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Anatomical basis of dimple creation – A new technique: Our experience of 100 cases

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Cheek dimples are usually considered as an attractive feature of facial beauty. Unfortunately, not all beautiful girls have dimples. Literature on dimple creation surgery is sparse. We used a new and simple technique for dimple creation, passing a transcutaneous bolster stitch after scraping off the dermis of all mucomuscular attachments. Our aim was to analyse the positive and negative findings of this technique. We used this procedure in creation of 100 dimples under local anaesthesia as a daycare procedure and analysed the results. This procedure is safe, reliable and easily reproducible. As no tissue is excised, chances of bleeding and haematoma formation are negligible. With this procedure, the patient satisfaction rate is very high, and patients seen long time after surgery continue to be pleased with their surgically created dimples.
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Anatomical basis of dimple creation – A new technique:
Our experience of 100 cases
A. R. Lari, Nikhil Panse1
Medical Director and Head, Lari Clinic, Kuwait, 1Department of Plastic Surgery, B.J Medical College, Sassoon Hospital, Pune,
Maharashtra, India
Address for correspondence: Dr. Abdul Reda Lari, Lari Clinic, Post Box Number 31420, Kuwait 90805. E-mail: drlari1@hotmail.com
ABSTRACT
Background: Cheek dimples are usually considered as an attractive feature of facial beauty.
Unfortunately, not all beautiful girls have dimples. Literature on dimple creation surgery is sparse.
Aims: We used a new and simple technique for dimple creation, passing a transcutaneous bolster
stitch after scraping off the dermis of all mucomuscular attachments. Our aim was to analyse the
positive and negative ndings of this technique. Materials and Methods: We used this procedure in
creation of 100 dimples under local anaesthesia as a daycare procedure and analysed the results.
Results and Conclusion: This procedure is safe, reliable and easily reproducible. As no tissue
is excised, chances of bleeding and haematoma formation are negligible. With this procedure,
the patient satisfaction rate is very high, and patients seen long time after surgery continue to be
pleased with their surgically created dimples.
KEY WORDS
Anatomical basis of dimple creation; dimple creation; natural dimples
Original Article
INTRODUCTION
Dimples on cheeks enhance facial beauty and
expression. They occur in both sexes with
no particular preponderance, may express
unilaterally or bilaterally and are genetically inherited as
a dominant trait.[1,2] Anatomically, dimples are thought to
be caused by a double or bifid zygomaticus major muscle,
whose fascial strands insert into the dermis and cause a
dermal tethering effect.[3,4] There is an increasing demand
for dimple creation surgery in our part of the globe. As
a result, we have used this simple technique for creating
cheek dimples in our patients.
MATERIALS AND METHODS
Between January 2006 and October 2010, we surgically
created 100 dimples in 64 patients by the technique
mentioned below. All the dimples were created under
local anaesthesia on an outpatient basis. Of the 64
patients, 60 were females and 4 were males. Sixteen
patients underwent unilateral dimple creation and
42 underwent bilateral dimple creation. Of the 16
unilateral dimples, 14 dimples were made on the left
side and 2 on the right side of the face. All the bilateral
dimples were created in females. The average age of
the patients was 31 years [Table 1].
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DOI:
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Lari and Panse: Anatomical basis of dimple creation
Anatomy of the dimple
Anatomically, dimples are thought to be caused by
a double or bifid zygomaticus major muscle, whose
fascial strands insert into the dermis and cause a
dermal tethering effect.
[3,4]
Operative technique
Positioning of the dimple
Generally, the position of the dimple is marked by the
patient in front of the mirror. If the patient is undecided
as to the site of the dimple, another landmark described
from the cosmetic viewpoint is the intersection of a
perpendicular line dropped from the external canthus
and a horizontal line drawn from the angle of mouth,
as reported by Boo-Chai.
[5]
However, we feel that the
position of the dimple marked by this method is too
low. We consider the position of the dimple at the point
of intersection of the perpendicular line dropped from
the external canthus and horizontal line drawn from
the highest point of the cupid’s bow laterally. It has also
been our observation in 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.
Surgery
The aim of the surgery is to create a scar in the dermis
which adheres to the underlying muscle, and becomes
a natural dynamic dimple. It is performed under local
anaesthesia. Around 2–3 ml of 0.5% lignocaine adrenaline
solution is injected from the skin side down to the
mucosal side at the marked site. A period of 10min is
allowed to lapse. A small stab incision is made with a
No. 15 knife, 2cm anterior (towards the lips) to the
proposed site of the dimple. Due care is taken to ensure
that we are away from the papilla of the stensons duct.
The No.15 blade is then inserted through the small stab
on the mucosal aspect, with its sharp edge facing the
skin. After the blade with its sharp edge comes below
the marked site of the dimple, the skin is scraped of all
the mucomuscular attachments. A similar procedure is
done on the mucosal side, taking care not to breach the
mucosa. If a wider dimple is to be created, a wider area
is scraped, so that two raw areas are created which will
adhere to each other and create the dimple. Similarly, if a
smaller dimple is to be created, a proportionately smaller
area is scraped. After the scraping is complete, a dent
is felt if palpated bimanually. If the desired depression
is not created, it means that the scraping is inadequate
and needs further scraping. The next step is to create
and maintain the adhesion. A No. 3 ethilon on a straight
needle is taken. It is inserted through the skin, brought
out through the mucosa, reinserted through the mucosa
and brought out through the skin and a bolster stitch is
taken [Figure 1]. The advantage of the bolster is to have a
better longitudinal dimple. Care is taken to keep a small
piece of vaseline gauze between the skin, mucosa and
the stitch. In the last few cases, we have used a silicon
cylinder (block) as a bolster as it is more hygienic and
does not keep moisture and food debris in the suture.
Due care is also taken to prevent excessive tightening
of the stitch to prevent the resulting ischaemia of the
mucosa (Video 1).
Postoperative care
The patient is discharged immediately with antibiotics
and analgesics. Meticulous oral hygiene with mouthwash
and oral rinse is of utmost importance. The bolster stitch
is removed on postoperative day 7. Initially, there is a
static dimple which deepens on animation, but gradually
with time there is only a hint of dimple when static and
accentuates on animation. Clinical pictures are shown
[Figures 2–9].
RESULTS
The follow-up of the patients ranged from 3 weeks
to 4 years. Of the 100 dimples, only 3 had intraoral
infection around the bolster, probably because of too
tight bolster leading to ischaemia of the mucosa and
poor maintenance of oral hygiene. These were managed
by removal of bolster and by antibiotic supplementation.
The infection had no adverse effect on the dimple and
probably accentuated the dimple because of excessive
scarring. Two patients demanded reduction in the
dimple size. Partial reduction of the scar was done by
releasing the scar intraorally and injecting 0.5 ml of
Table 1: Dimple distribution in patients
Dimple details Males Females Unilateral Bilateral Unilateral (Left) Unilateral (Right) Average age
100 dimples in
64 patients
4 60 16 42 14 2 31
Videos available online
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Lari and Panse: Anatomical basis of dimple creation
hyaluronic acid in the defect. Three patients demanded
accentuation of the dimple for which a redo procedure
was done. There was no incidence of haematoma,
bleeding or injury to the buccal branch of the facial
nerve in any of the patients. By the end of 3 months
after the surgery, there was only a small hint of the
Figure 1: Diagrammatic representation of transcutaneous bolster stitch Figure 2: Pre-op frontal view case 1
Figure 3: Pre-op lateral view case 1 Figure 4: Post-op 2 years case 1 – Small dent visualised without animation
Figure 5: Post-op frontal view case 1 Figure 6: Post-op lateral view case 1
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Lari and Panse: Anatomical basis of dimple creation
dimple which was seen without animation and which
accentuated on animation. With time, the small dent
gradually diminished, but a definite dent was still seen
on follow-up to 4 years. The patient satisfaction rate
was very high, and patients seen long time after surgery
continue to be pleased with their surgically created
dimples. None of the patients in the series demanded a
complete dimple reversal surgery.
