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Dr. Barry Eppley

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Archive for the ‘cheek dimples’ Category

Chin Dimple Injection Test

Friday, March 25th, 2016


chin dimpleChin dimples are central depressions on the upper portion of the chin pad below the labiomental sulcus. They are caused by a defect in the mentalis muscle, a lack of subcutaneous fat thickness or both. While some people that have chin dimples may find them creating a desired facial feature, others do not. Women in particular often want to get rid of their chin dimple.

Reducing or eliminating a chin dimple is best and most simply done with an injectable filler in most cases. Any of the commercially available synthetic injectable fillers can be used although their effects will be temporary. Fat injections offer the potential for a more permanent effect although their take and volume persistence can be unpredictable.

But before placing any injectable material and incurring the cost,  one would like to know if it would be successful. I have seen cases where placing injectable filler does not create an outward push on the central region of the chin dimple. Instead it created a doughnut effect where the filler ends up as a ring around the most indented portion of the chin dimple.

Saline Injection Test for Chin Dimples Dr Barry Eppley IndianapolisA simple test to determine whether an injectable filler will create a reduction in a chin dimple is to inject saline. Saline solution has a very soft push on the overlying tissues compared to more dense synthetic fillers or fat. Thus a saline injection causes noticeable reduction in a chin dimple, then any type of injectable filler should also.

Positive Saline Injection Test for Cheek Dimple Reduction Dr Barry Eppley IndianapolisPostive Saline Injection Test for Chin Dimple Treatment Dr Barry Eppley Indianapolis

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fat Grafting Chin Dimples

Tuesday, December 29th, 2015


Chin dimples are a not uncommon but anatomically perplexing facial feature. Sitting as a round central depression on the soft tissue chin pad, it serves no functional purpose other than a distinctive facial adornment. Like all facial dimples the cause has been shown to be caused by an underlying muscle deformity, specifically that of the mentalis muscle. Unlike its close cousin, the vertical or Y-shaped chin cleft, there is not an associated underlying bony deformity. Chin dimples and clefts are known to be an inherited trait on a dominant gene with variable penetrance.

The most common treatment to reduce or eliminate a chin dimple is by using an injectable filler. All of the commercially available injectable fillers can be used although their results will not be permanent. The use of silicone oil offers a permanent injection method although it is not FDA-approved for any facial augmentation procedure. Before placing any injectable filler a saline injection test should first be done to ensure that the dimple will be pushed out rather remaining indented and creating a ‘doughnut’ deformity.

Chin Dimple Release Dr Barry Eppley IndianapolisOne potentially permanent injection treatment option is that of fat grafting. Since injected fat is far more viscous than any injectable filler and does not have good linear flow, the bed into which it is injected should first be released. This can be done by using an 18 gauge needle placed in the center of the dimple and then rotating it around 360 degrees. The beveled edge of the needle will act like a small scalpel blade releasing the skin from its deeper attachments.

Chin Dimple Fat Injections Dr Barry Eppley IndianapolisOnce the chin dimple is released, a small amount of fat can be injected into the released subcutaneous space. This usually takes anywhere from .2ml to .5ml of concentrated fat. No one can predict with certainty how well injected fat takes so it is possible a second injection treatment may be needed. Three months should be allowed to pass to judge the retained injected fat volume.

There are alternative approaches to treating the chin dimple indentation done through an intraoral approach with muscle repair, but injection fat grafting offers a minimally invasive technique that has a high rate of success.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery- A Simplified Cheek Dimpleplasty Method

Monday, December 15th, 2014


The cheek dimple is an anatomic anomaly that is often inherited. They can occur on just one side of the face but more commonly are bilateral. They can be present only when one smiles or is always present and just gets deeper when one smiles. Cadaveric studies have shown that it is created by a defect in the zygomaticus muscle and represents, in essence, a tissue defect/deficiency between the skin and the underlying muscosa.

This anatomic knowledge is important when trying to create a surgical technique to create  cheek dimples. (cheek dimpleplasty)  Few surgical techniques have been published and one consistent reliable method has not been described to my knowledge. I have tried numerous cheek dimple creation methods and it is not as simple to achieve a more natural  looking dimple as it may seem.

Cheek Dimpleplasty Technique mucosal punch incision Dr Barry Eppley IndianapolisMaking a cheek dimple is really about creating a dermal adhesion to the underlying muscle. The first step is to mark where the patients wants the cheek dimple and numb the area with local anesthesia. A small incision is made inside the mouth using a dermal punch to remove the mucosa passing it over a needle introduced from the outside skin mark.

