Anatomical basis of dimple creation – A new technique: Our experience of 100 cases
Abstract and Figures
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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... [13] Some surgeons consider this point too low to create a cheek dimple and believe that the intersection of the vertical line from the lateral canthus with the horizontal one from the highest part of the cupid's bow is a better site to create a cheek dimple. [14] Another way to determine the location of the cheek dimple is to ask patients to pull the cheek area inward by creating suction in the mouth; the site of the cheek depression will be the site of creating the cheek dimple. [15] suRgeRy technIques This surgery is performed under general anesthesia or local anesthesia. ...
... The bolster is removed on the 7 th day after surgery. Initially, a static dimple is created; over time, there is only a slight depression in the static state, and the dimple shows itself more with facial movements [14] [ Figure 2]. ...
... [12] coMplIcatIons Although cheek dimple surgery is a safe and relatively simple procedure, it can have side effects such as any other surgery. These side effects include the possibility of infection, [13,14] bleeding, [19] postoperative edema, [18] hyperpigmentation at the surgery site, [19] scleroma, [20] and damage to the buccal branches of the facial nerve. [21] Furthermore, the sudden disappearance of the cheek dimple, [22] asymmetry, [3] reaction to a foreign body, [19] and damage to the Stensen duct has reported. ...
... 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. ...
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.
... 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. ...
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. ...
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. ...
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]. ...
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.