Aesth. Plast. Surg. 31:380383, 2007 DOI: 10.

1007/s00266-006-0191-8

Original Article

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 2 Beijing, China

Abstract. In Asia, especially in China, women think a dimple is an important part of a beautiful smiling face. The dimple can make them more condent. Unfortunately, not all women have dimples. Hence, with the development of the Chinese economy, there is an increasing demand among Chinese women for the creation of dimples. Most women hope the impairment of the operation will be slight and the period of recovery short so they can go to work as quickly as possible. Some of them want to have dimples only when they smile. The authors have used a new simple technique to form 56 dimples for 36 women. During the operation, they use a syringe needle to guide a monolament nylon suture through the dermis and the active facial muscles (usually the buccinator). A sling is formed between the skin and the buccinator muscle. The knot is tied, and the dimple is created. After the operation, patients have been satised with the shape of the dimples. Furthermore, hematoma and infection never occurred. As a result, on the basis of their experience, the authors conclude that this technique is simple and easy to duplicate. Moreover, this technique has many benets. For example, with this procedure, it is easy to adjust the bulk of dimples by adjusting the tension of the knot and the amount of dermis tissue the injection needle sutures. Because no tissue is resected, there is mild postoperative swelling. Consequently, patients can return to work or other activities 2 days after the operation. Key words: Buccinator muscleDimple

Chinese women have believed that the dimple is able to bring good fortune to their family. Until currently, Chinese women also believed that a dimple was an important part of a beautiful smiling face. Hence, there is a constant demand among Chinese women for the creation of dimples to make them more charming and condent [2]. Generally, they want their dimples to be distinct from those of others. Some women want to display dimples only when they are smiling. Almost all patients hope for a short recovery period so they can return to work as quickly as possible. As a result, we use a new simple technique to create dimples for these women.

Operative Technique The operation we use to create dimples is a relatively simple outpatient procedure. The operation is performed with the patient under a local anesthesia. Before the operation, the patients are asked to select the site of the desired dimples in front of a mirror. The bilateral cheeks are the most popular area, and a single dimple, usually in the left cheek, is preferred by some patients. If the patient is undecided as to the site of the dimple, it is suggested that the best location from the cosmetic viewpoint is the intersection of a perpendicular line dropped from the external canthus and a horizontal line drawn from the angle of the mouth, as reported by Boo-Chai [2]. When the site and the number of the dimples have been determined, the patient is asked to lie in the supine position. Local anesthetic (23 ml of 0.5% lidocaine with epinephrine) is injected from the buccal mucosa to the skin. The buccal mucosa is incised by a no.11 blade. The incision, 2 to 3 mm long, is positioned below the papilla of the duct to avoid cutting Stensens duct.

The Oxford English Dictionary denes the word dimple as a small hollow, especially in the cheek or chin. In eastern countries, especially in China, the dimple is a symbol of good luck. Since ancient times,

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

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Fig. 4. The syringe needle is withdrawn to the dermis. Fig. 1. The buccal mucosa is incised, and the syringe needle is punctured into the skin of the cheek, then pulled from the incision.

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

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

Fig. 3. The suture is pulled from the bottom of the syringe needle. Fig. 6. The suture is pulled from the pinhole of the syringe needle.

The syringe needle is punctured through the cheek from the marked skin and pulled from the incision of the buccal mucosa (Fig. 1). A 1-0 monolament nylon suture is inserted into the pinhole of the syringe needle and pumped from the bottom of the syringe needle using the vacuum extractor (Fig. 2). After the suture has been pulled from the bottom of the syringe needle (Fig. 3), the needle is gradually withdrawn to the dermis (Fig. 4). Then the direction of the needle point is changed, punctured through the dermis and the muscle, and pulled from the incision of the buccal mucosa again (Fig. 5). The suture cannot be pulled too tightly, or it will be cut by the needle point. The suture is pulled from the pinhole of the syringe needle (Fig. 6), and the syringe needle is removed from the skin (Fig. 7). Thus, the

active facial muscles and the dermis are sutured together. The knot is tied, and the dimple is formed (Figs. 8 and 9). The depth of the dimple can be determined by adjustment of the knot tension. Also, the width of the dimple can be regulated by changing the amount of dermis tissue the injection needle sutures. Two or three procedures can be performed to make the dimple look more natural. The mirror is put in front of the patient until both the patient and the surgeon are satised. The buccal mucosa is closed with 5-0 monolament nylon suture (Fig. 10). No dressing is needed, and antibiotic may be used for 3 days. The 5-0 suture is removed after 7 days.

