The cheek is a facial area where many different procedures are available for enhancement. From cheek implants, to cheek lifts, to buccal fat removal, plastic surgery changes to the cheek are numerous. All of these procedures are about altering its volume or shape. But there is one topographic change to the cheek skin that can be done that is a small and eloquent change…the creation of a dimple.

Dimples are skin indentations that are not really in the classic position of the cheek per se, but are actually in the submalar or below the cheek region. They are located above the nasolabial fold and most frequently just outside the corner of the mouth. They may be present only when smiling or can be present (although less so) when one’s face is not moving.

Whether a dimple is appealing is a matter of personal taste. For many, they are seen as a cute and rare adorable quirk of nature. Perhaps they are envied as they lend a more child-like appearance. They are frequently a feature of many dolls. Their universal description of cute would suggest so. Or it may be their appearance in association with smiling that provides a favorable review. Whether they exist in a child or adult, dimple lovers find them adorable.Dimples are not very common and exist due to a congenital defect. While some describe dimples being formed due to an absence underlying muscle and fat in the cheek, this is not accurate. They have been anatomically shown to be present due to a defect in the zygomaticus muscle. This muscle runs from the corner of the mouth in its soft tissue up obliquely to its attachment to the underside of the cheek bone. A split or bifurcation of the muscle allows the intervening fat between the skin and the muscle to be tethered or pulled down into this muscular defect. Much like the belly button, the skin is pulled down closer to the muscle resulting in an overlying skin indentation or dimple.

For those born without dimples who want them, there is no way to get them other than surgery. Cheek dimple devices have been available in the past but they appear to have gone the way of the Sears Roebuck catalog.

Dimpleplasty can be done under local or IV sedation and takes about an hour to do if both sides are done. There is no recovery to speak of other than some mild cheek swelling and the rare potential for bruising, all of which goes away in a week or less. There are no restrictions on eating or drinking after the procedure. The only undesired effects of significance is too much or not enough final dimple result and asymmetry in the dimples when done on both sides.

Dr. Barry Eppley

Indianapolis, Indiana

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 1998, Dr. Joel Pessa of Dallas actually performed a study on them. He 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

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

People with a narrow-appearing face have often a deficiency in the width of where the upper jaw and cheek meet, known as the cheek or malar complex. The most common and simple method to improve the amount of cheek that one has is to place a cheek implant. There are some patients who do not want a synthetic implant in their face and may ask if there are any other ways to have ‘more cheek’.

There is one bone-moving alternative. Like the reverse of the bone cut used to make the cheek area more narrower, the cheek can similarly be made wider. Rather than removing a wedge of bone when the cheek cut is made, a single cut is made and the cheek complex pushed out. Because moving the cheek bone out creates a bone gap, the separated edges of bone need to be held apart with a small plate and screws. It is thought best to fill this bone gap with some material but a bone graft is unappealing for a cosmetic procedure. Filling this gap with synthetic bone particles or blocks is one option. I actually prefer not to fill this bone gap at all with the exception of the very top area which can be felt on the outside of the face by the eye. A small piece of ceramic bone substitute can be wedged up high near the top of the bone gap. The rest of the bone gap will fill in and heal over time on its own.

The use of this cheek expansion technique is for a very small number of patients. Cheek expansion builds out the side of the cheek but will not bring it forward or add forward projection, which many patients need more than they do width. Having adequate cheek projection but with a narrow face is a very rare cosmetic problem. Furthermore, there are fewer still that want to go through an operation to correct it. For this reason, cheek bone expansion is an operation of more theoretical than practical significance.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The need to reduce or narrow wide cheeks is a far less frequent request than making them bigger. Most commonly, cheek reduction surgery is requested by Asian cultures, notably Eastern Asians. East Asian cultures value a small face, and wide cheekbones appear to make the face bigger. In rare cases, a patient may have developed a wide cheek(s) due to a facial bone fracture from an injury or may simply have a more flat face appearance which makes the face look wide.

Cheek reduction can be done by two methods, Through an incision from inside the mouth, the prominence of the cheek bone can be burred down or a piece of cheek bone can be removed allowing it to become narrower. Burring down the cheek bone is rarely a good idea. It takes a lot of bone reduction to make a visible external difference and the soft tissues of the cheek may sag after if they do not heal back down to the bone. Taking  a vertical wedge of cheek bone out where it attaches to the main bone of the upper jaw, allows the entire cheek bone complex to fall in, narrowing the width of the face. I usually place a very small plate and screws to make sure the outer part of the cheek bone stays in the newly narrowed position permanently. The back end of the cheek bone, where it attaches to the skull (temple) , can also be cut as well as the front end. When both are done together, the face is further narrowed.

While cutting and removing a piece of cheek bone sounds like a complex procedure, it is really quite simple and quick to perform. It is similar to a chin osteotomy but it is easier on the patient as this part of the upper jaw is not responsible for jaw movement even though there are some muscles attached to it. It is far more effective than burring of the cheek prominence and poses no risk of the soft tissues of the cheek sagging after surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis 

THE BUCCAL FAD PAD IN FACIAL SURGERY

In select patients, removal of the buccal fat pad (which lies immediately under the cheekbone and is about the size of a golfball in most patients) can help contour a fuller face. I have performed this procedure, in conjunction with liposuction of the neck andchin implants, many times in patients whose desire is to thin out their fuller faces.

 
In numerous anatomic studies, dissectors have detailed the known relationship
between the facial nerve, buccal fat pad and the parotid duct. Given the frequent
proximity to this area during many types during aesthetic and reconstructive facial
surgery, it is useful to have a better appreciation of this midfacial crossroads region.

Like most cadaveric studies, there are no absolutes for each person’s anatomy.
However, it is clear that several buccal branches of the facial nerve interlace with the
multi-lobed buccal fat pad. Most commonly, this is on the superficial (outer) aspect of
the buccal lobe, away from intraoral approaches of manipulation. For this reason,
aggressive buccal lipectomies may inadvertently damage these branches. I have never
observed facial nerve injury from a buccal lipectomy procedure but this attests to a more
limited resection. Complete removal is usually aesthetically undesireable but also places
these nerve branches at risk. Since the parotid duct shares a similar pattern
of proximity as that of the nerve, injury to it is also theoretically possible. However, it is a
much larger structure that is tethered by its attachment to the oral mucosa and, as such,
not as easily avulsed from its anatomic bed.

In performing buccal lipectomies, it is important to bear the anatomy of the facial nerve
branches in mind and adjust the amount of buccal fat resection accordingly. This is why it is always better to under remove when taking out the buccal fat pad. This is probably better from a long-term cosmetic standpoint anyway.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis