A New Simple Technique for Making Facial Dimples

Shiwei Bao, M.D., Chuande Zhou, M.D., Senkai Li, M.D., and Muxin Zhao, M.D.

Department of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, South £2Beijing, China

Abstract. In Asia, especially in China, women think adimple is an important part of a beautiful smiling face. The

dimple can make them more confident. Unfortunately, notall women have dimples. Hence, with the development ofthe Chinese economy, there is an increasing demand among

Chinese women for the creation of dimples. Most womenhope the impairment of the operation will be slight and theperiod of recovery short so they can go to work as quickly

as possible. Some of them want to have dimples only whenthey smile. The authors have used a new simple techniqueto form 56 dimples for 36 women. During the operation,

they use a syringe needle to guide a monofilament nylonsuture through the dermis and the active facial muscles(usually the buccinator). A sling is formed between the skinand the buccinator muscle. The knot is tied, and the dimple

is created. After the operation, patients have been satisfiedwith the shape of the dimples. Furthermore, hematoma andinfection never occurred. As a result, on the basis of their

experience, the authors conclude that this technique issimple and easy to duplicate. Moreover, this technique hasmany benefits. For example, with this procedure, it is easy

to adjust the bulk of dimples by adjusting the tension of theknot and the amount of dermis tissue the injection needlesutures. Because no tissue is resected, there is mild post-operative swelling. Consequently, patients can return to

work or other activities 2 days after the operation.

Key words: Buccinator muscle—Dimple

The Oxford English Dictionary defines the word‘‘dimple’’ as a small hollow, especially in the cheek orchin. In eastern countries, especially in China, thedimple is a symbol of good luck. Since ancient times,

Chinese women have believed that the dimple is ableto bring good fortune to their family. Until currently,Chinese women also believed that a dimple was animportant part of a beautiful smiling face. Hence,there is a constant demand among Chinese womenfor the creation of dimples to make them morecharming and confident [2]. Generally, they wanttheir dimples to be distinct from those of others.

Some women want to display dimples only whenthey are smiling. Almost all patients hope for a shortrecovery period so they can return to work as quicklyas possible. As a result, we use a new simple tech-nique to create dimples for these women.

Operative Technique

The operation we use to create dimples is a relativelysimple outpatient procedure. The operation is per-formed with the patient under a local anesthesia.Before the operation, the patients are asked to selectthe site of the desired dimples in front of a mirror.The bilateral cheeks are the most popular area, and asingle dimple, usually in the left cheek, is preferred bysome patients. If the patient is undecided as to the siteof the dimple, it is suggested that the best locationfrom the cosmetic viewpoint is the intersection of aperpendicular line dropped from the external canthusand a horizontal line drawn from the angle of themouth, as reported by Boo-Chai [2].

When the site and the number of the dimples havebeen determined, the patient is asked to lie in thesupine position. Local anesthetic (2�3 ml of 0.5%lidocaine with epinephrine) is injected from the buc-cal mucosa to the skin. The buccal mucosa is incisedby a no.11 blade. The incision, 2 to 3 mm long, ispositioned below the papilla of the duct to avoidcutting Stensen�s duct.

Correspondence to Shiwei Bao, M.D.; email: baoshiwei@163.com

Aesth. Plast. Surg. 31:380�383, 2007DOI: 10.1007/s00266-006-0191-8

Original Article

The syringe needle is punctured through the cheekfrom the marked skin and pulled from the incision ofthe buccal mucosa (Fig. 1). A 1-0 monofilamentnylon suture is inserted into the pinhole of the syringeneedle and pumped from the bottom of the syringeneedle using the vacuum extractor (Fig. 2). After thesuture has been pulled from the bottom of the syringeneedle (Fig. 3), the needle is gradually withdrawn tothe dermis (Fig. 4). Then the direction of the needlepoint is changed, punctured through the dermis andthe muscle, and pulled from the incision of the buccalmucosa again (Fig. 5).The suture cannot be pulled too tightly, or it will be

cut by the needle point. The suture is pulled from thepinhole of the syringe needle (Fig. 6), and the syringeneedle is removed from the skin (Fig. 7). Thus, the

active facial muscles and the dermis are suturedtogether. The knot is tied, and the dimple is formed(Figs. 8 and 9). The depth of the dimple can bedetermined by adjustment of the knot tension. Also,the width of the dimple can be regulated by changingthe amount of dermis tissue the injection needlesutures.

Two or three procedures can be performed to makethe dimple look more natural. The mirror is put infront of the patient until both the patient and thesurgeon are satisfied. The buccal mucosa is closedwith 5-0 monofilament nylon suture (Fig. 10). Nodressing is needed, and antibiotic may be used for 3days. The 5-0 suture is removed after 7 days.

