Sunday, May 29, 2011

Dimple Surgery | Dimple Creation | Houston, Texas

Dimples, Dimples, Dimples -- How to Get Dimples?

Several people consider facial dimples an attractive feature.  Dimples are considered a sign of good luck and prosperity in some cultures.  They are also generally associated with cheerfulness.  But everyone would agree that dimples brighten and add character to a beautiful smile.  

Miranda Kerr's Beautiful Dimples (Photograph courtesy of
Dimples are genetically inherited, and thus this naturally given gift is not for everyone.  Research has shown that parents with dimples will pass this attractive trait to their children.  Studies of the human facial anatomy revealed that dimples occur secondary to an abnormal insertion of the muscles of the face (zygomaticus major muscle), rather than a soft tissue defect.  With the popularity of cosmetic surgery and celebrities with dimples, such as Cheryl Cole & Miranda Kerr, there has been a recent increased in demand  for dimple surgery or "dimpleplasty".  

Fast Facts about Dimple Surgery (Dimple creation)
  • Dimple surgery can be done under local anesthesia by a skilled plastic surgeon.
  • Majority of the techniques, if not all, involves adherence of the buccinator muscles of the face to the dermis of the skin.  This can be done by transcutaneous sutures or by an open technique done under local anesthesia.
  • Typically, there is no incision done on the skin of the face.  The incision is done through the mouth which would show no scarring.
  • Like a natural dimple, dimples created surgically typically appears with smiling.  Although surgically created dimples may appear most of the time depending on the surgical technique used.
  • The dimple may be present even without smiling the first several days  or even weeks.   Eventually, the surgically created dimple most likely be present with smiling as scar develops between the inner skin and the buccinator muscle.
  • The procedure typically takes less than 30 minutes.

The Ideal Dimple
  • When one surgically create a dimple, the ideal location would be the area where a less obvious faint dimple is present with smiling.  This would create a pre-existing dimple more prominent.
  • If one cheek has a dimple, the ideal site would be marked at the corresponding site that would create symmetry of the face.
  • If preexisting dimple is present, the ideal location would be the intersection between a horizontal line from the corner of the mouth and a vertical line from the lateral canthus of the eye.

Potential Complications of Dimple Surgery (Dimpleplasty)
  • Sudden disappearance of the dimple.
  • Asymmetry
  • Foreign body reaction
  • Bleeding
  • Injury to a nerve (buccal branch of the facial nerve) or salivary gland duct (Stensen’s duct),  which are rare.

It is possible to create dimples surgically, and this procedure may be simple and straightforward when done properly.  It is essential that one be properly educated before one undergoes any procedure.  I recommend seeing a plastic surgeon if one is interested in dimple surgery.
Emmanuel De La Cruz M.D., PLLC
Houston Plastic Surgeon

Bao S, Zhou C, Li S, Zhao M. A new simple technique for making facial dimples. Aesthetic Plastic Surgery.  2007;31: 380-383.  
Boo-chai K. The facial dimple: clinical study and operative technique. Plastic Reconstructive Surgery. 1962;30:281-288. 
Pessa JE et al. Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation. Clinical Anatomy. 1998;11:310-313.
Thomas et al.  Improved Surgical Access for Facial Dimple Creation. Aesthetic Surgery Journal. 2010; 30 (6): 798-801.
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Sunday, May 22, 2011

The Fine Art behind Facial Fat Transfer| Houston

The Fine Art behind Facial Fat Transfer
Facial lipoaugmentation or fat transfer is the art and science of restoring volume and contour of the human face using autologous fat.  The popularity of facial fat transfer seemed relatively new, but the concept is not.  Free fat graft was pioneered in 1893 by Franz Neuber who transferred a small piece of fat from the upper arm to fill a soft tissue defect of the face.  Its use to correct deficits of the cheek and chin areas was further reported as early as 1909.   
The advent of liposuction in the 1980s spurred the move toward modern fat grafting.  Dr. Ilouz reported the transfer of liposuction aspirate in 1984, and Dr. Ellenbogen, a Beverly Hills plastic surgeon, reported the use of fat autografts in atrophic and posttraumatic facial defects in 1986. 

So Is There an Art Behind Facial Fat Transfer?