DISCUSSION
The dimple is, from a colourless description given in the
Oxford Dictionary, a small hollow especially in the cheek
or chin. However, the same word in Chinese calligraphic
writing is a picturesque one conveying the dramatic
picture of a whirlpool with its ever present ripples.
[5]
The Orientals view this anatomical endowment with a
good will and their women folk cherish and desire it.
[5]
Unfortunately, not all pretty girls have dimples. But with
simple techniques, dimples can be created with much
ease.
Published reports of technique of dimple creation are
sparse in literature. All the techniques described essentially
have the same principle to create adhesion between the
underlying muscular structures and the dermis, so that
traction may create a dimple due to the dermal tethering
effect. All the techniques described have claimed dimple
creation surgery to be a very safe procedure with good
results and a very low complication rate.
In 1962, Khoo Boo Chai
[5]
reported his technique.
He used a non-absorbable suture as a sling between
skin and buccinators muscle; in effect, this simulated
integumentary insertion of the muscle.
Shiwei Bao et al.
[6]
have used a syringe needle to guide
a monofilament nylon suture through the dermis and
the active facial muscles (usually the buccinators). They
formed a sling between the skin and buccinators muscle.
The knot is tied and dimple is created.
Thomas et al.
[7]
have described an open technique that
replicates the anatomical basis of a natural dimple.
Saraf et al.
[8]
used a punch biopsy instrument and an
intraoral approach to create a dimple. A circular core
composed of mucosa, submucosal fat and cheek muscles
is removed, sparing the skin. This creates a shallow
cylindrical shaped defect under the skin. A suture is
then taken through the cheek muscle on one side of the
defect, then through the dermal layer of the skin and
finally through the cheek muscle on the other side of
Figure 8: Post-op case 2 at 3 years follow-up with very small dent of
dimple without animation
Figure 7: Pre-op case 2
Figure 9: Post-op case 2
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Lari and Panse: Anatomical basis of dimple creation
the defect. The knot is then tied, resulting in dimpling
of the skin.
The open techniques which necessitate excision of
tissue have got a risk of bleeding during or after dimple
creation surgery. There is also an increased risk of
haematoma formation and infection. Though extremely
uncommon,
there is a potential for injury to the buccal
branch of the facial nerve.
We feel that the techniques using syringe needle as a guide
to create a sling by Shiwei Bao et al.[6] is cumbersome. They
also recommend that patient can return to work or other
activities 2 days after the operation, which we feel is a
very long time for a minor procedure like dimple creation.
To adjust the dimensions of the dimple, Shiwei Bao et al.
have recommended adjusting the tension on the knot and
the amount of dermis tissue the injection needle sutures.
This may need repeated passes and more tissue trauma
to get the desired effect, especially for the beginner.
Natural dimples are longitudinal depressions of 0.5–
1.5 cm. This long depression cannot be uniformly
achieved by a single stitch, and further excision of mucosa
and muscle is a cause of concern. The technique which
we have used is very simple and easily reproducible
even in the less-experienced hands. More so, it provides
the anatomical basis of the dimple creation. No tissue
is resected, and so there are no chances of haematoma
formation or bleeding and excessive postoperative
oedema. The size of the dimple is easy to control. One
can easily feel and visualise the indentation before
placing the suture to control the size of the dimple. The
procedure is done on an outpatient basis, and the patient
can immediately go to work after the procedure. One
drawback of this procedure is that the bolster suture is
visible on the cheek for the first 7 days after the surgery.
However, considering the numerous advantages this
procedure has, we feel that this is inconsequential.
CONCLUSION
We conclude that dimple creation surgery is a very safe
procedure. The patient satisfaction rate is very high, and
patients seen long time after surgery continue to be
pleased with their surgically created dimples.
REFERENCES
1. Argamaso RV. Facial dimple: Its formation by a simple technique.
Plast Reconstr Surg 1971;48:40-3.
2. Pentozos Daponte A, Vienna A, Brant L, Hauser G. Cheek
dimples in Greek children and adolescents. Int J Anthropol
2004;19:289-95.
