these results should not be assigned an unqualified follow-up duration. Healthy retained plate and tissue coverage influenced selection; results do not justify one-stage reconstruction in every failed repair.[14]

Hongyong 2017 compared 33 lingual with 29 grafts labeled “buccal.” Its operative Methods and Figures 7–8 identify the comparator as lower-lip mucosa. Patients were treated in different eras, follow-up was only 5–12 months, and donor-site outcomes were not collected. Success was 28/33 versus 24/29. This is not a randomized cheek-versus-tongue trial or evidence of better oral morbidity with either donor.[15]

Female stricture: Sharma 2010 reported 15 women treated with dorsal-onlay LMG; one needed repeated dilation for submeatal stenosis. Richard 2021 included 19 women receiving either buccal or lingual grafts. Its primary outcome was early subjective LUTS improvement, not anatomical patency, and it reported de novo SUI. These series support feasibility while leaving comparative donor, continence and long-term durability questions open.[16][17]

Donor-Site Counseling​

Discuss pain, eating/drinking difficulty, altered speech, tongue movement, taste and sensory change. Do not promise resolution by a fixed date or absence of salivary-duct risk.

Lumen's 29-versus-29 comparison found more lingual speech/eating difficulty on day 3 and more cheek tightness at two weeks. At six months, 31% of lingual and 44.8% of cheek patients still reported sensory symptoms; the difference was not significant. Median pain scores were zero in both groups at that visit, which does not mean every patient was symptom-free.[11]

Xu 2011 included 110 patients, but only 96 had follow-up beyond 12 months. Among those 96, seven reported tongue numbness and three each reported altered taste and slurred speech. Use the followed denominator, and recognize that bilateral/long-strip harvest may carry different morbidity from a short unilateral graft.[18]

Buccal mucosa remains a common first donor: 99% of 134 respondents in the 350-member 2024 GURS survey selected cheek first. That practice pattern does not override the AUA's acceptance of LMG or an individual patient's donor limitations.[19]

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. Lopez R, Lauwers F, Paoli JR, Boutault F, Guitard J. Vascular territories of the tongue: anatomical study and clinical applications. Surg Radiol Anat. 2007;29(3):239–44. doi:10.1007/s00276-007-0202-8

3. Shangkuan H, Xinghai W, Zengxing W, et al. Anatomic bases of tongue flaps. Surg Radiol Anat. 1998;20(2):83–8. doi:10.1007/BF01628906

4. Rusu MC, Nimigean V, Podoleanu L, Ivaşcu RV, Niculescu MC. Details of the intralingual topography and morphology of the lingual nerve. Int J Oral Maxillofac Surg. 2008;37(9):835–9. doi:10.1016/j.ijom.2008.05.014

5. Yang HM, Woo YJ, Won SY, et al. Course and distribution of the lingual nerve in the ventral tongue region: anatomical considerations for frenectomy. J Craniofac Surg. 2009;20(5):1359–63. doi:10.1097/SCS.0b013e3181ae42fa

6. 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

7. Kumar A, Das SK, Sharma GK, et al. Lingual mucosal graft substitution urethroplasty for anterior urethral strictures: our technique of graft harvesting. World J Urol. 2008;26(3):275–80. doi:10.1007/s00345-008-0255-2

8. Abrate A, Gregori A, Simonato A. Lingual mucosal graft urethroplasty 12 years later: systematic review and meta-analysis. Asian J Urol. 2019;6:230–241. doi:10.1016/j.ajur.2019.01.001

9. Simonato A, Gregori A, Lissiani A, et al. The tongue as an alternative donor site for graft urethroplasty: a pilot study. J Urol. 2006;175(2):589–92. doi:10.1016/S0022-5347(05)00166-7

10. Wang A, Chua M, Talla V, et al. Lingual versus buccal mucosal graft for augmentation urethroplasty: a meta-analysis of surgical outcomes and patient-reported donor site morbidity. Int Urol Nephrol. 2021;53:907–918. doi:10.1007/s11255-020-02720-7

11. 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

12. 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):401–6. doi:10.1016/j.juro.2017.03.045

13. Aldaqadossi HA, Eladawy M, Shaker H, et al. Dorsal onlay urethroplasty using lingual mucosal grafts for lichen sclerosis anterior urethral strictures repair: long-term outcomes. Int J Urol. 2020;27(4):320–5. doi:10.1111/iju.14187

14. Li HB, Xu YM, Fu Q, et al. One-stage dorsal lingual mucosal graft urethroplasty for the treatment of failed hypospadias repair. Asian J Androl. 2016;18(3):467–70. doi:10.4103/1008-682X.157545

15. 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

16. Sharma GK, Pandey A, Bansal H, et al. Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women. BJU Int. 2010;105(9):1309–12. doi:10.1111/j.1464-410X.2009.08951.x

17. Richard C, Peyronnet B, Drain A, et al. Dorsal onlay oral mucosa graft urethroplasty for female urethral stricture. Urology. 2021;158:215–21. doi:10.1016/j.urology.2021.09.001

18. Xu YM, Xu QK, Fu Q, et al. Oral complications after lingual mucosal graft harvesting for urethroplasty in 110 cases. BJU Int. 2011;108(1):140–5. doi:10.1111/j.1464-410X.2010.09852.x

19. 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