CASE REPORT
Surface Anatomy of the Lip for the Dermatologist Tessa Weinberg, Max Solish, Ibrahim Fayez, and Christian Murray Background: Expert treatment of cutaneous facial pathology requires the correct diagnosis and precise anatomic knowledge. Lip surface anatomy is complex. Case Report: This brief report reviews the clinically relevant surface anatomy of the lip. Contexte: Le traitement spe´cialise´ des le´sions cutane´es de la face ne´cessite la pose du bon diagnostic et une connaissance pre´cise de l’anatomie; et l’anatomie de surface des le`vres est complexe. Expose´ de cas: Nous passerons en revue, dans ce court expose´, l’anatomie de surface des le`vres, juge´e pertinente sur le plan clinique.
HE LIP is an area of frequent dermatologic pathology. It is thus an area frequently treated by dermatologists for cosmetic, medical, and surgical conditions. Dermatologic surgery requires an in-depth understanding of the anatomy, specifically the surface anatomy, of the lip. The lips are complex, and frequently, multiple terms are used for each anatomic structure. This article describes the surface anatomy of the lip using a common case to illustrate some key points.
T
Case Report A 38-year-old woman was referred as basal cell carcinoma (BCC) of the lip for Mohs micrographic surgery (MMS) (Figure 1). The center of the BCC was located on the left upper cutaneous lip, just lateral to the left philtral column and the left philtral crest. The medial edge involved the left philtral crest, the left philtral column, and some of the white roll lateral to the philtral crest. Excision was performed with MMS, requiring two levels (Figure 2). Reconstruction was accomplished by a mucosal advancement at the left philtral crest to recreate the cupid’s bow
and bilateral (A-T) advancement flaps of the cutaneous lip along the vermilion border.
Discussion The BCC of the upper lip noted in Figure 1 is not an unusual referral to the MMS unit. Excision and reconstruction required a detailed description and thus understanding of the complex lip anatomy.1,2,3 Lesions on the lip are exceptionally common and thus frequently referred to dermatologists. The lip and surrounding areas form common cosmetic concerns for patients. Treatment, especially surgical and cosmetic, requires a detailed understanding of the complex surface anatomy. This can be seen in Figure 3, Figure 4, and Figure 5 and is summarized in Table 1.
From the Division of Dermatology, Women’s College Hospital, University of Toronto, Toronto, ON. Address reprint requests to: Christian A. Murray, MD, FRCPC, FACMS, Division of Dermatology, University of Toronto, Women’s College Hospital, 76 Grenville Street, Room 842, Toronto, ON M5S 1B2; e-mail: [email protected]
DOI 10.2310/7750.2013.13134 # 2014 Canadian Dermatology Association
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Figure 1. Patient referred as basal cell carcinoma of the lip.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
Surface Anatomy of the Lip
Figure 4. Surface anatomy of the lip in the oblique view.
Figure 2. Defect after Mohs surgery.
Figure 3. Surface anatomy of the lip in the frontal view.
Figure 5. Surface anatomy of the lip, left melolabial subunits.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
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Weinberg et al
Table 1. Terminology of the Surface Anatomy of the Lip Anatomic Site
Description
Cupid’s bow
The contour of the line formed by the white roll of the upper lip. The double curve of the upper lip that is said to resemble the bow of Cupid. The peaks of the bow coincide with the philtral columns, giving a prominent bow appearance to the lip. Cutaneous lower lip An area bordered by the lower lip white roll superiorly, the marionette lines laterally, and the labiomental crease inferiorly. Cutaneous upper lip An area bordered by the philtral column medially, the upper lip white roll inferiorly, the nasolabial folds laterally, and the alar base and nasal sill superiorly. Chelion A bilateral landmark located at the outermost corner (commissure) of the mouth where the cutaneous upper lip and cutaneous lower lip join. As such, it is the point marking the lateral extent of the labial fissure. Labiomental crease The semicircular crease forming the junction between the chin and lower cutaneous lip Labial fissure The slit-like space between the lips Lip tubercle (prochelion) A protrusion of the upper lip vermilion in the midline just inferior to the lowest point of the cupid’s bow Nasolabial fold (melolabial fold) The line of varying depth formed at the junction of the medial cheek (melo) and lateral cutaneous lip (labial) Melonasal triangle (melonasal isthmus, A triangle-shaped area at the junction of the superiormost alar base, the superiormost nasolabial apical triangle) fold Mucosal lip The lip posterior (internal) to the wet line Oral commissure The point at which the upper and lower lips join Philtral crest The apex of the white roll located at the inferior base of the philtral column. The highest point of the cupid’s bow on each side. Philtrum The concave area between the two philtral columns (laterally), the white roll (inferiorly), and the columellar base Vermilion (red lip) The visible or ‘‘red’’ part of the lip. It is bordered by the cutaneous lip white roll and the mucosal lip Vermilion border The periphery of red lip just adjacent to the white roll. The transition point from the red lip to the white roll and cutaneous lips, both upper and lower. Wet line A transverse line demarcating the junction between the vermilion and the mucosal lip. The point where the lips touch when the lips are lightly closed. White roll The raised line running along the vermilion border. The dermal expansion at this point creates a lighter appearance compared to the adjacent skin. An important landmark for filler injection of the lips when accentuating lip demarcation.