3. Gassner HG, Rai A, Young A, Murakami C. Surgical anatomy of
the face: Implications for modern face lift techniques. Arch Facial
Plast Surg 2008;10:9-19.
4. Pessa JE, Zadoo VP, Garza PA, Adrian EK Jr, Devitt AI. Double
or bid zygomaticus majot muscle: Anatomy, incidence and
clinical correlation. Clin Anat 1998;11:310-3.
5. Khoo BC. The facial dimple: Clinical study and operative
technique. Plast Reconstr Surg 1962;30:281-8.
6. Bao S, Zhou C, Li S, Zhao M. A new simple technique for making
facial dimples. Aesthetic Plast Surg 2007;31:380-3.
7. Thomas M, Menon H, Silva JD. Improved surgical access for
facial dimple creation. Aesthet Surg J 2010;30:798-801.
8. Saraf S, Pillutia R. Complication of dimple creation. Indian
Dermatol Online J 2010;1:42-3.
How to cite this article: Lari AR, Panse N. Anatomical basis of
dimple creation - A new technique: Our experience of 100 cases.
Indian J Plast Surg 2012;45:89-93.
Source of Support: Nil, Conict of Interest: None declared.
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Supplementary resource (1)

... A similar procedure is done on the mucosal side; procedure should be done carefully to avoid breach the mucosa. [16] The area of scraping depends on the size of the dimple needed; if a wider dimple is required, a wider area is scraped so that two raw areas are created which will adhere to each other and create the wide dimple. Similarly, if a smaller dimple is required, a proportionately smaller area is scraped. ...
... We should avoid excessive tightening of the stitch to prevent the ischemia of the mucosa. [16] Then, advise the patient to take antibiotics and analgesics and maintain meticulous oral hygiene with mouthwash. The bolster stitch will be removed after 7 days. ...
... A relatively safe procedure, dimple surgery like any other surgical procedure is associated with certain complications such as mild postoperative swelling, postoperative hemorrhage, buccal branch of facial nerve injury, scar formation at operated area, abscess formation, and foreign body granuloma. [4,16,17,19,21,23] Scar formation at operated area persistence of unwanted dimples weakness of the involved muscles after the surgery. [14] Judicious use of antibiotics and proper maintenance of oral hygiene reduce the risk of complications considerably. ...
Article
Full-text available
Cosmetic surgery is not a new thing. The boom of cosmetic surgery is at its pace in India; people have been getting habituated to esthetics for so many years. Esthetic adjustment of various body parts such as rhinoplasty and lip modifications are more common nowadays. A dimple is a small depression on the surface of the body which can be easily noticeable; people appreciate the presence of dimple on the face and believe that it is a sign of good fortune and prosperity. With the advancements in the cosmetic surgery, there has been a upsurge in having artificial dimple on face. With this increased demand in having facial dimples in people, surgeons now are in an idea of creating an artificial dimple with dimple surgery or “dimpleplasty.” The procedure of dimpleplasty is as simple as making a cut in the skin, suturing the underside of the skin to a deeper layer to create a small depression. The suture creates a permanent scar which maintains the dimple. It is a thumb rule that any surgery has minor risks which are avoidable; the current review enumerates the various procedures for dimpleplasty and their outcomes. This article emphasizes on routine as well as recent procedures used for dimpleplasty and its relative complications.
... Facial dimple creation is a common cosmetic practice with a very low rate of complications. [1][2][3][4][5][6] Hematoma formation or bleeding is one of the most common complications. Injury to the buccal branch of facial nerve or salivary gland duct is rare. ...
... Injury to the buccal branch of facial nerve or salivary gland duct is rare. [1][2][3][4][5][6] Excessive scarring secondary to foreign body reaction or infection with abscess formation is also uncommon but can result in disfigurement. [1][2][3] In general, open techniques have more risk of complications because more tissue is resected, in contrast to closed techniques with little tissue defect. ...
