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J Oral Maxillofac Surg70:e403-e407, 2012

Dimple Creation Surgery Technique:A Review of the Literature and

Technique NoteSeied Omid Keyhan, DDS,* Kazem Khiabani, DDS, PhD,† and

Seifollah Hemmat, DDS‡

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Dimples are small visible indentations on the surfaceof the skin; they may appear on various parts of thebody, such as the abdomen, back, shoulder, or limbs.When dimples occur on the face, they are highlyprized because the face is highly visible, and it is animportant outlet for expressing thoughts and emo-tions beyond words. Dimples tend to accentuate asmile, thus increasing the perception of attractive-ness, sociability, and facial beauty.1 However, somepeople see dimples as unattractive and would preferto have the dimples removed; this aversion is morecommon for cases of chin dimples.1

The presence of dimples on the face has beenappreciated by many people and in different cultures.This is a characteristic inherited in an autosomal dom-inant fashion; the cleft chin dimple is on chromosome5 and cheek dimples are on chromosome 16, withvariable penetrance.1 The inheritance of facial dim-ples follows the basic principles of the law of segre-gation and the law of independent assortment. Facialdimples are inherited as autosomal dominant traits,1

and in people having the homozygous recessive ge-notype, the ability to express the facial dimple trait islacking.

The chin dimple is an example of variable pen-etrance, because other factors, such as the environ-ment and other modifier genes, operate to affect thephenotypic expression of the actual genotype.1 When

of the 2 parents expresses the trait, there is a 25% to0% likelihood of passing it to their children; how-ver, if both parents express the trait, the probability

Received from the Department of Oral and Maxillofacial Surgery,

Joundishapoor University of Medical Science, Ahvaz, Iran.

*Resident.

†Assistant Professor.

‡Resident.

Address correspondence and reprint requests to Dr Keyhan:

Department of Oral and Maxillofacial Surgery, Joundishapoor Uni-

versity of Medical Science, Golestan Boulevard, Ahvaz, Iran; e-mail:

keyhanomid@ymail.com

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7006-0$36.00/0

noi:10.1016/j.joms.2012.02.015

e403

oubles (50% to 100%).1 Other traits inherited in anutosomal dominant pattern include free earlobe, ear-y-onset myopia, bent little finger, ACHOO (Auto-omal Dominant Compelling Helio Ophthalmic Syn-rome) syndrome, tongue rolling, eye color, mid-igital hair, and hand clasping.1

Dimples can be transient or permanent, dependingon the cause or factor responsible for their occur-rence. The process of growth and development couldcontribute to this. Excessive fat deposition, whichdisappears with the aging process, causes transientdimples, whereas the stretching or lengthening ofmuscles during growth can lead to gradual oblitera-tion of the facial feature.1 This explains why somedimples are more common and conspicuous inyounger age groups. Dimples on the face are com-monly situated on the cheeks and chin, although thelatter occurs less frequently.2 Structurally, cheek dim-ples occur because of a defect created by muscles onthe face, whereas the chin dimple is a result of anunderlying bony defect. Cheek dimples occur lateralto the angle of the mouth, and in a study published in1998 by Pessa et al,2 cheek dimples were shown to becaused by the presence of dermocutaneous insertionof the fibers on the inferior bundle of the double orbifid zygomaticus major muscle. Smiling makes theoverlying skin draw inward and the dimple becomeslarger, thereby making it more visible. Either or bothof the cheeks can present with 1 or more dimples, butit is more common to have dimples occurring on bothcheeks than only 1 cheek.2 Incomplete fusion of the2 halves of the mandibular bone in utero is responsi-ble for a cleft chin, resulting in a Y-shaped fissure atthe center of the lower jaw bone.1-3

