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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 genital skin cannot be used. It offers a concealed donor scar and potentially suitable thin skin, but its clinical evidence is limited. The often-quoted 89% result comes from a 35-patient retrospective series, not a comparison proving equivalence to buccal mucosa.[1]

The AUA favors oral mucosa as the first graft choice by expert opinion and considers buccal and lingual mucosa equivalent alternatives (strong, Grade A). 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. Postauricular location does not guarantee complete absence of follicles or eliminate future urinary infection or stones. Intraluminal hair can cause obstruction, infection and calculi.[4]
  • Dermal vascularity: Tomita's cadaveric work found a rich vascular network in postauricular dermis. Its composite-graft observations do not prove superior urethral graft take over STSG or oral mucosa.[5]
  • Available area: measure the recipient requirement and donor laxity directly. A dermatologic STSG donor study does not establish a universal maximum FTSG length for urethroplasty.[6]

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.

Primary Urologic Application — Anterior Urethroplasty​

The Manoj 2009 Series​

ParameterReported finding
Patients35 men, aged 20–64 years; oral mucosa and genital skin were unsuitable
EtiologyLichen sclerosus 12; unknown 10; trauma eight; infection five
LocationPanurethral 15; penile 12; bulbar eight
Stricture lengthMean 8.9 cm, range 3–15 cm
Result31/35 successful; four failures
Follow-upEAU's summary table reports mean 22 months, range 3–48
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. It does not establish superiority or equivalence to oral grafting. Stricture length is not the same measurement as donor graft length, and the cohort's 15-cm upper range does not support imposing an arbitrary 10-cm stricture exclusion. Conversely, it does not prove that every patient can provide a sufficiently long postauricular graft.[1][14]

LS-associated strictures are a reason to avoid genital skin. They are not proof that every extragenital donor is disease-free or that postauricular skin has the same evidence as oral mucosa. 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. Its scar scores cannot be used as a precise estimate of this operation's morbidity. 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. A hidden donor site is not a complication-free donor site.

Comparison with Other Graft Materials​

AlternativeDecision-relevant distinction
Buccal/lingual mucosaGuideline-preferred donors with substantially more clinical experience. Assess the actual remaining oral tissue rather than treating any previous buccal harvest as an absolute exclusion.[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. Its 14.5% hair rate is not a universal donor-site risk.[8]
Rectal mucosaSelected salvage option with separate colorectal harvest expertise and limited cohorts; different morbidity from skin harvest.[9][10]
SISA processed acellular matrix with a different indication and evidence base; poorer long-term results than buccal grafts in the matched 2024 cohort.[13]

Do not rank these materials by combining percentages from unrelated urethral cohorts or by including penile surface-graft take as though it were urethral patency. A GURS survey describing surgeon preference is practice-pattern evidence, not a comparative trial.[2]

Limitations and Selection​

The dedicated series is small, retrospective and has limited follow-up. Animal comparisons of buccal mucosa, bladder mucosa and skin suggest differences in inflammation and contraction, but cannot establish a precise human postauricular failure risk or show that all mucosa is superior to all skin.[11][12]

Consider postauricular skin when the recipient configuration, donor skin and available area are suitable and more established options are inappropriate. Do not choose it solely because of presumed hairlessness, absence of rejection, or a promised fixed success rate. Poor recipient perfusion and ongoing disease remain relevant even with autologous tissue.

There is no established routine urogynecologic indication supported by the urethral series discussed here. This limited evidence should not be turned into a claim that the donor can never have any other reconstructive use.

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.

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.