... [1][2][3][4][5][6] Excessive scarring secondary to foreign body reaction or infection with abscess formation is also uncommon but can result in disfigurement. [1][2][3] In general, open techniques have more risk of complications because more tissue is resected, in contrast to closed techniques with little tissue defect. [1][2][3][4][5][6] Nonabsorbable sutures that are kept for a long time tend to have an increased potential risk of complications than that of absorbable sutures because they increase the risk of foreign body reaction and provide an access point for food debris, dental plaques, and oral actinomyces. ...
Article
Even though actinomyces are common oral commensals, actinomycosis is an uncommon oral infection. Cheek dimple creation is a common surgical procedure with rare complications. Bacterial infection with abscess formation and foreign body reaction were reported. We report a rare example—and, to our knowledge, the first—of oral actinomycosis after cheek dimple creation. A young woman complained of a chronic tender nodule of the right buccal mucosa with pus discharge after surgery for cheek dimple creation. Histologic examination showed a sinus tract with actinomyces microorganisms. This complication can be mimicked by other oral or dental sinus-forming lesions, can be chronic and insidious, and could therefore clinically be missed or mistreated. This might delay the diagnosis and cause scarring and disfigurement. The treatment of choice is early recognition and complete surgical excision to avoid irreversible complications and prevent recurrence. Awareness of this potential complication by aesthetic surgeons, oral clinicians, and dentists is important. Patients’ adherence to preventive measures and plastic surgeons’ application of inclusion criteria and contraindications, as well as their choice of best technique per patient, should help minimize such a problem in a simple and safe aesthetic procedure. Level of Evidence: 5
... Almost every clinician prefers creating artificial dimples on KBC point only. Different landmarks were preferred by various surgeons for creating dimples, such as Lari, [9] suggested two methods for determining the site of dimple creation: Shaker [10] created a dimple by asking the patient to smile and then marking the dimple site 2-2.5 cm lateral to the nasolabial fold at the same level or slightly above the angle of the mouth. El-Sabbagh [11] suggested creating a dimple at a point in level with or above the angle of mouth, according to the vector of smile. ...
Article
Full-text available
Background: Dimple is one of the special indentations in skin of the face, which is considered as a sign of beauty. Dimpleplasty/surgical creation of dimple is a cosmetic procedure done by surgeons. Determining accurate position of dimple to create maximum beauty is always challenging to surgeons. Aims and objectives: This study aimed at evaluating the prevalence and morphology (position and size) of naturally occurring dimple among population of Sullia taluk. Materials and methods: In total, 1462 people were screened for the occurrence of natural dimples in face. Among them, 121 were found to have natural dimples. Prevalence of dimple, position of the dimple, and the variation in distance from the Khoo Boo-Chai's (KBC) point to the naturally occurring dimple was assessed. Results: Among 121 patients with dimples, unilateral cheek dimples (72.88%) were more common than bilateral (27.11%). Ninety-one dimples (60.66%) were at KBC point and 59 dimples (39.33%) occurred anterior to KBC point at a mean distance of 9.86 mm. The mean size of dimple superoinferiorly on the right side was 8.29 mm and on the left side it was 8.96 mm. The mean size anteroposteriorly on the right side was 6.48 and on the left side it was 6.51 mm. Conclusion: The mean measurements in size and position of the dimple might help the surgeon in creating dimples resembling naturally occurring dimples.
... This has led to an increasing demand for artificial dimples, especially in Asia. 14 The extensive study on the bifid ZMj variant and its insertion sites is useful in providing the anatomical basis to create safe and reproducible techniques for artificial dimples. 14,15 A variety of techniques have been described. ...
