|Year : 2017 | Volume
| Issue : 4 | Page : 282-286
Facial dimple creation surgery: A review of literature
M Kiran Kumar1, Arka Kanti Dey1, Dhirendra Kumar Singh2, KN V Sudhakar1, Rajat Mohanty1
1 Department of Oral and Maxillofacial Surgery, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India
2 Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||1-Dec-2017|
Arka Kanti Dey
Department of Oral and Maxillofacial Surgery, Kalinga Institute of Dental Sciences, Campus-5, KIIT University, Patia, Bhubaneswar - 751 024, Odisha
Source of Support: None, Conflict of Interest: None
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.
Keywords: Cosmetic surgery, dimple, dimple creation surgery, dimpleplasty
|How to cite this article:|
Kumar M K, Dey AK, Singh DK, V Sudhakar K N, Mohanty R. Facial dimple creation surgery: A review of literature. Indian J Dent Sci 2017;9:282-6
|How to cite this URL:|
Kumar M K, Dey AK, Singh DK, V Sudhakar K N, Mohanty R. Facial dimple creation surgery: A review of literature. Indian J Dent Sci [serial online] 2017 [cited 2021 Mar 3];9:282-6. Available from: http://www.ijds.in/text.asp?2017/9/4/282/219626
| Introduction|| |
Dimples are small visible indentations on the skin, and when present on the face, it supposedly enhances beauty and expression and is much appreciated by others. Social superstitions such as good luck and prosperous lives are believed by many cultures. Mostly, they are visible on different parts of body such as shoulder, abdomen, back, and limbs. When dimples are present on the face, they are a sign of beauty of face, and it is an important factor for expressing thoughts and emotions beyond the words. Dimple can be shallow or deep, the deep dimple on the cheek looks more attractive than shallow dimple whereas the shallow dimple on the chin gives adorable look. Dimples make the smile more prominent, which increase the perception of expressions and facial beauty. There are two schools of thoughts regarding gender predilections of dimples. One indicating uniformity between males and females while the other proving more in the latter.,,,,
Etiology of facial dimple occurrence is unknown. It is thought to be inherited in an autosomal dominant fashion, and hereditary factors play a role in its occurrence; the genetic background of dimple is the cleft chin dimple is associated with chromosome 5 and cheek dimples are with chromosome 16, with variable penetrance.
Studies concluded that mostly dimples are hereditary in inheritance. Growth and development of dimples showed varied pattern. They may be transient or permanent. Transient dimples develop due to disappearance of excessive deposited fat with the aging process; stretching or lengthening of muscles during growth may lead to gradual obliteration of the dimple area. This explains the phenomena that some dimples are more prominent in children age groups.
The present article is going to provide a meticulous review on the basic and up-to-date information of the various procedures used for creation of facial dimples and complications of creation of artificial dimples.
| Anatomy of Dimple|| |
Dimples on the face are commonly situated on the cheeks and chin although the latter occurs less frequently., Anatomically, dimples are thought to be caused by insertion of fascial bands of zygomaticus major muscle into dermis or dermal tethering effect of zygomaticus major muscle which may be bifid. Studies of human facial anatomy of the dimple demonstrated that dimple is caused by an abnormal insertion of the muscles of the face. It is usually formed by a small defect in the buccinator muscle of cheek, such as dermocutaneous insertion of the fibers on the inferior bundle of the bifid zygomaticus major muscle.,,
Dimple surgery is performed by skilled cosmetic surgeons, oral, and maxillofacial surgeons under local anesthesia or general anesthesia. Numerous surgical approaches exist for doing dimple creation, such as transcutaneous sutures or by an open technique that is performed through intraoral approach, which would show no scar formation. Most of the procedure involves attachment of the buccinator muscles of the face to the dermis of the skin.
Dimpleplasty is a surgical procedure to create dimple on face artificially to enhance the facial attractiveness and smile. Although it is a small surgical procedure and begins several decades ago, it has been gaining some recent popularity and media coverage.