Regardless of cultural background, there is in-creased demand for the creation of facial dimples, andmany people seek the expertise of cosmetic surgeonsto achieve facial dimple creation.4 Although this is a

inor procedure, it has been gaining some recentopularity and press coverage; it is not new, and itsistory dates back several decades. Dimple surgeryan be performed by a skilled surgeon with the pa-ient under local anesthesia. Most of the techniques, if

ot all, involve adherence of the buccinator muscles

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e404 DIMPLE CREATION SURGERY

of the face to the dermis of the skin; this can beachieved with transcutaneous sutures or by an opentechnique that is performed through the mouth,which would show no scarring. Like natural dimples,dimples created surgically typically appear with smil-ing, although surgically created dimples may be visi-ble most of the time depending on the surgical tech-nique used. The dimple may be present even withoutsmiling for the first several days, or even weeks, aftersurgery; eventually, the surgically created dimple willmost likely be present with smiling as scar developsbetween the inner skin and the buccinator mus-cle.1,4-7 When one surgically creates a dimple, the idealocation would be the area where a less obvious faintimple is present with smiling; thus the pre-existingimple is made more prominent. If 1 cheek has a dim-le, the ideal location for the other dimple would bearked at the corresponding site that would create

ymmetry of the face. If a pre-existing dimple is notresent, the ideal location would be the intersectionetween a horizontal line from the corner of the mouthnd a vertical line from the lateral canthus of the eye.5

Potential complications of dimple surgery consistof sudden disappearance of the dimple, asymmetry,foreign body reaction, bleeding, and injury to a nerve(buccal branch of the facial nerve) or salivary glandduct (Stensen duct), which are rare.1,5,6 Many tech-

iques have been introduced to create dimples.4-7

They can be categorized into 2 major categories,namely blind coring and open approaches. The goalsof this article consist of introducing a novel techniquefor dimple creation surgery and reviewing the litera-ture that has been published in this field.

Surgical Technique

The patient’s face and mouth were prepared, andeither local or general anesthesia was administered,depending on patient preference. Hypodermic nee-dles were then passed through the marked line intothe buccal mucosa. A soft tissue trephine bur con-nected to a latch-type handpiece (10 to 20 rpm) wasused to punch the buccal mucosa while the oppositehand pushed the buccal mucosa inward and sup-ported this area externally (Fig 1). The soft tissuecylindrical fragment (consisting of the mucosa, asmall portion of the buccinator muscle, and a part ofthe Bichat fat pad) was removed with scissors, andthe skin was kept intact.

Next, the most important part of procedure wasperformed, namely defect closure. Defect closure wasperformed by placing a nonabsorbable suture (No. 3-0silk) through the cheek mucosa, muscle, and Bichatfat pad on 1 side of the defect; then through thedermis layer of the skin; and finally, through the

Bichat fat pad, the buccinator muscle, and the mucosa

on the other side of the defect. In some cases asubmucosal absorbable suture (No. 3-0 Vicryl; Ethi-con, Somerville, NJ) is placed through the muscle on1 side of defect, then through the dermis layer of theskin, and finally, through the muscle on the other sideof the defect (some non absorbable materials such as;nylon and prolen, can be used, also). The knot is thentied, and the dimple is thereby created (Fig 2).

Patients were instructed to maintain good oral hy-giene in the immediate postoperative period and ad-vised not to smile fully during the first 2 weeks. Thedimple became prominent in the initial few weeksafter surgery and resembled a natural dimple (appear-ing only on smiling) within 4 to 6 weeks (Fig 3).Suture removal was performed 10 to 14 days aftersurgery (in nonabsorbable suture cases).

Results

The postoperative results for 3 patients are

FIGURE 1. A, A soft tissue trephine bur was used to punch thebuccal mucosa while the opposite hand pushed the buccal mucosainward and supported this area externally. B, Soft tissue trephinebur.

Keyhan, Khiabani, and Hemmat. Dimple Creation Surgery.J Oral Maxillofac Surg 2012.

shown in Figures 3-5. In total 20 patients have

al Max

KEYHAN, KHIABANI, AND HEMMAT e405

undergone the dimple creation procedure usingour technique; a total of 40 dimples were placed inthose patients. Of the patients, 18 have been fol-lowed up for 1 year.