Fig. 1. The buccal mucosa is incised, and the syringe needleis punctured into the skin of the cheek, then pulled from theincision.

Fig. 2. A nylon suture is put into the pinhole of the syringeneedle and pumped from the bottom of the syringe needleusing the vacuum extractor.

Fig. 3. The suture is pulled from the bottom of the syringeneedle.

Fig. 4. The syringe needle is withdrawn to the dermis.

Fig. 5. After the direction of the needle point is changed,the needle is punctured through the dermis and the muscleand pulled from the incision of the buccal mucosa again.

Fig. 6. The suture is pulled from the pinhole of the syringeneedle.

S. Bao et al. 381

Clinical Information

From May 2000 to August 2005, we used the newtechnique to create 56 dimples for 36 patients. Of the10 patients who wanted only to have one dimple in aunilateral cheek, 7 wanted it on the left side and 3wanted it on the right side. Six patients who alreadyhad a dimple on one side of the cheek wanted adimple on the other side for a more symmetricappearance. Among 56 dimples, 52 patients weresatisfied (Fig. 11). Four dimples disappeared after 3months. Consequently, we performed the sameoperations again using the same technique, and thedimples remained. Infection and hematoma did notoccur in any of the 36 patients.

Discussion

The key point of the described operation is to connectthe active facial muscles (usually the buccinator) tothe dermis. Since Khoo Boo-Chai�s [2] report of histechnique in 1962, several authors have reported adifferent technique for connecting the active facialmuscles to the dermis. In 1971, Argamaso [1] excisedthe cylindrical segment of tissue consisting of thebuccal mucosa muscle and subcutaneous fat to formthe permanent dimple. However, this technique hasthe risk of severing the buccal branch of the facial

nerve. It may produce postoperative cheek swelling,and the period of recovery is longer.

Some authors have used a needle to suture betweenthe skin and the buccinator muscle [2,3]. However,when the needle goes through the skin, it is not easyto suture the dermis alone without including theepidermis. We use the syringe needle to guide themonofilament nylon suture to form the sling betweenthe dermis and the buccinator muscle. Because theneedle point does not pull out of the epidermis butchanges direction in the dermis, it is easy to suture thedermis without the epidermis. Because no tissue isresected, little operative impairment occurs. Thepostoperative swelling is mild, and the deformity ofthe face is unrecognized. Patients may return to workor other activities 2 days after the operation. Asdiscussed earlier, this technique is simple and easy toduplicate. Moreover, the complications of this oper-ation are rare. Hematoma and infection have notoccurred in our patients.

Before making the facial dimple, the surgeonshould take the site, size, and shape of the dimple intoconsideration. The proposed site of the dimple is onthe intersection of a perpendicular line dropped fromthe external canthus and a horizontal line drawnfrom the angle of the mouth [2]. However, it isobvious that the request of the patient is moreimportant and can be accepted if it is reasonable. The

Fig. 8. The active facial muscles and the dermis are suturedtogether.

Fig. 7. The syringe needle is removed from the skin.

Fig. 9. The knot is tied, and the dimple is formed.

Fig. 10. The buccal mucosa is closed with the nylon suture.

382 A New Simple Technique for Making Facial Dimples

size and the shape of the dimple also are decided bythe patient. Generally, patients want the dimple tolook natural and distinct from others. They hope thedimple appears small or invisible when they are notsmiling. Its subtle appearance with animation and itsevanescence when the muscles of the face are at restwill invariably invite attention. This dynamic char-acteristic is necessary for a successful result fromsurgery [1]. Using our new technique, we can do iteasily. Furthermore, it is easy to adjust the bulk ofthe dimple by adjusting the tension of the knot andthe amount of dermis tissue that the injection needlesutures. Two or three points are sutured to form thedifferent shape of the dimple. If after several monthsthe patient regrets having this operation, the suture

can be removed from the oral cavity, and the dimpleis reversible. In other words, the patient can recoverthe preoperative feature.

References

1. Argamaso RV: Facial dimple: Its formation by a simpletechnique. Plast Reconstr Surg 48:40�43, 1971

2. Boo-Chai K: The facial dimple: Clinical study andoperative technique. Plast Reconstr Surg 30:281�288,1962

3. Jinling Lu: Plastic operation of simulating naturaldimple. J Pract Aesth Plast Surg 9:191�192, 1998

Fig. 11. A 31-year-old woman under-went surgery to form dimples with thenew simple technique. Preoperativeview: (1a) Front view. (1b) Left lateralview. (1c) Right lateral view. Postoper-ative view: (2a) Front view. (2b) Frontview after smiling. (2c) Left lateral view.(2d) Right lateral view. Postoperativeview after 6 months: (3a) Front view.(3b) Front view after smiling. (3c) Leftlateral view. (3d) Right lateral view.

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