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A New Simple Technique for Making Facial Dimples

Fig. 7. The syringe needle is removed from the skin. Fig. 9. The knot is tied, and the dimple is formed.

Fig. 8. The active facial muscles and the dermis are sutured together. Fig. 10. The buccal mucosa is closed with the nylon suture.

Clinical Information From May 2000 to August 2005, we used the new technique to create 56 dimples for 36 patients. Of the 10 patients who wanted only to have one dimple in a unilateral cheek, 7 wanted it on the left side and 3 wanted it on the right side. Six patients who already had a dimple on one side of the cheek wanted a dimple on the other side for a more symmetric appearance. Among 56 dimples, 52 patients were satised (Fig. 11). Four dimples disappeared after 3 months. Consequently, we performed the same operations again using the same technique, and the dimples remained. Infection and hematoma did not occur in any of the 36 patients. Discussion The key point of the described operation is to connect the active facial muscles (usually the buccinator) to the dermis. Since Khoo Boo-Chais [2] report of his technique in 1962, several authors have reported a dierent technique for connecting the active facial muscles to the dermis. In 1971, Argamaso [1] excised the cylindrical segment of tissue consisting of the buccal mucosa muscle and subcutaneous fat to form the permanent dimple. However, this technique has the 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 between the skin and the buccinator muscle [2,3]. However, when the needle goes through the skin, it is not easy to suture the dermis alone without including the epidermis. We use the syringe needle to guide the monolament nylon suture to form the sling between the dermis and the buccinator muscle. Because the needle point does not pull out of the epidermis but changes direction in the dermis, it is easy to suture the dermis without the epidermis. Because no tissue is resected, little operative impairment occurs. The postoperative swelling is mild, and the deformity of the face is unrecognized. Patients may return to work or other activities 2 days after the operation. As discussed earlier, this technique is simple and easy to duplicate. Moreover, the complications of this operation are rare. Hematoma and infection have not occurred in our patients. Before making the facial dimple, the surgeon should take the site, size, and shape of the dimple into consideration. The proposed site of the dimple is on the intersection of a perpendicular line dropped from the external canthus and a horizontal line drawn from the angle of the mouth [2]. However, it is obvious that the request of the patient is more important and can be accepted if it is reasonable. The

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Fig. 11. A 31-year-old woman underwent surgery to form dimples with the new simple technique. Preoperative view: (1a) Front view. (1b) Left lateral view. (1c) Right lateral view. Postoperative view: (2a) Front view. (2b) Front view after smiling. (2c) Left lateral view. (2d) Right lateral view. Postoperative view after 6 months: (3a) Front view. (3b) Front view after smiling. (3c) Left lateral view. (3d) Right lateral view.

size and the shape of the dimple also are decided by the patient. Generally, patients want the dimple to look natural and distinct from others. They hope the dimple appears small or invisible when they are not smiling. Its subtle appearance with animation and its evanescence when the muscles of the face are at rest will invariably invite attention. This dynamic characteristic is necessary for a successful result from surgery [1]. Using our new technique, we can do it easily. Furthermore, it is easy to adjust the bulk of the dimple by adjusting the tension of the knot and the amount of dermis tissue that the injection needle sutures. Two or three points are sutured to form the dierent shape of the dimple. If after several months the patient regrets having this operation, the suture

can be removed from the oral cavity, and the dimple is reversible. In other words, the patient can recover the preoperative feature. References
1. Argamaso RV: Facial dimple: Its formation by a simple technique. Plast Reconstr Surg 48:4043, 1971 2. Boo-Chai K: The facial dimple: Clinical study and operative technique. Plast Reconstr Surg 30:281288, 1962 3. Jinling Lu: Plastic operation of simulating natural dimple. J Pract Aesth Plast Surg 9:191192, 1998