What type of specialist is recommended to perform a biopsy on a lesion located on the upper lip and philtrum?

Specialist for Biopsy of Upper Lip and Philtrum Lesions

For a suspicious pigmented lesion on the upper lip and philtrum, a dermatologist or dermatologic surgeon experienced in facial biopsies should perform the procedure, with oral and maxillofacial surgeons serving as an appropriate alternative for this anatomic location.

Primary Specialist Recommendations

Dermatologist as First-Line Specialist

• Dermatologists are the primary specialists for performing biopsies of suspicious pigmented lesions on facial skin, including the upper lip and philtrum. 1
• The facial location requires expertise in cosmetically sensitive biopsy techniques that preserve tissue while obtaining adequate diagnostic material. 1, 2
• Dermatologists routinely perform punch biopsies and excisional biopsies on facial structures and are trained in selecting appropriate biopsy techniques based on lesion characteristics. 1

Oral and Maxillofacial Surgeons as Alternative

• Oral and maxillofacial surgeons frequently manage lip lesions and represent an appropriate alternative specialist for this anatomic region. 3
• In a large retrospective study, skin lesions of the lips accounted for 41.7% of all dermatologic cases submitted to oral and maxillofacial pathology services, demonstrating their expertise in this area. 3
• These specialists have particular experience with the vermillion border and transitional zones between oral mucosa and facial skin. 3, 4

Biopsy Technique Selection for This Location

Facial Anatomic Considerations

• The face is designated as an anatomic area where full-thickness incisional or punch biopsy is acceptable rather than excisional biopsy, due to cosmetic preservation concerns. 1, 2
• For suspected melanoma on the face, a full-thickness punch biopsy of the clinically thickest portion is an acceptable alternative to excisional biopsy. 1
• The upper lip and philtrum are cosmetically sensitive areas where tissue preservation is important while still obtaining adequate diagnostic material. 1, 2

Preferred Biopsy Approach

• If the lesion is small enough, narrow excisional biopsy with 1-3 mm margins remains the preferred technique, even on the face. 1
• When excisional biopsy is not feasible due to lesion size or location, a full-thickness punch biopsy (4 mm or larger when possible) of the thickest portion should be performed. 1, 2
• Superficial shave biopsies should be avoided for pigmented lesions as they may underestimate Breslow thickness and compromise accurate staging. 1

Critical Pathology Requirements

Essential Information for Pathologist

• The specimen must be sent with complete clinical information including patient age, exact anatomic site (upper lip/philtrum), and clinical suspicion for melanoma or other malignancy. 5, 2
• Inadequate clinical information can lead to inaccurate pathologic interpretation and inappropriate sectioning protocols. 2

Required Pathologic Reporting Elements

• The pathology report must include Breslow thickness, presence or absence of ulceration, mitotic rate, Clark level (especially for lesions ≤1.0 mm), and margin status. 1, 5
• The specimen should be read by a pathologist experienced in pigmented lesions to ensure accurate diagnosis. 1

Common Pitfalls to Avoid

Inadequate Sampling

• Punch biopsies that are too superficial or too small risk missing the thickest portion of the lesion, leading to understaging and inadequate initial treatment. 5
• If the initial biopsy is inadequate for diagnosis or accurate microstaging, narrow-margin excisional biopsy should be performed rather than repeating the punch biopsy. 1, 2

Biopsy Orientation Planning

• The orientation of any biopsy should be planned with definitive wide excision in mind, typically oriented parallel to skin tension lines when possible. 1, 5
• Avoid wider margins on the initial diagnostic biopsy as this can interfere with subsequent sentinel lymph node mapping if melanoma is diagnosed. 1

Hemostasis Technique

• Topical hemostatic agents (aluminum chloride or ferric subsulfate) are preferred over electrocautery to avoid tissue destruction that compromises histologic assessment. 1
• Spot electrocautery may be used if necessary, but should be minimized. 1