Apart from the dimples on the cheeks, there have been advancements in the cosmetic and oral maxillofacial surgery which had led to novel techniques of creation of dimples in the chin region.
The efforts of various researchers had showed a considerable contribution to the literature about dimpleplasty and surgical approaches to dimpleplasty.
| Determination of Location of Dimple|| |
Shaker et al. proposed a simple technique for creation of artificial facial dimple. According to their technique, they asked the patients to smile and mark the dimple at a distance of 2–2.5 cm lateral to the nasolabial fold at the same level or slightly above the angle of the mouth. This point is suggested to the patient and it may need some adjustment by the patient.
This dimpleplasty surgery can be done irrespective of anesthesia, i.e., local or general anesthesia. Before going to the surgery, we should decide the position of the dimple by asking the patient to face the mirror to avoid any kind of hesitation that the patient might have.
Boo-Chai reported another landmark described from the cosmetic viewpoints; it is the point of intersection of two lines, a perpendicular drawn from the external canthus and another drawn horizontally from the angle of the mouth.
However, mostly considered position of the dimple is the intersection point of the perpendicular line dropped from the external canthus on the horizontal line drawn from the highest point of the Cupid's bow laterally. It is observed that when a negative pressure is created inside the oral cavity by asking the patient to suck the cheek inside, the point of maximum depression should be taken as the position for dimple creation as seen in naturally occurring dimples as well.
| Surgical Approaches to Dimple Creation Surgery|| |
Many techniques are developed to create dimple artificially; some of the techniques are discussed below.
Bao et al. reported a technique; in this technique, they guided a monofilament suture material using a syringe needle through the dermis and the active facial muscles as the buccinators and forming a sling between the skin and it. Dimple is created by tying knot.
Mokal and Desai in 2012 developed a new technique to create a chin dimple. According to their technique, after patient preparation and local or general anesthesia induction, a lower gingivobuccal sulcus incision was given, and the full thickness flap and periosteum were elevated to expose the midline of the mandible. They made an indentation in the mandibular symphysis using a round burr. Two drill holes were made on either side of this indentation. A small amount of subcutaneous tissue and muscle was removed at the predetermined site of the dimple. Double sutures of 3-0 polypropylene were passed through the drill holes on either side of the bone indentation and through the thinned overlying skin and muscle to develop the dimple. After that, vestibular incision were closed with 3-0 polyglactin sutures in two layers.
Shaker et al. proposed a simple technique of dimpleplasty. According to their technique, they gave a stab incision in the buccal mucosa on the site of planed dimple and the No. 11 blade is advanced till it can be felt by the other hand palpating extraorally. Then, blunt dissection is done with scissors till the cheek dermis by leaving a sufficient amount of dermis to facilitate suturing. Suturing is done by a heavy monofilament suture (poly-Prolene 1) involving some of the fibers of the buccinators muscle coming out through the cheek skin, and it is returned back through the same skin hole to come through the intraoral incision again. To free the epidermis from the suture, gentle sawing movement is done and then the knot is tightened. The buccal mucosa is closed using fine absorbable 3/0 suture.
In 1962, Boo-Chai reported a sling suture technique between buccinator muscle and skin with a nonabsorbable material. In this technique, simulation occurred by integumentary insertion of the muscle.
The latest method of dimple creation was elicited by Rahpeyma and Khajehahmadi in 2014; they proposed a conservative approach for facial dimpling after elimination of the odontogenic infection in the facial space area and is a novel technique that ease the removal of odontogenic infection in the masseteric space and the buccal space and also gives esthetics by creation of dimple in the defect area.
