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

cases

Article in Indian Journal of Plastic Surgery · July 2012

DOI: 10.4103/0970-0358.96593 · Source: PubMed

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Original Article

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 findings 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

INTRODUCTION for dimple creation surgery in our part of the globe. As

a result, we have used this simple technique for creating

D
imples on cheeks enhance facial beauty and cheek dimples in our patients.
expression. They occur in both sexes with
no particular preponderance, may express MATERIALS AND METHODS
unilaterally or bilaterally and are genetically inherited as
a dominant trait.[1,2] Anatomically, dimples are thought to Between January 2006 and October 2010, we surgically
be caused by a double or bifid zygomaticus major muscle, created 100 dimples in 64 patients by the technique
whose fascial strands insert into the dermis and cause a mentioned below. All the dimples were created under
dermal tethering effect.[3,4] There is an increasing demand local anaesthesia on an outpatient basis. Of the 64
patients, 60 were females and 4 were males. Sixteen
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patients underwent unilateral dimple creation and
Quick Response Code:
Website: 42 underwent bilateral dimple creation. Of the 16
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unilateral dimples, 14 dimples were made on the left
side and 2 on the right side of the face. All the bilateral
DOI:
10.4103/0970-0358.96593
dimples were created in females. The average age of
the patients was 31 years [Table 1].

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Lari and Panse: Anatomical basis of dimple creation

Table 1: Dimple distribution in patients

Dimple details Males Females Unilateral Bilateral Unilateral (Left) Unilateral (Right) Average age
100 dimples in 4 60 16 42 14 2 31
64 patients

Anatomy of the dimple adhere to each other and create the dimple. Similarly, if a
Anatomically, dimples are thought to be caused by smaller dimple is to be created, a proportionately smaller
a double or bifid zygomaticus major muscle, whose area is scraped. After the scraping is complete, a dent
fascial strands insert into the dermis and cause a is felt if palpated bimanually. If the desired depression
dermal tethering effect.[3,4] is not created, it means that the scraping is inadequate
and needs further scraping. The next step is to create
Operative technique and maintain the adhesion. A No. 3 ethilon on a straight
Positioning of the dimple needle is taken. It is inserted through the skin, brought
Generally, the position of the dimple is marked by the out through the mucosa, reinserted through the mucosa
patient in front of the mirror. If the patient is undecided and brought out through the skin and a bolster stitch is
as to the site of the dimple, another landmark described taken [Figure 1]. The advantage of the bolster is to have a
from the cosmetic viewpoint is the intersection of a better longitudinal dimple. Care is taken to keep a small
perpendicular line dropped from the external canthus piece of vaseline gauze between the skin, mucosa and
and a horizontal line drawn from the angle of mouth, the stitch. In the last few cases, we have used a silicon
as reported by Boo-Chai.[5] However, we feel that the cylinder (block) as a bolster as it is more hygienic and
position of the dimple marked by this method is too does not keep moisture and food debris in the suture.
low. We consider the position of the dimple at the point Due care is also taken to prevent excessive tightening
of intersection of the perpendicular line dropped from of the stitch to prevent the resulting ischaemia of the
the external canthus and horizontal line drawn from mucosa (Video 1).
the highest point of the cupid’s bow laterally. It has also
been our observation in patients having natural dimples Postoperative care
that if the person sucks his cheeks inside, the area of the The patient is discharged immediately with antibiotics
maximum depression is the area of the dimple. Similarly, and analgesics. Meticulous oral hygiene with mouthwash
the patient is asked to create a negative suction and suck and oral rinse is of utmost importance. The bolster stitch
the cheeks inside. The site of the maximum depression is is removed on postoperative day 7. Initially, there is a
the marked site of the dimple. static dimple which deepens on animation, but gradually
with time there is only a hint of dimple when static and
Surgery accentuates on animation. Clinical pictures are shown
The aim of the surgery is to create a scar in the dermis [Figures 2–9].
which adheres to the underlying muscle, and becomes
a natural dynamic dimple. It is performed under local
RESULTS
anaesthesia. Around 2–3 ml of 0.5% lignocaine adrenaline
solution is injected from the skin side down to the
The follow-up of the patients ranged from 3 weeks
mucosal side at the marked site. A period of 10min is
to 4 years. Of the 100 dimples, only 3 had intraoral
allowed to lapse. A small stab incision is made with a
infection around the bolster, probably because of too
No. 15 knife, 2cm anterior (towards the lips) to the
tight bolster leading to ischaemia of the mucosa and
proposed site of the dimple. Due care is taken to ensure
poor maintenance of oral hygiene. These were managed
that we are away from the papilla of the stensons duct.
by removal of bolster and by antibiotic supplementation.
The No.15 blade is then inserted through the small stab
The infection had no adverse effect on the dimple and
on the mucosal aspect, with its sharp edge facing the
probably accentuated the dimple because of excessive
skin. After the blade with its sharp edge comes below
scarring. Two patients demanded reduction in the
the marked site of the dimple, the skin is scraped of all
dimple size. Partial reduction of the scar was done by
the mucomuscular attachments. A similar procedure is
releasing the scar intraorally and injecting 0.5 ml of
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 Videos available online

