The appearance of depressions or indentations on the face, commonly referred to as “dents,” reflects changes within the skin’s structure and underlying tissues. These changes range from surface-level damage to deeper, structural volume depletion. This article explores the various mechanisms that lead to the development of facial indentations.
Depressions Caused by Skin Damage and Scarring
Many noticeable depressions result from atrophic scarring, which forms when the skin’s natural healing process is incomplete following trauma or inflammation. This occurs because insufficient collagen is produced to rebuild the damaged tissue structure. Instead of forming a smooth, level surface, the skin sinks inward, creating a pitted appearance.
Inflammatory conditions, most notably severe acne, are the most frequent cause of atrophic scars because the deep infection destroys underlying dermal tissue and fat. These scars are categorized into three types based on shape and depth. Ice pick scars are narrow, V-shaped indentations that extend deep into the dermis. Boxcar scars are broader with sharply defined, vertical edges, giving them a rectangular, crater-like appearance. Rolling scars are wider depressions with sloping, rounded edges, which create an undulating, wave-like texture.
Indentations Resulting from Volume Loss
Indentations that are deeper and more structural often result from the loss or displacement of subcutaneous tissues (fat, muscle, or bone), a process distinct from surface-level scarring. A primary cause is age-related volume depletion, where facial fat pads shrink and shift downward over time, causing the overlying skin to appear sunken or hollow. This change is compounded by the gradual loss of collagen and elastin, and the subtle recession of facial bones, particularly around the eye sockets and jawline. This combination leads to characteristic hollowness that can create visible depressions, such as the deepening of tear troughs beneath the eyes.
A different, medically significant cause is localized lipodystrophy, a condition characterized by the specific loss of fat tissue in a circumscribed area. This can be a side effect of medication injections, such as corticosteroids or insulin, which may trigger an inflammatory response that destroys fat cells at the injection site. Certain autoimmune disorders, trauma, or genetic predisposition can also cause this localized fat atrophy, resulting in a distinct structural indentation.
Anatomical Features and Temporary Marks
Some facial indentations are not the result of damage or disease but are either temporary pressure marks or inherent anatomical variations. The most common anatomical feature is the dimple, which forms when the zygomaticus major muscle attaches tightly to the overlying dermis. When the muscle contracts during a smile, the attachment point pulls the skin inward, creating a temporary depression.
Temporary indentations, often termed “sleep lines,” occur due to mechanical compression of the face against a pillow during sleeping. When the skin is subjected to prolonged compression, it folds and creases, leaving a mark that dissipates after waking. Unlike expression lines, sleep lines are caused purely by external pressure and typically fade quickly as tissue fluid redistributes. However, repeated, long-term compression can contribute to the formation of permanent wrinkles.
Next Steps: When to Consult a Dermatologist
Seeking professional advice is advisable if a facial dent is new, rapidly progressing, associated with pain, or if its origin is unknown. A dermatologist can accurately diagnose the cause, differentiating between scarring, volume depletion, and medical conditions like localized lipodystrophy. Early diagnosis is important for identifying conditions that may require systemic medical management or for preventing the progression of scarring.
For depressions caused by a lack of collagen, common treatment options aim at resurfacing the skin or stimulating new collagen production. These may involve microneedling, chemical peels, or laser resurfacing. Indentations resulting from deeper volume loss are often addressed by replacing the lost tissue volume. This is typically achieved using dermal fillers, which are injected below the skin surface to elevate the depression and restore contour. For severe, deep scars, surgical methods like subcision or punch excision may be used to release the scar tissue tethering the skin down.