Dimple creation Tips and tricks

Dimples have always been seen as a beauty symbol which is very attractive to all. Dimples tend to accentuate a smile, thus increasing the perception of attractiveness, sociability, and facial beauty. This is a characteristic inherited in an autosomal dominant fashion; the cleft chin dimple is on chromosome 5 and cheek dimples are on chromosome 16, with variable penetrance.

Dimples can be transient or permanent, depending on the cause or factor responsible for their occurrence. The process of growth and development could contribute to this. Excessive fat deposition, which disappears with the aging process, causes transient dimples, whereas the stretching or lengthening of muscles during growth can lead to gradual obliteration of the facial feature. This explains why some dimples are more common and conspicuous in younger age groups. Dimples on the face are commonly situated on the cheeks and chin, although the latter occurs less frequently. Structurally, cheek dimples occur because of a defect created by muscles on the face, whereas the chin dimple is a result of an underlying bony defect.

Cheek dimples are caused by the presence of dermocutaneous insertion of the fibers on the inferior bundle of the double or bifid zygomaticus major muscle. Smiling makes the overlying skin draw inward and the dimple becomes larger, thereby making it more visible. Either or both of the cheeks can present with 1 or more dimples, but it is more common to have dimples occurring on both cheeks than only 1 cheek.

Dimple surgery can be performed easily  with the patient under local anesthesia. Most of the techniques, if not all, involve adherence of the buccinator muscles of the face to the dermis of the skin; this can be achieved with transcutaneous sutures or by an open technique that is performed through the mouth, which would show no scarring. Like natural dimples, dimples created surgically typically appear with smiling, although surgically created dimples may be visible most of the time depending on the surgical technique used. The dimple may be present even without smiling for the first several days, or even weeks, after surgery; eventually, the surgically created dimple will most likely be present with smiling as scar develops between the inner skin and the buccinator muscle

Positioning

When one surgically creates a dimple, the ideal location would be the area where a less obvious faint dimple is present with smiling; thus the pre-existing dimple is made more prominent. If 1 cheek has a dimple, the ideal location for the other dimple would be marked at the corresponding site that would create symmetry of the face. If a pre-existing dimple is not present, the ideal location would be the intersection between a horizontal line from the corner of the mouth and a vertical line from the lateral canthus of the eye. Alternatively 1.5 to 2 cm superior to a point bisecting an angle formed by the projection of the lateral commissure and the lateral canthus. Also patients having natural dimples that if the person sucks his cheeks inside, the area of the maximum depression is the area of the dimple. Similarly, the patient is asked to create a negative suction and suck the cheeks inside. The site of the maximum depression is the marked site of the dimple. Sometimes the marking is migrated slightly laterally if pulsation of facial artery is palpable to avoid hematoma.  The final position is usually chosen by the patient based on preference and also vector of smile.

Dimple creation

 

Surgical Technique

2 3 4   Dimple

They can be categorized into 2 major categories,namely blind coring and open approaches.

The patient’s face and mouth are prepared, and  local anesthesia administered, along the marked area. Hypodermic needles are then passed through the marked point into the buccal mucosa. A soft tissue trephine bur connected to a latch-type handpiece  or a punch biopsy needle is used to punch the buccal mucosa while the opposite hand pushes the buccal mucosa inward and supported this area externally. The soft tissue cylindrical fragment (consisting of the mucosa, a small portion of the buccinator muscle, and a part of the Bichat fat pad) is removed with scissors, and the skin is kept intact. Alternatively you could incise the mucosa and under vision excise a small part of muscle and fat. The advantage of open approach is the depth and size of dimple can be adjusted based on the amount of fat present. For more depth of dimple more fat can be excised and a larger defect in muscle created.

Dimple creation

Defect closure is performed by placing a nonabsorbable /absorbable suture   through the cheek mucosa, muscle, and Bichat fat pad on 1 side of the defect; then through the dermis layer of the skin; and finally, through the Bichat fat pad, the buccinator muscle, and the mucosa on the other side of the defect. The knot is tied and tension adjusted based on the depth  of dimple required. The patient is advised to maintain good oral hygiene with chlorhexidine mouth wash and oral antibiotics and analgesics prescribed. Suture removal is done in non absorbable sutures at 10-14 days.

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Potential complications of dimple surgery consist of sudden disappearance of the dimple, asymmetry, foreign body reaction, bleeding, and injury to a nerve (buccal branch of the facial nerve) or salivary gland duct (Stensen duct), which are rare.

 

Tips

  1. Non excision suture techniques do not provide long lasting results.
  2. Location of dimple must be chosen based on vector of smile blindly following the intersection of oral commissure and lateral canthus may place it too inferiorly.
  3. For a bulky cheeks choose a open approach with excision of adequate amount of fat to create a deep dimple rather than a core excision and single stitch.
  4. Prolene sutures for muscle to dermis approximation causes long lasting results but increases chances of foreign body reaction and infection alternatively Polydiaxone suture can be used and mucosa closed with catgut.
  5. Explain the patient that the dimple will be exaggerated in first few weeks and will be present even at rest and over time only on animation.

 

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