The Inverted Triangle of Youth   

The young face typically has an inverted triangular appearance.  Having more volume in the cheeks and a soft angle of the jaw suggests a youthful appearance.  As one ages, this inverted triangle of youth becomes more rectangular as one develops jowls and as the malar fat pad (cheek) descends.  Thus, facelift/neck lift procedures, along with selected fat transfer to the face,  revivify this inverted triangle of youth.
Inverted Triangle of Youth (Photograph courtesy of; AP Photo/Damian Dovarganes)
The Ideal Beautiful Cheek
One of the secrets to a beautiful face is a pronounced cheek bone with narrow cheeks.  The ideal beautiful cheek has been found to be oval, not round.  It is also angled which extends from the angle of the mouth to the base of the helix of the ear.  Fat transfer to the aged face into the ideal cheek area may beautify the face in selected patients.  Cheek augmentation that deviates from this "ideal" may result in a less attractive and unnatural facial appearance.
Angelina Jolie's Beautiful Cheeks (Photograph courtesy of
The Young Brow Line
Recently, aesthetic plastic surgeons have recognized that young attractive female models have a brow line that is low lying with anterior projection of the brow.   Hollowness around the eyes may suggest advancing age.  Atrophy of the fat underneath the brows may cause a tired aged appearance.  Thus, re-establishing the contour of the brow line, such as a fat transfer (as suggested by Ellenbogen), may restore some youthfulness as well as can visually make the eyes bigger.    This powerful technique, especially in combination with other facial rejuvenation procedures, may only be applied in  very select cases, such as the presence of a hollowed eye appearance.  
What are the Indications for Fat Transfer?
  •    Depressed scars of the face & body
  •   Aging skin with loss of supportive tissue, such as the dorsal hand, hollow cheeks & eyes, upper lip and nasolabial folds.
  •   Facial Reshaping for the gaunt/thin face
  •   Cheek augmentation
  •   Buttock augmentation, such as the Brazilian Butt Lift
  •   Chin augmentation
  •   Hemifacial atrophy
  •   Flattened upper lip 
Complications of Facial Fat Transfer
  • Fat resorption is the most common problem encountered.
  • Bruising
  • Fat embolism, very rare.
  • Blindness, extremely rare.
  • Iatrogenic injuries, such as vessels & nerves.  Thus, it is important to select a plastic surgeon to perform this procedure.
  • Asymmetry may occur due to multiple factors, such as the variable nature of the viability of the fat grafted/transferred and pre-existing asymmetry of the face.
Stay tuned for more....  Next:  The Art of Facial Fat Transfer.
The Golden Ratio of Angelina Jolie (Photograph Courtesy of by Brandon Wright)
Houston Plastic Surgeon References: Arthur Swift's Beautiphication.  American Society of Aesthetic Plastic Surgery Conference 2010. 
Ellenbogen R. Free autogenous pearl grafts in the face: a preliminary report of a rediscovered technique. Annals of Plastic Surgery. 1986;16:179-19
Illouz YG. L'avenir de la reutilization de la graisse apres liposuccion. Rev Chir Esthet Lang Franc. 1984;9:36
Neuber F. Fat transplantation. Chir Kongr Verhandl Dsch 
Gesellch Chir 1893;20:66   Please click +1 below if you like the article.  Thank you! 

Saturday, May 14, 2011

What Makes a Face Beautiful?

The Secret to a Beautiful Face
The secret to a beautiful face has been a quest for humans since antiquity.  Many women spend up to $12,000 on average annually on beauty products and grooming to enhance their beauty.  Studies have shown that there's a significant wage disparity between the beautiful and the average woman.  A Federal Reserve study has shown that exceptionally attractive women tend to earn more money per hour than their Plain Jane counterparts.  Unfortunately, this "plainness penalty" and "beauty premium" exist across all occupations, including lawyers.  So what makes someone's face beautiful?
Florence Colgate "Most Beautiful Face per Science" (Photograph courtesy of

 Note: Florence Colgate indeed has a very attractive face and fits the golden ratio.  However, there's still some asymmetry with her face, such as the left nasolabial fold is higher on the left with smiling and the small asymmetry of the nose.  So does she have a perfect face?  ~Dr. De La Cruz

The Study of Beauty
Extensive research has been conducted on the analysis of beauty.  This has shown that whether you're Asian or European, the idea of what constitutes an attractive face is very similar. What defines a beautiful face transcends racial boundaries.  Thus, there's a common element of what constitutes beautiful across all ethnicities.  The ancient Greeks believed that all beauty is based on mathematics, as exemplified by Venus de Milo. 

Venus de Milo (Photograph Courtesy of

The beauty of a face was studied mathematically since the 5th century BC by the Greek sculptor, Polykleitos.  Through a system of ideal mathematical proportions, Polykleitos developed a set of aesthetic principles and wrote a treatise called the "canon".
  • The ideal distance between the eyes should be equal to the width of the nose.
  • The length of the ears should be equal to the length of the nose. 
Doutzen Kroes (Photograph Courtesy of

Greek sculptors also believed that the relationship between many pairs of measurement, such as the lips, should be equal to the "Golden ratio" (¤ć), which is approximately equal to 1.618.  This is exemplified of what constitutes a beautiful lip with an upper to lower lip ratio of 1:1.618.
The Golden Ratio/Mask of Megan Fox (Photograph Courtesy of
Golden Ratio of some of the Beautiful People (Photograph courtesy of
Facial Features Identified on a Beautiful Face 
  • Facial shape (chin, cheeks)
  • Facial Symmetry
  • Eyebrow Shape
  • Eye size
  • Nose shape
  • Lips
  • Skin texture

Traits Having the Greatest Effect on Facial Attractiveness
  • Narrow jaw, short chin and lips close to the nose
  • Large eyes
  • Thick lips
Facial Symmetry and Beauty
There is a significant correlation between a symmetric face and beauty.  It has been shown that a symmetrical face is a sign of good health and genetic quality.  Several studies have shown that the perceived age can be lowered when facial asymmetry is improved. With aging, any facial asymmetry present becomes more pronounced as revealed by one study on patients who were about to undergo a facelift.   Prior to surgery, all patients were found to have asymmetry in their facial features which was improved after surgery.