Article
Facial expression muscles have significant morphological variability, including its size, shape, attachment patterns, and prevalence. The zygomaticus major (ZMj) represents one such important structure involved in facial expressions. The bifid ZMj muscle is a known anatomical variation that clinically presents as a dimple in the cheek; however, its prevalence and variation with ethnicity and geography remains poorly understood. The authors performed the first meta-analysis examine and established the prevalence of bifid ZMj variant across different population groups. From 7 studies identified via electronic databases, the prevalence of bifid ZMj variant was most prominent in the American subgroup 34% (95% CI 22.3%-48%), followed by the Asian subgroup at 27.4% (95% CI 14.3%-46.1%) and European subgroup at 12.3% (95% CI 6.5%-22.1%). Subgroup difference was found to be statistically significant (P = 0.027). The overall prevalence of the bifid ZMj is 22.7% (95% CI 14.3%-34.2%). This contributes to the understanding of various facial muscle morphologies and attachment patterns, which have significant implications in surgical planning and procedures for facial reanimation and recreation of natural patient appearances.
... For example, Lari, 13 in 2012, suggested two methods for determining the site of dimple creation: 1) using the point of intersection of a perpendicular line dropped from the external canthus and a horizontal line drawn from the highest point of the Cupid's bow and 2) asking patients to suck in their cheeks and then marking the site of maximum depression as the location for the dimple. 13 Shaker 10 created a dimple by asking the patient to smile and then marking the dimple site 2 to 2.5cm lateral to the nasolabial fold at the same level or slightly above the angle of the mouth. ...
Article
Dimleplasty is the surgical creation of dimples. The demand for dimpleplasty has increased over the past few years. Despite this increasing demand, the most widely used reference point for determining where to place a surgically created dimple, the Khoo Boo Chai (KBC) point, dates back more than 60 years. The aim of our study was to assess the facial shape of a sample of men and women, all of whom had natural dimples, to determine if characteristic patterns in dimple size, location, and shape existed according to each specific facial shapes. For our study, 1,194 people were examined for dimples and of these, 216 individuals with a group total of 336 naturally occurring dimples were included in the study. Facial form was categorized as mesoprosopic, euryprosopic, or leptoprosopic. We found that 54.8 percent of the total dimples were not positioned on the KBC point. In mesoprosopic group, out of 204 dimples, 117 were not positioned on the KBC point (87 were); in leptoprosopic group, out of 66 dimples, 30 dimples were not positioned on the KBC point (36 were); and in the euryprosopic group, out of 66 dimples, 36 were not positioned on the KBC point (30 were). Most of the dimples in the mesoprosopic group were positioned 4mm anterior to the KBC point, and in the eryprosopic group, most dimples were positioned 3mm above and behind the KBC point. Most of the dimples in the leptoprosopic group were positioned on the KBC point. We also observed differing patterns in size and shape between the groups. Understanding these differences could help surgeons achieve optimal outcomes by creating more natural looking and thus more aesthetically pleasing dimples among their patients seeking dimpleplasty.
... This study is not only useful to know the anatomical variation in zygomaticus major but the basic anatomy learned with the insertion of this muscle is very much useful in making artificial dimples [10]. Nowadays artificial dimples are created on this anatomical basis by plastic surgery to those who wish to have it [11]. ...
Article
Full-text available
Background: Zygomaticus major is one of the muscles of facial expressions and is also known as musculus zygomaticus major, the greater zygomatic muscle, as well as musculus zygomaticus. There are so many variations in the insertion of this muscles and may leads to the formation of dimple in the cheek region. This particular property of this muscle is quiet interesting and became the background of this study. Materials and Methods: Present study was done among 10 cadaveric hemi faces belongs to the department of anatomy Tagore Medical College to find the occurrence of bifid zygomaticus major which is responsible for dimple formation in cheeks. Result: Among the 10 hemi faces we found only 2 faces with bifid zygomaticus major along its insertion. Conclusion: Even though bifid zygomaticus major is considered as a developmental defect, the dimple in cheek formed by it is always measured as a mark of beauty. So learning more about the muscle and its variation paved ways to produce artificial dimples in the face to beautify it.