Keyhan et al. proposed a procedure to create the dimple through an intraoral approach with the help of a punch biopsy instrument. After administrating the anesthesia, hypodermic needles passed through the line marked on the buccal mucosa. A soft tissue trephine bur connected to a latch-type handpiece with a speed of 10–20 rpm is used to punch the buccal mucosa. While punching mucosa, the opposite hand should push the buccal mucosa inward and support this area externally. The soft tissue cylindrical fragment containing of the mucosa, a small portion of the buccinator muscle, a part of the Bichat fat pad was removed with scissors, and the skin was kept intact. Next, the most important part of procedure is defect closure. Defect closure is performed by placing a no absorbable suture (No. 3-0 silk) or submucosal absorbable suture (No. 3-0 Vicryl; Ethicon, Somerville, NJ, USA) through the cheek mucosa, muscle, and Bichat fat pad on one side of the defect then 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 the dimple will be created.
Thomas et al. in 2010 introduced a new technique for improved surgical access as an alternative to blind coring methods. According to their technique, after patient preparation and local or general anesthesia induction, hypodermic needles were passed through the line marked at a specific location into the buccal mucosa; a vertical incision was made on the mucosa at this site, with care taken to avoid injury to the Stensen's duct; an L or T limb was then added to the vertical cut; and the mucosal flaps were elevated. A few fascicles of the buccinator muscle were dissected over an artery forceps; a No. 3-0 suture (Prolene) was passed through the proximal portion of the muscle fibers, the dermis was exposed, the muscle fibers were cut immediately distal to the stitch, and muscle was sutured to the dermis. An additional suture was placed between the muscle and dermis to secure the attachment (myodermal attachment), and an absorbable suture was then passed between the submucosa and the dermis. Finally, the mucosal incision was closed with No. 4-0 chromic catgut sutures.
The simple closed and open procedures to create the dimple are described by Thomas et al. and provide a predictable outcome with minimal complications, which makes it an excellent alternative to existing techniques.
Lari and Panse in 2012 proposed that dimples can be induced naturally with a dynamic appearance through open surgical method by forming a scar in the dermis and adhering it to the underlying muscle. This procedure can be performed under local anesthesia. Local anesthesia administrated from the skin side down to the mucosal side at the marked site. A stab incision is given using a No. 15 blade, 2 cm anterior (toward the lips) to the marked area of the dimple. Incision should be placed away from the papilla of the Stensen's duct to avoid injury to the duct. The blade is inserted through the small incision on the mucosal aspect, and once the sharp edge is felt just below the marked site of the dimple, scraping of all attachments from the skin is done. A similar procedure is done on the mucosal side; procedure should be done carefully to avoid breach the mucosa.
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. After the scraping is complete, on palpation, we can feel a dent bimanually. Inadequate scraping may lead to failure to get desired depression and needs further scraping. The next step is to create and maintain the adhesion. With the help of a straight needle, suturing material stitch is placed in the skin, brought out along the mucosa, reinserted in the mucosa and brought out through the skin and a bolster knot is applied. The advantage of the bolster is to have a better longitudinal dimple. We can use a silicon cylinder (block) as a bolster as it is more hygienic and it keeps the suture dry; clean from food debris and moisture. We should avoid excessive tightening of the stitch to prevent the ischemia of the mucosa.
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. Initially, dimple is stable and deepens further on movement; but gradually with time, there is only a hint of dimple when static and accentuates on animation.
Ansari and Joshi in their case report have explained a novel technique for creation of facial dimples. They have used open approach to create dimples. After anesthesia is achieved, a circular incision is placed intraorally at the desired dimple location. Buccinators muscle is identified and part of it is excised. Again, desired dimple site is rechecked on cheek by pulling from intraorally. 2-0 (prolene) suture was used for suturing the buccinators muscle to the epidermis layer of skin. Then, suture the intraoral mucosa with no. 3-0 black silk. Postoperative instructions are explained to the patient and recalled for suture removal after 7 days.
Ramman et al. advocate that there is a small group of patients who are emotionally unhappy with the presence of dimpling documented following the MACS and few cases of SMAS face-lifting procedures, whose resolution will occur spontaneously. The use of 0.5 ml medium-density hyaluronic acid fillers (Restylane) was advocated by using fanning and tunneling technique to temporarily fill the defect. The filler will spontaneously resolve while the dimple defect is subsiding.