Cheek Dimpleplasty Technique percutaneous suturing Dr Barry Eppley IndianapolisSharp scissors are then used to make a pathway from the oral mucosa through the muscle and out to the underside of the skin. A plain gut dissolving suture on a straight needle is passed from inside the mouth and out through the skin. The needle is turned around and passed back inside the mouth moving it over from the skin exit hole by about a millimeter.

Cheek Dimp[eplasty Technique suture tying Dr Barry Eppley IndianapolisBecause it is a dissolveable suture, I pass two separate sutures and tie each one down individually with the knots on the inside of the mouth. When tying the sutures the cheek dimple is created and it is always best to tight them fairly tight and ‘overcorrect’ the depth of the dimple. The unpredictable part is how well the dermis will adhere down to the muscle. But with two sutures per dimple, the odds are increased that some adhesion (and dimpling) will occur. After the sutures are tied down, a single resorbable suture is used to close the small circular cheek mucosal incision.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Techniques in Cheek Dimpleplasty

Sunday, May 4th, 2014


Cheek Dimple Surgery Dr Barry Eppley IndianapolisCheek dimples are natural indentations some people have when they smile. Although some people have them naturally when they are not smiling and they merely become deeper when they do. The aesthetics of cheek dimples are personal, some like them and want them placed and a few others have them wand want them reduced/removed.

The anatomic basis of cheek dimples has been shown to be a defect or diastasis in the muscle layer between the skin and the buccal mucosal lining of the mouth. This is demonstrated by how a dimple deepens when one smiles. Depending upon the location on the cheek, this could involve the zygomaticus or buccinator facial muscles. Although this does not fully explain why one can have a cheek dimple without any facial animation, indicating that there must be a fat defect as well in some patients.

The surgical creation of a cheek dimple, often called a cheek dimpleplasty, does not have a standard technique. It is still a relatively uncommon procedure done by just a few plastic surgeons. How to effectively create a cheek dimple, and then have it maintained, varies amongst different surgeons.

Cheek Dimple Muscle Surgery Technique Dr Barry Eppley IndianapolisIn the March 2014 issue of the Annals of Plastic Surgery, an article entitled ‘Transoral Buccinator-Pexy (TBP)’ was published that details out a method of creating cheek dimples. In this method, the cheek dimple point is marked out about 2 cms above the corner of the mouth on its course to the lateral canthus. Under local anesthesia, a needle is passed through the skin and into the mouth through the buccal mucosa. The key manuever is to avoid the location and course of the parotid duct. Using the needle as a guide, a tissue punch is used to remove a piece of buccal mucosa down to the muscle. The needle is then used to thread a suture back out to the skin, the needle is removed, a bite of the dermis is taken and the suture passed back into the mouth where it is tied down to create the desired depth of the dimple. Their series of patients had successful results with no complications. As is common the cheek dimples because less pronounced as the swelling subsided and only appeared with smiling.

The authors chose to call their cheek dimple procedure a transoral buccinator-pexy, which  is an anatomic description of what is actually done. This technique is remarkably similar to the cheek dimple creation technique that I have evolved to over the years. I still refrain from using a permanent suture having had a few infections and extrusions from a permanent suture. This is a risk when a permanent suture is placed into the dermis of the skin. I have found good success even using a 4-0 plain suture on a straight needle.

Regardless of these suture nuances, this technique of cheek dimpleplasty is a very safe and effective one that can be done successfully under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomy and Surgical Technique For Cheek Dimpleplasty

Sunday, June 3rd, 2012

Cheek dimples are considered by some to be an attractive facial feature. Why there are appealing is not precisely known but, since they appear largely on smiling, one can assume that they cast an impression of happiness. For others they may merely be ‘cute’ or a sign of facial distinction much like a well placed mole. The location of a cheek dimple varies on different faces. It has been described as being located at the intersection of a horizontal line drawn out from the corner of the mouth and a vertical line dropped down from the corner of the eye. (lateral canthus) While that may be true for some people, dimples can also frequently be seen superior to that point.


The anatomy of a cheek dimple has been studied and has been found to be an anomaly of the underlying muscles The zygomaticus major muscle originates on the zygomatic (cheek) bone and runs down to insert into the corner of the mouth. It is a major elevator of the lip, particularly the corner of the mouth. Cheek dimples occur because there is a natural split or bifidity of the muscle as it heads downward into the lip. When the muscle contracts and the lip lifts, this split in the muscle pulls the overlying skin downward into the muscle defect much like an inward hernia. This creates the classic indentation on the cheek that either appears or is magnified on smiling.