      The Ideal Beautiful Cheeks
      One of the features of a beautiful face in a woman is a pronounced cheek bone with narrow cheeks.  The ideal beautiful cheek has been found to be oval, not round.  It is also angled which extends from the angle of the mouth to the base of the helix of the ear. 
      Ideal Cheek of Angelina Jolie (Photograph courtesy of

      That Beautiful Smile
      A beautiful smile says a lot about a face.  Facial expressions that show interest and kindliness, such that of a smile, increase facial attractiveness in both males and females. Smiles that show a lot of white teeth (incisor display) was found to be more attractive and youthful in women.  With aging, there is a gradual reduction of the display of the upper teeth (upper central incisors) and a gradual increase of the display of the lower teeth.  Increased upper incisor display not only is aesthetically pleasing but also is a sign of youth.  
      (Photograph courtesy of

      The Beautiful Lip
      Having fuller lips, like that of Angelina Jolie, have been considered a desirable trait.   A study has shown that female models who are selected in the fashion industry, in general, have fuller lips (upper and lower) than ordinary women.  Several studies have also shown that men preferred women with thick and prominent lips.  Over the past several years, there has been an increasing number of women who are seeking lip augmentation to achieve that sought after look of having voluptuous lips.  

      The Ideal Beautiful Brow
      As many women would know, the eyebrows bring attention to the eyes and help frame the face.  This is evidenced by the ubiquitous plucking, waxing, threading and tattooing of eyebrows by women across all ethnic backgrounds.  So what is the ideal eye brow?  The youthful and beautiful brow is typically arched at the junction of the medial 2/3 and outer 1/3 of the eyebrow.  The lateral tip of a beautiful brow should be higher than the medial tip of the brow.  Any alteration of this brow pattern, such as found in an incorrect Botox injection, will have an unnatural and less attractive appearance.
      Megan Fox (Photograph Courtesy of

      Stay tuned for more about the Secret of a Beautiful Face.... Page 2
      Taylor Swift:  Is there a Secret to a Beautiful Nose? (Photograph from Wikimedia Commons by Angela George)
      Recommended articles:
      1)  Dimples, Dimples, Dimples.... How to Get Dimples?

      2) Fine Art Behind Facial Fat Transfer

      3) The Secret to a Beautiful Lip

      Emmanuel De La Cruz, M.D., PLLC
      The Woodlands Plastic Surgeon

      Arthur Swift's "Beautiphication". Aesthetic Surgery Society Meeting 2010. 
      Baudouin J, and G. Tiberghien. Symmetry, Averageness, and Feature Size in the Facial Attractiveness of Women. Acta Psychol. 117:313-332
      Biddle, Jeff E. and Hamermesh, Daniel S. “Beauty, Productivity, and Discrimination: Lawyers’Looks and Lucre.” Journal of Labor Economics. 1998, January; (16);1:172-201.
      Da Motta, et al.  Display of the incisors as functions of age
      and gender. Australian Orthodontic Journal.  2010. 26(1): 27-32
      Engemann, Kristie and Michael Owyang.  So Much for That Merit Raise: The Link between Wages and Appearance.  The Regional Economist. April 2005.
      Johnston VS, and M. Franklin.  Is Beauty in the Eye of the Beholder. Ethol. Sociobiol. 1993;14:183-199
      Mickiwicz, Adam.  Facial Attractiveness: General Patterns of Facial Preferences. Anthropological Review. 2007; (70): 45-79
      Rohrich, et al.  The Individualized Component Facelift: Developing a Systematic Approach to Facial Rejuvenation.  Plastic & Reconstructive Surgery. 2009. 123:1050-1063  
      Valentine, et al. Why are average faces attractive? The effect of view and averageness on the attractiveness of female faces. Psychonomic Bulletin & Review. 2004 Jun;11(3):482-7.

      Thursday, May 5, 2011

      Smile Train May 2011: Sierra Leone

      One of my craniofacial plastic surgery mentors, Jack Yu M.D., once told me that "to be able to speak is to be human."  Helping children repair their cleft lip and palate not only improve one's speech, but also enable one to live his/her life with dignity.   More than 200,000 children all over the world are born with a severe cleft deformity each year.   With the non-profit organizations, such as the Smile Train and Operation Smile, thousands of children each year are given the chance to smile, to speak, to eat, and live their lives with dignity.  Let's give our support to these non-profit organizations:  The Smile Train and Operation Smile.

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      Silicone Gel Breast Implant or Saline Breast Implant?