Article
Cheek dimpleplasty has become a popular request amongst patients requesting cosmetic surgery. Since the first reported dimpleplasty in 1962, there have been many reported procedures in the literature for cheek dimple creation. Some of the procedures described by various authors as “novel” are actually similar if not identical to existing procedures. This study reviews the different procedures of cheek dimple creation and provides the first ever systematic classification for these techniques. EMBASE, Cochrane library, Ovid medicine, and PubMed databases were searched from its inception to June of 2019. We included all studies describing the surgical creation of cheek dimples. The studies were reviewed, and the different procedures were cataloged. We then proposed a new classification system for these procedures based on their common characteristics. The study included 12 articles published in the English language that provided a descriptive procedure for cheek dimple creation. We classified the procedures into 3 broad categories and subcategories. Type 1 procedures are nonexcisional myocutaneous dimpleplasties. In these procedures, the buccinator muscle is not excised. In type 1A, the suture used to create the adhesion traverses the epidermis. In type 1B, the suture does not traverse the epidermis, rather, the suture travels up into the dermis and returned back to the mucosa. Type 2 procedures are excisional dimpleplasties. In these procedures, the buccinator muscle is excised with (open) or without (closed) the excision of the mucosa. Type 3 procedures are incisional dimpleplasty. In these procedures, the muscle is incised and fixed to the dermis. Each of these groups of procedures has potential unique advantages and disadvantages. There are multiple procedures reported in the English language literature for the creation of cheek dimples. Most of the procedures are based on similar concept with minor variations. Our classification system, the Opoku-Simone Classification, will help facilitate communication when describing the different configurations of these procedures. Procedure within each group has similar potential advantages and disadvantages.
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Dimpleplasty is the surgical creation of dimples on the face for aesthetic purposes. Dimples have been associated with a sign of beauty and even good fortune in some cultures and have also found themselves in Western cultures. Since the first described procedure of cheek dimple creation in 1962, there have been multiple studies on the topic. The aim of this article is to review the literature on the anatomy, creation, postoperative care, and complications associated with cheek dimpleplasty. The authors performed a literature review that focused on cheek dimpleplasty. EMBASE, Cochrane Library, Ovid Medicine, MEDLINE, Google Scholar, and PubMed databases were searched from its inception to July 2019. Peer-reviewed articles published in the English language were included. Our search in the various databases yielded multiple publications. There were different described techniques published on the determination of the ideal site for a cheek dimple. There were also multiple procedures described for the creation of cheek dimples. The basic tenet of cheek dimple creation is to create an adhesion between the dermis and buccinator muscle to create a dynamic dimple which is present on facial animation. Multiple procedures have been reported with few reported complications. Patient satisfaction is dependent on appropriate determination of the site and morphology of the dimple. Most of the complications associated with cheek dimple creation are minor, easily managed, and avoided by understanding the regional anatomy and attention to meticulous surgical technique.
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The purpose of the study is to provide a review of published techniques for creating facial dimples as context for describing a new streamlined approach, and to describe our experience and results in a series of 20 patients. A consecutive series of 20 patients was selected. All patients underwent bilateral open, trans-oral dimpleplasty procedures consisting of the use of an 8-mm punch to excise a core of tissue extending from mucosa to subcutaneous fascia, followed by placement of intradermal polydioxanone (PDS) sutures placed from the intra-oral mucosa, including the dermis, and all intervening layers. Patients were followed for a period of 6 months, with postoperative complications, persistence of static versus dynamic dimple formation, and overall patient satisfaction recorded as primary endpoints. Out of 20 patients, 2 adverse outcomes were reported: one reversal of dimpling was associated with accidental removal of PDS sutures by the patient’s dentist, and one, unilateral, postoperative infection was associated with postoperative antibiotic noncompliance. All other patients reported persistent bilateral dynamic dimple formation and excellent overall satisfaction with aesthetic results. Our experience with a new streamlined approach to surgical dimple creation produced consistent, reliable, and durable results with a low rate of complications, minimal investment of surgical time, and excellent patient satisfaction with their aesthetic results.
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چال گونه (cheek dimple) یکی از خصوصیات یک صورت جذاب و زیبا است. چال گونه می‌تواند به‌صورت طبیعی در صورت فرد وجود داشته باشد یا با جراحی ایجاد شود. در این مقاله علت ایجاد چال گونه، خصوصیات آناتومیک و نیز تکنیک‌های جراحی برای ایجاد چال گونه و هم‌چنین عوارض این اعمال جراحی بیان شده است.
