What type of surgeon should a patient with a lesion involving the upper lip and philtrum be referred to?

Referral for Upper Lip and Philtrum Lesions

Patients with lesions involving the upper lip and philtrum should be referred to a plastic surgeon, specifically one with expertise in facial reconstruction or, in pediatric cases, a pediatric plastic surgeon. 1

Why Plastic Surgery?

The upper lip and philtrum represent one of the most technically demanding areas for reconstruction due to their critical aesthetic and functional importance. Distortion of the lips from surgical intervention is common, and restoring normal lip contour is one of the greatest challenges in reconstructive surgery. 2

Key Technical Challenges Requiring Plastic Surgery Expertise:

• Precise alignment of the vermilion border is essential - even 1mm of misalignment creates permanent visible cosmetic deformity 1
• The philtrum is a distinct aesthetic unit requiring specialized reconstruction techniques to preserve its natural contour and philtral ridges 3, 4
• Setting the "white roll" (ridge at the vermilion-cutaneous border) and restoring normal sublabial concavity are particularly challenging 2, 3
• Separating lesion tissue from orbicularis oris muscle is exceedingly difficult and requires advanced surgical skill 2, 3

Specific Surgical Considerations:

For Lesions Confined to the Philtrum:

• Reconstruction should keep scars within one cosmetic unit (the philtrum itself) without extending along the vermilion border 4
• Island pedicle flaps utilizing donor tissue from the superior philtrum provide excellent cosmetic results with minimal distortion 4
• Incisions should be placed along natural boundaries such as philtral columns when possible 3

For Larger or Full-Thickness Lesions:

• Bulkier lesions causing lip lengthening or crossing the vermilion-cutaneous border require wedge excision, often as a staged procedure 2, 3
• Full-thickness defects require layered closure with precise alignment of anatomical landmarks including the white roll, philtral columns, and vermilion border 1
• Reconstruction may require local/regional flaps, free tissue transfer, or specialized techniques like Abbe flaps for philtral reconstruction 5

Special Populations:

Pediatric Patients:

• The American Academy of Pediatrics specifically recommends that children with major facial trauma or congenital lip deformities be referred to pediatric plastic surgeons 1, 6
• Children ≤5 years with significant facial injuries should be transferred to pediatric trauma centers with pediatric plastic surgeons 1

Timing Considerations:

• For certain lesions (like infantile hemangiomas), early surgical resection should only be considered for small lesions in cosmetically favorable areas 2
• Otherwise, reconstruction is best performed after lesion growth has definitively ceased to minimize the number of surgical interventions and optimize cosmetic outcomes 2

Common Pitfalls to Avoid:

• Do not refer to general surgeons or dermatologists for complex philtral reconstruction - the technical demands exceed routine excision and closure 4, 5
• Avoid simple side-to-side closure for philtral defects, as this commonly results in vermilion border distortion and obliteration of normal philtral contour 4
• For malignant lesions (like squamous cell carcinoma), radiotherapy may offer comparable cure rates with superior cosmetic/functional results for lip lesions, so consider multidisciplinary oncology team involvement 2