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Lari and Panse: Anatomical basis of dimple creation

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

hyaluronic acid in the defect. Three patients demanded bleeding or injury to the buccal branch of the facial
accentuation of the dimple for which a redo procedure nerve in any of the patients. By the end of 3 months
was done. There was no incidence of haematoma, after the surgery, there was only a small hint of the

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Lari and Panse: Anatomical basis of dimple creation

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]
Figure 7: Pre-op case 2 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.

Figure 8: Post-op case 2 at 3 years follow-up with very small dent of
dimple without animation
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
Figure 9: Post-op case 2
is removed, sparing the skin. This creates a shallow
cylindrical shaped defect under the skin. A suture is
dimple which was seen without animation and which then taken through the cheek muscle on one side of the
accentuated on animation. With time, the small dent defect, then through the dermal layer of the skin and
gradually diminished, but a definite dent was still seen finally through the cheek muscle on the other side of
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Lari and Panse: Anatomical basis of dimple creation

the defect. The knot is then tied, resulting in dimpling can immediately go to work after the procedure. One
of the skin. drawback of this procedure is that the bolster suture is
visible on the cheek for the first 7 days after the surgery.
The open techniques which necessitate excision of However, considering the numerous advantages this
tissue have got a risk of bleeding during or after dimple procedure has, we feel that this is inconsequential.
creation surgery. There is also an increased risk of
haematoma formation and infection. Though extremely CONCLUSION
uncommon, there is a potential for injury to the buccal
branch of the facial nerve. We conclude that dimple creation surgery is a very safe
procedure. The patient satisfaction rate is very high, and
We feel that the techniques using syringe needle as a guide patients seen long time after surgery continue to be
to create a sling by Shiwei Bao et al.[6] is cumbersome. They pleased with their surgically created dimples.
also recommend that patient can return to work or other
activities 2 days after the operation, which we feel is a REFERENCES
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dimples in Greek children and adolescents. Int J Anthropol
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and muscle is a cause of concern. The technique which 6. Bao S, Zhou C, Li S, Zhao M. A new simple technique for making
we have used is very simple and easily reproducible facial dimples. Aesthetic Plast Surg 2007;31:380-3.
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oedema. The size of the dimple is easy to control. One How to cite this article: Lari AR, Panse N. Anatomical basis of
can easily feel and visualise the indentation before dimple creation - A new technique: Our experience of 100 cases.
Indian J Plast Surg 2012;45:89-93.
placing the suture to control the size of the dimple. The
Source of Support: Nil, Conflict of Interest: None declared.
procedure is done on an outpatient basis, and the patient

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