The lip anatomy is quite intricate, and some terms are confusing. This is further complicated by the fact that some terms are used interchangeably and appropriately, such as melolabial fold and nasolabial fold, whereas others are used interchangeably and inappropriately, such as vermilion border and white roll.
Conclusion An in-depth knowledge of surface anatomy of the lip is crucial to cosmetic, surgical, and medical dermatologic practice. The surface anatomy of the lip has many subtle and crucial structures.
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Acknowledgment Financial disclosure of authors and viewers: None reported.
References 1. Czerninski R, Zini A, Sgan-Cohen HD. Lip cancer: incidence, trends, histology and survival: 1970-2006. Br J Dermatol 2010;162: 1103–9, doi:10.1111/j.1365-2133.2010.09698.x. 2. Binnie WH, Lehner T. Histology of the mucocutaneous junctions at the corner of the human mouth. Arch Oral Biol 1970;15:777–86, doi:10.1016/0003-9969(70)90041-5. 3. Aston SJ, Steinbrech DS, Walden JL. Aesthetic plastic surgery. Philadelphia: W. B. Saunders; 2009.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Surface Anatomy of the Lip for the Dermatologist Tessa Weinberg, Max Solish, Ibrahim Fayez, and Christian Murray Background: Expert treatment of cutaneous facial pathology requires the correct diagnosis and precise anatomic knowledge. Lip surface anatomy is complex. Case Report: This brief report reviews the clinically relevant surface anatomy of the lip. Contexte: Le traitement spe´cialise´ des le´sions cutane´es de la face ne´cessite la pose du bon diagnostic et une connaissance pre´cise de l’anatomie; et l’anatomie de surface des le`vres est complexe. Expose´ de cas: Nous passerons en revue, dans ce court expose´, l’anatomie de surface des le`vres, juge´e pertinente sur le plan clinique.
HE LIP is an area of frequent dermatologic pathology. It is thus an area frequently treated by dermatologists for cosmetic, medical, and surgical conditions. Dermatologic surgery requires an in-depth understanding of the anatomy, specifically the surface anatomy, of the lip. The lips are complex, and frequently, multiple terms are used for each anatomic structure. This article describes the surface anatomy of the lip using a common case to illustrate some key points.
T
Case Report A 38-year-old woman was referred as basal cell carcinoma (BCC) of the lip for Mohs micrographic surgery (MMS) (Figure 1). The center of the BCC was located on the left upper cutaneous lip, just lateral to the left philtral column and the left philtral crest. The medial edge involved the left philtral crest, the left philtral column, and some of the white roll lateral to the philtral crest. Excision was performed with MMS, requiring two levels (Figure 2). Reconstruction was accomplished by a mucosal advancement at the left philtral crest to recreate the cupid’s bow
and bilateral (A-T) advancement flaps of the cutaneous lip along the vermilion border.
Discussion The BCC of the upper lip noted in Figure 1 is not an unusual referral to the MMS unit. Excision and reconstruction required a detailed description and thus understanding of the complex lip anatomy.1,2,3 Lesions on the lip are exceptionally common and thus frequently referred to dermatologists. The lip and surrounding areas form common cosmetic concerns for patients. Treatment, especially surgical and cosmetic, requires a detailed understanding of the complex surface anatomy. This can be seen in Figure 3, Figure 4, and Figure 5 and is summarized in Table 1.