All patients had an overcorrected appearance oftheir dimples during the initial postoperative periodfor a duration of approximately 3 to 4 weeks. Thedimples persisted in all patients after 1 year. Revisionsurgery was required in 1 case because the patientreported feeling that the dimples were asymmetric.Foreign body reaction was seen in 1 case in whichsuturing was performed with nonabsorbable material(No. 3-0 silk), so incision and drainage with routineantibiotic therapy were performed.

Reported complications with other techniques,such as hemorrhage and sudden disappearance of thedimple, were not noted with our technique, probablybecause of improved visibility and control during the

FIGURE 2. Defect closure was performed by placing a nonabsorbfat pad on 1 side of the defect; then through the dermis layer ofmucosa on the other side of the defect (A) or, in some cases, withside of the defect, then through the dermis layer of the skin, and finis tied, and the dimple is created.

Keyhan, Khiabani, and Hemmat. Dimple Creation Surgery. J Or

surgical procedure (Figures 3-5).

Discussion

Dimples are genetically inherited, and thus thisnaturally given gift is not for everyone. Research hasshown that parents with dimples will pass this attrac-tive trait to their children. Studies of human facialanatomy have shown that dimples occur because ofan abnormal insertion of the muscles of the face(dermocutaneous insertion of the fibers on the infe-rior bundle of the bifid zygomaticus major muscle)rather than a soft tissue defect.1 With the popularityof cosmetic surgery and celebrities with dimples,such as Cheryl Cole, Miranda Kerr, and Hilary Duff,there has been a recent increase in demand for dim-ple surgery, or “dimpleplasty.”

In Asia, women think that a dimple is an importantpart of a beautiful smiling face and can make them moreconfident. Unfortunately, not all women have dimples;

uture (No. 3-0 silk) through the cheek mucosa, muscle, and Bichat; and finally, through the Bichat fat pad, buccinator muscle, andcosal absorbable suture (No. 3-0 Vicryl) through the muscle on 1rough the muscle on the other side of the defect (B). C, D, The knot

illofac Surg 2012.

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furthermore, there is an increasing demand among Ira-

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e406 DIMPLE CREATION SURGERY

nian women for the creation of dimples. Most womenhope that the side effects of the operation will be slightand the period of recovery short so that they can return

FIGURE 3. A, Preoperative image of a 28-year-old woman whopresented for dimple placement. B, C, Result after surgical place-

ent of dimples with our open technique.

eyhan, Khiabani, and Hemmat. Dimple Creation Surgery.Oral Maxillofac Surg 2012.

to work as quickly as possible.

Many techniques have been introduced to createdimples.4-7 They can be categorized into 2 major cat-egories, blind coring and open approaches. Bao et al4

in 2007 described a simple technique in which theyused a syringe needle to guide a monofilament nylonsuture through the dermis and the active facial mus-cles (usually the buccinator), a sling was formed be-tween the skin and the buccinator muscle, the knotwas tied, and the dimple was created. The shape ofdimples was satisfactory, and hematoma or infectionwas not seen. Other advantages of their techniqueinclude the following: 1) mild postoperative swelling

ccurs and, consequently, patients can return to workr other activities 2 days after the operation; 2) it is

easy to adjust the bulk of dimples by adjusting thetension of the knot and the amount of dermis tissue;and 3) no tissue was resected.4 On the other hand,

lind coring of the soft tissue from the buccal mucosao the dermis carries the risk of injury to the buccalranch of the facial nerves5; furthermore, transcuta-eous sutures can cause puncture scars and haveeen reported to cause foreign body granulomas.1,4

FIGURE 4. A, Preoperative image of a 26-year-old woman whopresented for dimple placement. B, Result at 1 year after surgicalplacement of dimples with our open technique.

