Smile You Got Dimples

A smile empowered with dimples can add attraction and cuteness to any face that’s why dimples have always been seen as symbols of beauty. It seems silver screen and media world has also been cast under the spell of dimples by just looking at how many celebs have dimples.

Dimples can adorn a face boosting up the appeal of the cheeks or chin, although the chin dimples are more rare than cheeks. Beauty decoded by science shows that dimples are inherited as an irregular autosomal dominant trait. Which in layman’s terms means: if both your parents have dimples you have a great probability of inheriting them, but this does not guarantee that you will get these cute facial dents for sure.  

Fun Science fact: Genetic research places the cleft chin dimple on chromosome 5 and cheek dimples on chromosome 16, with a variable penetrance.

Looking At The Anatomy Of Dimples

Structurally speaking dimples are a facial muscle deformity. Where as the chin dimple is a result of an underlying bony defect. Both happen to be envious and popular deformities that are requested by many cosmetic surgery patients.

There are two different theories that attempt to explain how cheek dimples form. First one states that theses cute divots form as a result of shorter muscles around the mouth. The second and more popular theory describes dimples as a defect in the facial muscle going by the brilliant name of Zygomaticus Major. This large muscle covers the side of the cheeks, and dimples are believed to form when there is a divide in this muscle; which is normally all in one piece. The skin in the region of the double or bifid Zygomaticus Major muscle is inserted onto the inferior bundle of the muscle fibers. Smiling makes the overlying skin draw inward and the dimple grows deeper, thereby making it more visible.

Dimples can be transient or permanent, depending on the cause or factor responsible for their occurrence. Excessive fat deposition, which disappears with the aging process, some times causes transient dimples. The stretching or lengthening of muscles during aging process can also lead to gradual obliteration of this facial feature. This explains why some dimples are more common and conspicuous in younger age groups.

Dimple Surgery

Dimples can be created surgically as a minor procedure done under local anesthesia. Most of the techniques, if not all, involve adherence of the buccinator muscles of the face to the dermis of the skin. This can be achieved with sutures inserted through the skin or by an open technique that is performed through the mouth, which has added bonus of avoiding any surface scarring. Like natural dimples, dimples created surgically typically appear with smiling, although surgically created dimples may be visible most of the time depending on the surgical technique used. The dimple may be present even without smiling for the first several days, or even weeks, after surgery; eventually, the surgically created dimple will most likely be present with smiling as scar develops between the inner skin and the buccinator muscle

Positioning Of The Dimples

While surgically creating a dimple, the ideal location should be the area where a less obvious faint dimple is present with smiling; thus the pre-existing dimple is made more prominent. If one cheek has a dimple, the ideal location for the other dimple can be marked at the corresponding site that would create symmetry of the face.

If a pre-existing dimple is not present, the ideal location reported by Boo-Chai is: the intersection between a horizontal line from the corner of the mouth and a vertical line from the lateral canthus of the eye. Some doctors choose a point 1.5 to 2 cm superior to a point bisecting an angle formed by the projection of the lateral commissure of lips and the lateral canthus of eye. Another landmark to correctly position the dimple can be established by asking the patient to create a negative suction and suck the cheeks inside. The site of the maximum depression can be the marked site of the dimple. The marking should be migrated slightly laterally if pulsation of Facial artery is palpable at the marked point to avoid hematoma.  The final position to do surgery is usually chosen by the patient based on preference and keeping in mind the vector of smile.

Technique

Surgical techniques can be categorized into 2 major categories, namely blind coring and open approach.

The patient’s face and mouth are prepared, and local anesthesia is administered, along the marked area. Hypodermic needles are then passed through the marked point into the buccal mucosa. A soft tissue trephine bur connected to a latch-type handpiece or a punch biopsy needle is used to punch the buccal mucosa while the opposite hand pushes the buccal mucosa inward and supports this area externally. The soft tissue cylindrical fragment (consisting of the mucosa, a small portion of the buccinator muscle, and a part of the Bichat fat pad) is removed with scissors, and the skin is kept intact. Alternatively you could incise the mucosa and under direct vision excise a small part of muscle and fat. The advantage of open approach is the depth and size of dimple can be adjusted based on the amount of fat present. For more depth of dimple more fat can be excised and a larger defect in muscle should be created.

Defect closure is performed by placing a non-absorbable or absorbable suture through the cheek mucosa, muscle, and Bichat fat pad on 1 side of the defect; then through 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 tension adjusted based on the depth of dimple required. The patient is advised to maintain good oral hygiene with chlorhexidine mouth wash and oral antibiotics. Analgesics are prescribed to keep the patient comfortable and pain free. Suture removal is done in non-absorbable sutures at 10-14 days.

Potential Complications Of Dimple Surgery

·      Sudden disappearance of the dimple,

·      Asymmetry,

·      Foreign body reaction,

·      Bleeding, and

·      Injury to a nerve (buccal branch of the facial nerve)

·      Injury to the salivary gland duct (Stensen duct)

All these potential side effects can present themselves during the surgery, but in experienced hands the chance of them happening is not very common.

Tips & Tricks To Improve Surgical Outcomes

·      The non-excision suture techniques do not provide long lasting results. Removing the part of the muscle and fat delivers more long lasting and

·      Location of dimple must be chosen based on vector of smile. Blindly following the intersection of oral commissure and lateral canthus may place dimples too inferiorly.

·      For bulky cheeks choosing an open approach with excision of adequate amount of fat to create a deeper dimple rather than a core excision and single stitch delivers better results.

·      Prolene sutures for muscle to dermis approximation causes long lasting results but increase chances of foreign body reaction and infection. Alternatively Polydiaxone suture can be used and mucosa closed with catgut.

·      Always explain to the patient that the dimple will be exaggerated in first few weeks and will be present even at rest and over time only on animation.

There you have it the nitty gritty and the surgical journey through the whole process of creation of cuteness factor called: dimples. Happy Valentines Day!!