The making of a cheek dimple (dimpleplasty) is a fairly simple procedure and has been traditionally described as a coring or soft tissue excision technique. Done from inside the mouth, a core of tissue is removed from the mucosa outward to the underside of the skin where the dimple is desired. A suture is placed from the dermis of the skin down to the mucosa where it is tied, thus pulling down the skin. While this can look effective when doing the procedure, I find that its results are very inconsistent. Dimples often don’t persist as it heals or asymmetry develops when cheek dimples are created on both sides. Some report problems, such as suture granulomas or even injury to the buccal branch of the facial nerve, neither of which I have seen.


 Any cheek dimple technique is intended to partially create what occurs in natural dimples, a defect in the muscle. The adherence or scarring of the underside of the skin down to the muscular defect is not what occurs naturally but is necessary to create the dimple effect. That is why all surgically created dimples will appear at some depth even when not smiling.


Creating this muscular adhesion is the key to surgical cheek dimpleplasty. While blind coring or cautery tissue excision creates a soft tissue defect, that does not always ensure that the skin will scar down to the muscle despite a pull down suture. An alternative and superior approach is to sew the muscle proper to the skin without any soft tissue excision. This is done by identifying the intervening muscle between the mucosa and the skin and isolating a strip of it. In theory this should be the zygomaticus muscle but the buccinators muscle will do as well. The muscle is transected and the superior end of it is then directly sewn to the underside of the skin. Thus when the muscle contracts the outer skin is pulled inward. This will also lessen the unnatural inward dimple that can occur when a coring technique is used.


While the recovery after cheek dimpleplasty involves no specific accommodations, it does take time to see the final result. It will take four to six weeks for the swelling and complete scarring and muscle adherence  to take place to see the final outcome. The stability of a surgical-created cheek dimple awaits for three months after the procedure.


Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? The Anatomy of Cheek Dimples

Saturday, April 7th, 2012

Cheek dimples have been proven by anatomic studies to be the result of an underlying muscle defect or unique muscular anatomy. They occur because of a split or defect in the zygomaticus muscle which runs from the underside of the cheek bone down into the upper lips. While appearing as a slight indentation at rest, the act of smiling contracts the muscle and pulls the overlying skin inward deepening the dimple. This anatomic knowledge makes it possible to surgically create cheek dimples or help to make them less noticeable.

The Surgical Creation of Cheek Dimples

Monday, May 25th, 2009

Cheek dimples are visible indentations of the skin that usually become apparent when one smile’s. They may be present in some people when their face is expressionless but most occur with facial movement. Cheek dimples are usually inherited and are a dominant genetic trait. What purpose they serve is unknown and the value of their genertically carried is even more obscure. When dimples are present, they are usually on both cheeks.  It is rare that they occur on one side of the face only.

While no one knows what the functional  purpose of cheek dimples is, it is known anatomically why they are present. In a study published in the 1998 journal of Plastic and Reconstructive Surgery, an anatomic study was performed and reported on them. It was discovered that they are caused by variation in the zygomaticus major facial muscle. This muscle is a major contributor to our smile by raising up the upper lip in an upward and outward direction. The muscle runs from its bony origin on the cheek (zygomatic) bone to insert into the upper lip. When a cheek dimple is present, it is caused by a split in the muscle. This makes the muscle be a double-band or is bifid. As one smiles, the muscle contracts or shortens and the split in it opens up drawing the overlying skin in. This explains why a cheek dimple may not be seen when one is not smiling but is when one is.

Very few people actually have dimples on their cheeks and the ones who have them are often viewed as an attractive feature. In my Indianapolis plastic surgery practice, it is possible to make dimples (cheek dimple creation surgery) through a relatively minor procedure. This is done by making a small incision on the inside of the cheek opposite the desired location of the dimple. Dimple locations are anterior to the parotid duct and the main body of the buccal fat pad. Dissection is carried through the zygomaticus muscle and a small permanent suture is placed between the underside of the skin and the muscle. It is important not to overtighten this suture since it isn’t particularly natural to have dimples when one isn’t smiling. The procedure definitely creates some bruising and it’s biggest complication is that the dimple may not be permanent if the suture pulls through in the first few weeks after surgery. Usually small to moderately-sized dimples can be created but large or deep indentations require tissue removal which I don’t advise.

A good question is ask is if this procedure is reversible or correctable if one doesn’t like the results. It is easily reversible in the first month or so after surgery which is in the time frame when one should know if the result is acceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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