Argamaso in 1970 introduced a technique, in which they used a long needle extraorally, perpendicular at the site of skin puncture taking care that the needle should be anterior to and below the papilla of Stensen's duct. An 8-mm punch biopsy is introduced in the mouth over the needle which acts as a guide for placement. A core of tissue is then cut by a rotatory motion from the buccal mucosa toward the dermis. Both the biopsy and needle are withdrawn when the dermis is reached. The cylindrical tissue is excised. Removal of underlying subcutaneous fat may be necessary. The wound is sutured with one or two monofilament 4-0 nylon sutures grasping all the layers.
Patients should be instructed to maintain good oral hygiene in the immediate postoperative period and advised not to smile fully during the first 2 weeks. Dimple becomes prominent in the initial few weeks after surgery and resembled a natural dimple within 4–6 weeks. Suture removal was done after 10–14 days of surgery (in nonabsorbable suture cases).
With many surgeons' opinion, the key to correct tissue grasping in dimple creation surgery is creating of a faint dimple in the planned area without any stretching of the suture or knot tying. In other words, knot is just used to adjust the depth and size of created dimples. Tightening the knot may lead to narrowing of the dimple. In patients with “chubby” cheeks, the depth of the field and fat tissue can make precise suturing difficult.
El-Sabbaghdeveloped a new technique by modifying the procedure described by Bao-Chai. The procedure was done under local anesthesia. In this technique, they used a syringe with needle which was introduced through the cheek from the marked skin and pulled from the site of puncture of the buccal mucosa. A 1-0 monofilament nylon or prolene suture was inserted into the pinhole of the syringe needle and pumped from the hub of the syringe needle using the vacuum extractor side. After that, the needle was gradually withdrawn from the dermis. The needle then passed through the dermis and the muscle and pulled to the buccal mucosa again at the same level in round face and above the previous puncture in long face. Then, suturing was done involving dermis and muscle. The knot was tightly tied, and the dimple was formed. The main advantage is no tissue was excised in this technique.
Jones et al. in 2014 proposed a novel technique named as transoral buccinator-pexy. It was done 1.5–2 cm superior to a point bisecting an angle formed by the projection of the lateral commissure and the lateral canthus. The operation was done under local anesthesia and an 18-gauge needle was introduced extaorally perpendicular through the skin marking and brought out through the buccal mucosa. A 4-mm punch biopsy or a small incision was made to excise a small amount of buccal mucosa. Suturing was done by 4-0 nonabsorbable suture through extraoral to intraoral, taking a portion of the dermis and buccinators muscle creating the desired dimple.
Argamaso et al. in a long-term review showed rarity of complications and high acceptance rate among the patients. The resultant dimples are highly pleasing and difficult to be distinguished from natural ones. They advocated prompt treatment that leads to reduction in the rate of complications.
As the literature cited, there are three methods of dimple creation. Intraoral method, extraoral method, both (intraoral and extraoral method); as per our knowledge, creation of dimple is effective when done as an extraoral method in local anesthesia which gives a prominent results with minimal complications.
| Complications of Dimple Surgery|| |
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.,,,,,
Scar formation at operated area persistence of unwanted dimples weakness of the involved muscles after the surgery.
Judicious use of antibiotics and proper maintenance of oral hygiene reduce the risk of complications considerably. Buccal nerve injury reports are minimal, but early detection and appropriate management avoid unesthetic complications.,,
| Conclusion|| |
Having a perfect nose, perfect ears, and scarless face is as esthetic as having a well and perfectly shaped dimple. It can be natural or well-crafted by an oral and maxillofacial surgeon, cosmetic surgeon. Hence, this review elaborates that dimple surgery is very safe procedure and can be completed as an outpatient procedure in less time with minimum discomforts. The various described procedures for placing the dimple in cheeks are very simple and easy to perform by the surgeons and can impart a bold and attractive facial esthetics.
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Conflicts of interest
There are no conflicts of interest.
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