From the Division of Dermatology, Women’s College Hospital, University of Toronto, Toronto, ON. Address reprint requests to: Christian A. Murray, MD, FRCPC, FACMS, Division of Dermatology, University of Toronto, Women’s College Hospital, 76 Grenville Street, Room 842, Toronto, ON M5S 1B2; e-mail: [email protected]
DOI 10.2310/7750.2013.13134 # 2014 Canadian Dermatology Association
200
Figure 1. Patient referred as basal cell carcinoma of the lip.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
Surface Anatomy of the Lip
Figure 4. Surface anatomy of the lip in the oblique view.
Figure 2. Defect after Mohs surgery.
Figure 3. Surface anatomy of the lip in the frontal view.
Figure 5. Surface anatomy of the lip, left melolabial subunits.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
201
Weinberg et al
Table 1. Terminology of the Surface Anatomy of the Lip Anatomic Site
Description
Cupid’s bow
The contour of the line formed by the white roll of the upper lip. The double curve of the upper lip that is said to resemble the bow of Cupid. The peaks of the bow coincide with the philtral columns, giving a prominent bow appearance to the lip. Cutaneous lower lip An area bordered by the lower lip white roll superiorly, the marionette lines laterally, and the labiomental crease inferiorly. Cutaneous upper lip An area bordered by the philtral column medially, the upper lip white roll inferiorly, the nasolabial folds laterally, and the alar base and nasal sill superiorly. Chelion A bilateral landmark located at the outermost corner (commissure) of the mouth where the cutaneous upper lip and cutaneous lower lip join. As such, it is the point marking the lateral extent of the labial fissure. Labiomental crease The semicircular crease forming the junction between the chin and lower cutaneous lip Labial fissure The slit-like space between the lips Lip tubercle (prochelion) A protrusion of the upper lip vermilion in the midline just inferior to the lowest point of the cupid’s bow Nasolabial fold (melolabial fold) The line of varying depth formed at the junction of the medial cheek (melo) and lateral cutaneous lip (labial) Melonasal triangle (melonasal isthmus, A triangle-shaped area at the junction of the superiormost alar base, the superiormost nasolabial apical triangle) fold Mucosal lip The lip posterior (internal) to the wet line Oral commissure The point at which the upper and lower lips join Philtral crest The apex of the white roll located at the inferior base of the philtral column. The highest point of the cupid’s bow on each side. Philtrum The concave area between the two philtral columns (laterally), the white roll (inferiorly), and the columellar base Vermilion (red lip) The visible or ‘‘red’’ part of the lip. It is bordered by the cutaneous lip white roll and the mucosal lip Vermilion border The periphery of red lip just adjacent to the white roll. The transition point from the red lip to the white roll and cutaneous lips, both upper and lower. Wet line A transverse line demarcating the junction between the vermilion and the mucosal lip. The point where the lips touch when the lips are lightly closed. White roll The raised line running along the vermilion border. The dermal expansion at this point creates a lighter appearance compared to the adjacent skin. An important landmark for filler injection of the lips when accentuating lip demarcation.
The lip anatomy is quite intricate, and some terms are confusing. This is further complicated by the fact that some terms are used interchangeably and appropriately, such as melolabial fold and nasolabial fold, whereas others are used interchangeably and inappropriately, such as vermilion border and white roll.
Conclusion An in-depth knowledge of surface anatomy of the lip is crucial to cosmetic, surgical, and medical dermatologic practice. The surface anatomy of the lip has many subtle and crucial structures.
202
Acknowledgment Financial disclosure of authors and viewers: None reported.
References 1. Czerninski R, Zini A, Sgan-Cohen HD. Lip cancer: incidence, trends, histology and survival: 1970-2006. Br J Dermatol 2010;162: 1103–9, doi:10.1111/j.1365-2133.2010.09698.x. 2. Binnie WH, Lehner T. Histology of the mucocutaneous junctions at the corner of the human mouth. Arch Oral Biol 1970;15:777–86, doi:10.1016/0003-9969(70)90041-5. 3. Aston SJ, Steinbrech DS, Walden JL. Aesthetic plastic surgery. Philadelphia: W. B. Saunders; 2009.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 200–202
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
