Recipient-Site Optimization in Moustache Reconstruction for Cleft Lip Scars: A Narrative Review of Scar Conditioning, Microneedling, and Follicular Unit Transplantation

Background: Residual moustache alopecia associated with cleft lip repair is an uncommon but visually important secondary deformity. Although follicular unit transplantation can restore hair within the philtral and upper-lip region, mature cleft lip scars may constitute a challenging recipient bed because of altered tissue architecture, fibrosis and reduced pliability. These characteristics may affect recipient-site preparation and potentially influence graft establishment. Objective: To review the evolution of moustache reconstruction in cleft lip scars and synthesize the available evidence regarding scar conditioning and recipient-site optimization, with particular emphasis on microneedling, hyaluronic acid and follicular unit transplantation/extraction. Materials and Methods: This narrative review qualitatively synthesizes the 18 publications included in the reference list, covering cleft lip scars, moustache reconstruction, follicular unit transplantation/extraction, scar conditioning, microneedling, hyaluronic acid, wound healing and scar assessment. Publications were interpreted according to study design, directness to the clinical question and relevance. A reproducible database search and formal risk-of-bias assessment were not documented; accordingly, the review is not presented as systematic. Results: The available cleft-specific literature consists predominantly of case reports and small clinical series. Early reports established the feasibility of microhair and single-follicular-unit transplantation into upper-lip scars. Later work described FUE and staged fat grafting with subsequent hair transplantation. A 2023 cohort study of 16 patients with cleft lip scars reported improvement in scar thickness and flexibility following four microneedling sessions combined with topical oil-based hyaluronic acid, using the Patient and Observer Scar Assessment Scale (POSAS). However, no cleft-specific study identified in the review directly establishes that microneedling or hyaluronic acid improves subsequent follicular graft survival. Conclusion: Recipient-site optimization is a biologically plausible adjunct to moustache reconstruction in selected patients with cleft lip scars. Microneedling has direct cleft-specific evidence for improving scar characteristics, while fat-based conditioning and hair transplantation provide supportive evidence for staged reconstruction. The use of microneedling with hyaluronic acid before FUE should currently be regarded as a promising but investigational strategy rather than an established graft-survival protocol. Prospective comparative studies with objective hair and scar outcomes are required.