Paramedian Forehead Flap Hair Removal: A Comprehensive Review of Techniques, Timing, Challenges, and Future Directions

The paramedian forehead flap (PFF) is a widely used and versatile reconstructive technique, highly valued for its reliable vascularity, close tissue match, and integration of both functional and aesthetic outcomes. Despite its versatility and broad applicability in reconstructive surgery, inclusion of hair-bearing scalp can compromise cosmetic results and patient satisfaction, making hair management a critical but often underappreciated aspect of flap-based reconstruction. Traditional depilation techniques provide only temporary results, whereas contemporary methods such as laser hair removal, intense pulsed light (IPL), electrolysis, and follicular unit extraction (FUE) enable durable or permanent hair reduction in transferred flaps. The timing of intervention, including preoperative, during tissue expansion, intraoperative, or postoperative treatment, significantly influences both efficacy and patient tolerance. FUE is particularly advantageous for patients with low hairlines or extensive donor sites, while laser hair removal remains the primary method for most flap applications. This review systematically summarizes current hair removal strategies in PFF reconstruction, evaluating their underlying mechanisms, clinical effectiveness, advantages, limitations, and optimal timing considerations. This review draws on clinical experience and published evidence to provide practical recommendations for hair management in paramedian forehead flaps. It focuses on improving aesthetic outcomes, guiding timing and technique selection, and supporting decisions in flap-based reconstruction.