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Mouth Retractors for Buccal Mucosa Graft Harvest

Adequate intraoral exposure is the first and most underappreciated step of a successful buccal mucosa graft (BMG) harvest. Good exposure shortens harvest time, reduces graft trauma, and avoids inadvertent injury to Stensen's duct (parotid orifice opposite the second maxillary molar) and the lip vermillion. The literature describes the general approach more than it compares specific devices head-to-head; most reconstructive urologists and oral / maxillofacial surgeons develop a preference based on mouth size, harvest side (unilateral vs bilateral), and available instrumentation.[1][2]

Retractor Options​

Dingman Mouth Gag​

Originally designed for cleft-palate surgery, the Dingman is one of the most widely used self-retaining retractors for BMG harvest.[3] It provides good mouth opening, integrated tongue depression, and self-retaining cheek retractors — making it well-suited for sustained intraoral exposure without continuous assistant retraction.

  • Good for: bilateral harvest, sustained exposure, the workhorse default at high-volume reconstructive centers
  • Trade-off: larger setup time and footprint than a simple bite-block + cheek retractor

Kilner-Doughty Mouth Gag​

A self-retaining retractor suspended from a Mayo stand or similar support, frequently referenced in BMG harvest descriptions in the oral and palatal surgery literature. Provides stable retraction of the lips and cheeks while freeing both surgeon hands.

  • Good for: bilateral harvest, prolonged cases, oral-surgery-team-shared trays
  • Trade-off: requires the Mayo-stand suspension setup

Denhardt Mouth Gag​

A ratcheted, spring-loaded jaw opener with flat tooth-pad blades between the molars. Provides stable mouth opening with fixed separation once set.

  • Good for: solo or lightly assisted harvest, longer harvests, bilateral harvest
  • Trade-off: wider profile; can obstruct posterior cheek mucosa access in a small mouth

Molt Mouth Gag​

A ratcheted spreader similar to the Denhardt with narrower tooth pads and a compact profile. Common in oral / maxillofacial surgery.

  • Good for: small mouths, posterior cheek exposure
  • Trade-off: less stable than the Denhardt for prolonged cases

Jennings Mouth Gag​

A side-opening spreader with curved blades that fit against the molars laterally — excellent lateral jaw separation without midline occupation.

  • Good for: anterior floor-of-mouth work (atypical for BMG); used when other gags are unavailable

Minnesota Cheek Retractor​

A single-handed curved blade for lateral cheek retraction — does not hold the mouth open on its own. Standard pairing with a bite-block or Dingman / Denhardt for intraoperative BMG access.

  • Good for: assistant-driven lateral retraction during graft harvest

Lone Star (Scott) Elastic Stay-Hook Adaptation​

Some surgeons adapt the Lone Star elastic stay-hook ring for cheek retraction during BMG harvest — the hooks evert and stabilize the buccal mucosa against the cheek, creating a taut donor surface without continuous handheld retraction.

  • Good for: surgeons already comfortable with the Lone Star ring system; off-label but effective adaptation

Seldin / Lip Retractor​

A simple lip retractor that pulls the lower or upper lip outward and protects the vermillion from stretching injury during prolonged retraction. Used as an adjunct, not alone.

Bite Block​

Not strictly a retractor — a soft plastic or rubber block placed between the contralateral molars that holds the mouth open passively under anesthesia.

  • Good for: small, quick harvests where a formal mouth gag is excessive
  • Trade-off: less stable than a ratcheted gag for extended exposure

Specialized Oral Retractors​

Eppley et al. (1997) described a dedicated specialized oral retractor for BMG harvest in their early urethroplasty series, reporting adequate graft size and no donor-site complications in 12 patients.[4] Several contemporary instrument vendors offer purpose-built buccal-harvest retractor sets, though comparative data vs general-purpose mouth gags is not published.

Workhorse Setup — Mouth Gag + Cheek Retractor + Lip Stay-Suture​

A practical and widely adopted combined technique:[5]

  • Standard mouth gag (Dingman / Denhardt / Kilner-Doughty) holds the mouth open
  • Stay sutures placed through the lateral edge of the lip further retract and stabilize the cheek — this combination provides excellent visualization of the inner cheek
  • Lip retractor to protect the ipsilateral corner of the mouth
  • Stay sutures at superior and inferior graft outline tied to the retractor frame to flatten the donor surface for sharp dissection

Practical Considerations for the Whole Harvest​

Retractor choice is necessary but not sufficient. The set of pearls that determine donor-site outcome:

  • Nasal intubation is preferred over oral intubation to avoid the ETT obstructing the operative field.[5][6]
  • Stensen's duct (parotid orifice opposite the second maxillary molar) identified and marked before incision to avoid injury during harvest.[5]
  • Submucosal hydrodissection with lidocaine + epinephrine (1:100,000 to 1:200,000) to facilitate sharp dissection, reduce bleeding, and define the plane.[5][6]
  • Standard graft dimensions ~ 4 cm × 2.5 cm from a single cheek; larger grafts are obtainable.[7]
  • For longer grafts (> 6 cm), 56% of GURS-affiliated reconstructive urologists harvest from both cheeks (Berg 2024 SGURS survey).[8]
  • Stay above the buccinator muscle — the buccal fat pad sits deep to it, and poor visualization is the dominant predictor of inadvertent buccinator entry.[9]

Donor-Site Morbidity — What the Data Show​

Donor-site morbidity is generally low across retractor choices when the principles above are followed:

  • Barbagli 2014, n = 553 consecutive patients undergoing oral mucosa graft harvest: 98.2% patient satisfaction; difficulty opening the mouth 4.5%, dry mouth 4.2%, persistent local pain uncommon.[10]
  • Soave 2018 RCT of closure vs nonclosure of the BMG harvest site: nonclosure was noninferior for oral-pain intensity and quality across detailed postoperative assessment.[11]
  • Fabbroni 2005 oral-surgery-driven series: trismus in a small proportion (4/23 early, 1 late), supporting the principle that adequate retraction + minimally traumatic dissection minimize this complication.[9]

Default Setup (At-a-Glance)​

A reasonable default for the bulbar / panurethral BMG harvest:

ElementChoicePurpose
Mouth-holdingDingman or Kilner-DoughtySustained self-retaining exposure
Cheek retractionMinnesota (or Lone Star hook adaptation)Lateral cheek eversion
Lip protectionSeldin / lip retractor + lateral-lip stay sutureVermillion protection + further cheek stability
Donor-surface flatteningStay sutures at graft cornersTaut surface for sharp dissection
AirwayNasal ETTOff the operative field
HydrodissectionLidocaine + epi 1:100k–1:200kPlane definition + hemostasis
Anatomic landmarkStensen's duct markedAvoid parotid-orifice injury

Local preference and institutional tray composition drive most variation. The constants: mouth held open stably, cheek retracted laterally, lip protected, donor surface taut and dry, Stensen's duct identified and avoided, dissection stays superficial to the buccinator.

See also: Buccal Mucosa Graft, The Oral Cavity, Lone Star Retractor.

References​

1. Markiewicz MR, Lukose MA, Margarone JE 3rd, Barbagli G, Miller KS, Chuang SK. "The oral mucosa graft: a systematic review." J Urol. 2007;178(2):387–94. doi:10.1016/j.juro.2007.03.094

2. Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. "Current controversies in reconstructive surgery of the anterior urethra: a clinical overview." Int Braz J Urol. 2012;38(3):307–16. doi:10.1590/s1677-55382012000300003

3. Rao LP, Peter S. "Modification of the Dingman mouth gag for better visibility and access in the management of cleft palate." Cleft Palate Craniofac J. 2015;52(2):250–3. doi:10.1597/13-070

4. Eppley BL, Keating M, Rink R. "A buccal mucosal harvesting technique for urethral reconstruction." J Urol. 1997;157(4):1268–70.

5. Gülpınar Ö, Zumrutbas AE, Sancı A, et al. "The outcomes of three buccal mucosal graft urethroplasty techniques in women with urethral stricture disease." Neurourol Urodyn. 2021;40(8):1921–1928. doi:10.1002/nau.24764

6. Goel A, Dalela D, Sinha RJ, Sankhwar SN. "Harvesting buccal mucosa graft under local infiltration analgesia — mitigating need for general anesthesia." Urology. 2008;72(3):675–6. doi:10.1016/j.urology.2008.04.047

7. Barbagli G, Vallasciani S, Romano G, et al. "Morbidity of oral mucosa graft harvesting from a single cheek." Eur Urol. 2010;58(1):33–41. doi:10.1016/j.eururo.2010.01.012

8. 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

9. Fabbroni G, Loukota RA, Eardley I. "Buccal mucosal grafts for urethroplasty: surgical technique and morbidity." Br J Oral Maxillofac Surg. 2005;43(4):320–3. doi:10.1016/j.bjoms.2004.11.025

10. 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):688–93. doi:10.1016/j.juro.2013.09.006

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