Keyhan, Khiabani, and Hemmat. Dimple Creation Surgery.

J Oral Maxillofac Surg 2012.

KEYHAN, KHIABANI, AND HEMMAT e407

Given the aforementioned disadvantages, Thomaset al7 in 2010 introduced a new technique for im-proved surgical access as an alternative to blind cor-ing methods. According to this technique, after pa-tient preparation and induction of either local orgeneral anesthesia, hypodermic needles were passedthrough the marked line into the buccal mucosa; avertical incision was made on the mucosa at this site,with care taken to avoid any injury to the Stensenduct; an L or T limb was then added to the vertical

FIGURE 5. A, Preoperative image of a 30-year-old woman whopresented for dimple placement. She had a faint dimple on bothsides upon smiling, so the sites were surgically marked over theexisting dimples, even though they were not symmetric. B, Result at1 year after surgical placement of dimples with our open technique.The result is most evident when the patient smiles.

Keyhan, Khiabani, and Hemmat. Dimple Creation Surgery.J Oral Maxillofac Surg 2012.

cut; and the mucosal flaps were elevated. A few fas-

cicles of the buccinator muscle were bluntly dis-sected over an artery forceps, a No. 3-0 Prolene suture(Ethicon) was passed through the proximal portion ofthe muscle fibers, the dermis was exposed, the mus-cle fibers were cut immediately distal to the stitch,and the muscle was sutured to the dermis. An addi-tional suture was placed between the muscle anddermis to secure the myodermal attachment, and anabsorbable suture was then passed between the sub-mucosa and the dermis. Finally, the mucosal incisionwas closed with No. 4-0 chromic catgut sutures.7

According to the opinion of Thomas et al, the anom-alous anatomy responsible for dimples is surgicallymimicked with this technique, without requiring anysoft tissue removal and by allowing adequate expo-sure. As the mucosal flaps were raised, sutures be-tween the muscle and the dermis were placed withimproved control.

In our opinion, the key to correct tissue grasping indimple creation surgery is creation of a faint dimple inthe planned area without any stretching of the sutureor knot tying. In other words, knot tying is just usedfor adjusting the depth and size of created dimples;the tighter the knot, the smaller and narrower thedimple. So, for better suturing technique, the en-hanced exposure is useful particularly in patientswith “chubby” cheeks, where the depth of the fieldand fat tissue can make precise suturing difficult. Thesimple and open procedure described in this articlefor placing a facial dimple provides a predictableoutcome with minimal morbidity, which makes it anexcellent alternative to existing techniques. On thebasis of our experience in 20 cases and after at least 1year of follow-up in most cases, we conclude that thistechnique is simple and easy to duplicate.

References1. Omotoso GO, Adeniyi PA, Medubi LJ: Prevalence of facial dim-

ples amongst South-western Nigerians: A case study of Ilorin,Kwara State of Nigeria. Int J Biomed Health Sci 6:241, 2010

2. Pessa JE, Zadoo VP, Garza PA, et al: Double or bifid zygomaticusmajor muscle: Anatomy, incidence, and clinical correlation. ClinAnat 11:310, 1998

3. Pessa JE, Zadoo VP, Adrian EK Jr, et al: Variability of the midfa-cial muscles: Analysis of 50 hemifacial cadaver dissections. PlastReconstr Surg 102:1888, 1998

4. Bao S, Zhou C, Li S, et al: A new simple technique for makingfacial dimples. Aesthet Plast Surg 31:380, 2007

5. Boo-chai K. The facial dimple: Clinical study and operativetechnique. Plast Reconstr Surg 30:281, 1962

6. Argamaso RV: Facial dimple: Its formation by a simple tech-nique. Plast Reconstr Surg 48:40, 1971

7. Thomas M, Menon H, D’Silva J: Improved surgical access forfacial dimple creation. Aesthet Surge J 30:798, 2010