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To delineate the anatomic architecture of the melolabial fold with surrounding structures and to elucidate potential implications for face-lift techniques. A total of 100 facial halves (from 50 cadaveric heads) were studied, including gross and microscopic dissection and histologic findings. Laboratory findings were correlated with intraoperative findings in more than 150 deep-plane face-lift dissections (300 facial halves) performed during the study period. In contrast to previous reports, the superficial musculoaponeurotic system (SMAS) was not found to form an investing layer in the midface. The SMAS, zygomatici muscles, and levator labii superioris alaeque nasi were found to be located in corresponding anatomic layers and to form a functional unit. Additional findings of the present study include the description of 3 structurally different portions of the melolabial fold, of an anatomic space below the levator labii superioris alaeque nasi (sublevator space), and of extensions of the buccal fat pad into the sublevator space and the middle third of the melolabial fold. The findings of the present study may contribute to augment our understanding of the complex anatomy of the midface and melolabial fold. Potential implications for modern face-lift techniques are discussed.
Article
The anatomy of the double or bifid zygomaticus major muscle is investigated in a series of 50 hemifacial cadaver dissections. The double zygomaticus major muscle represents an anatomical variation of this muscle of facial expression. This bifid muscle originates as a single structure from the zygomatic bone. As it travels anteriorly, it then divides at the sub-zygomatic hollow into superior and inferior muscle bundles. The superior bundle inserts at the usual position above the corner of the mouth. The inferior bundle inserts into the modiolus below the corner of the mouth. The incidence of the double zygomaticus major muscle was 34% in the present study, as it was found to be present in 17 of 50 cadaver dissections. This study shows that variation in the individual morphology of the mimetic muscles can be a common finding. Clinically, the double or bifid zygomaticus major muscle may explain the formation of cheek “dimples.” The inferior bundle was observed in several specimens to have a dermal attachment along its mid-portion, which tethers the overlying skin. When an individual with this anatomy smiles, traction on the skin may create a dimple due to this dermal tethering effect. Clin. Anat. 11:310–313, 1998. © 1998 Wiley-Liss, Inc.
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In 14141 male and 14141 female Greek children and adolescents ranging in age between seven and fifteen years the presence of cheek dimples was investigated. Neither sex (12.6% in both female and males) nor side differences when expressed unilaterally were observed. There was however a significant increase of dimples with age as well as significantly higher numbers of asymmetric than symmetric expressions in all age groups. With respect to these observations hypotheses of origin of cheek dimples and related effects of age are discussed.
Article
As an alternative to blind coring of the soft tissue from the buccal mucosa to the dermis or the placement of transcutaneous sutures, both of which can be associated with untoward side effects, the authors describe a safe and effective method for creating dimples through an open technique that replicates the anatomical basis of a natural dimple.
Article
In Asia, especially in China, women think a dimple is an important part of a beautiful smiling face. The dimple can make them more confident. Unfortunately, not all women have dimples. Hence, with the development of the Chinese economy, there is an increasing demand among Chinese women for the creation of dimples. Most women hope the impairment of the operation will be slight and the period of recovery short so they can go to work as quickly as possible. Some of them want to have dimples only when they smile. The authors have used a new simple technique to form 56 dimples for 36 women. During the operation, they use a syringe needle to guide a monofilament nylon suture through the dermis and the active facial muscles (usually the buccinator). A sling is formed between the skin and the buccinator muscle. The knot is tied, and the dimple is created. After the operation, patients have been satisfied with the shape of the dimples. Furthermore, hematoma and infection never occurred. As a result, on the basis of their experience, the authors conclude that this technique is simple and easy to duplicate. Moreover, this technique has many benefits. For example, with this procedure, it is easy to adjust the bulk of dimples by adjusting the tension of the knot and the amount of dermis tissue the injection needle sutures. Because no tissue is resected, there is mild postoperative swelling. Consequently, patients can return to work or other activities 2 days after the operation.