Facial dents, depressions, and indentations have a wide range of causes, from acne scars and natural aging to rare medical conditions that erode fat or bone beneath the skin. The most common culprit is atrophic acne scarring, but structural changes in the facial skeleton and fat pads as you age can also create hollows that weren’t there before. Some dents are harmless anatomical quirks you were born with, while others signal an underlying condition worth investigating.
Acne Scars Are the Most Common Cause
If you had moderate-to-severe acne at any point in your life, the dents you see are most likely atrophic scars. These form when inflammation from an acne lesion destroys tissue beneath the skin and the body can’t rebuild it fully. Dermatologists generally recognize three subtypes. Ice-pick scars are narrow and deep, like tiny puncture wounds. Boxcar scars are wider with sharply defined edges. Rolling scars have a gentler, wave-like contour that makes the skin look uneven rather than pitted. A histological study of these scar types found that ice-pick scars averaged roughly 1.9 millimeters deep, while boxcar and rolling scars were shallower at about 1.3 millimeters each.1PubMed. A cross-sectional pilot study evaluating the histopathology of atrophic acne scars with a focus on the vertical depth of ice pick, boxcar, and rolling scars and its implications in skin of colour
What makes these scars persist is not just missing tissue but a fundamental change in the skin’s architecture. The collagen that remains tends to be loose and disorganized, elastic tissue drops dramatically, and the hair follicles and oil glands that normally populate healthy skin are largely absent within the scar. Research on the cellular level has found that key stem cell markers in the skin are significantly reduced in atrophic acne scar tissue compared to normal skin, which helps explain why these scars don’t simply repair themselves over time the way a shallow cut might.2PubMed. Alterations in epidermal stem cells within the pilosebaceous unit in atrophic acne scars
The psychological toll can be considerable. In one study of people with facial acne scars, about 38% met criteria for clinical depression, and nearly all participants reported that their facial appearance had a large effect on quality of life, particularly around embarrassment and intimacy.3PubMed Central. Depression, body image and quality of life in acne scars That finding is worth keeping in mind: if facial dents are affecting how you feel about yourself, that reaction is extremely common, not a sign you’re being vain about it.
Aging Changes That Create New Hollows
If your face has developed dents or sunken areas that weren’t there in your twenties, age-related structural changes are a likely explanation. Facial aging isn’t just about wrinkles on the surface. Beneath the skin, the bones of your face are slowly resorbing, your fat pads are shifting or shrinking, and your muscles are losing tone. A review of these layered changes describes the process as happening from the “inside out,” involving skeletal remodeling, fat pad atrophy and repositioning, changes in muscle thickness, and skin thinning.4PubMed Central. The Facial Aging Process From the “Inside Out”
The fat loss doesn’t happen evenly across your face. A study using 3D MRI found that buccal fat (the pad in your cheek) and nasolabial fold volume significantly decreased with age, while fat in the upper face stayed relatively stable and infraorbital fat (the area under your eyes) actually increased over time.5PubMed Central. Study on Age-Related Facial Fat Changes Using 3D MRI and a Novel Algorithm This selective pattern explains why aging faces often look hollow in the cheeks and temples while appearing puffy under the eyes. It’s region-specific remodeling, not a uniform deflation.
The bone beneath your face matters just as much. As you age, distinct resorption patterns develop around the eye sockets, the nasal opening, and the jawline.6PubMed Central. Facial bone aging: An update and literature review A CT-based study found that the eye socket floor angle increases with age, midfacial height decreases, and the nasal opening widens, with these changes driven by a resorption center in the back of the upper jaw rather than by a simple rotational movement of the skeleton.7PubMed. The Relationship between Bone Remodeling and the Clockwise Rotation of the Facial Skeleton: A Computed Tomographic Imaging-Based Evaluation The practical result is that even people who maintain their weight and take care of their skin can develop new concavities in the temples, under the cheekbones, or along the jawline simply because the scaffolding underneath has changed.
HIV-Related Lipodystrophy and Other Drug-Induced Facial Wasting
One of the more medically significant causes of facial dents is lipodystrophy, a condition where subcutaneous fat wastes away in specific areas. This is perhaps most widely recognized in people living with HIV who are on antiretroviral therapy. The condition, called HIV-associated lipodystrophy, emerged as a recognized problem in the mid-1990s when effective antiretroviral drugs became available. It involves subcutaneous fat atrophy in certain areas (including the face), abdominal fat buildup, and metabolic changes like abnormal cholesterol and insulin resistance.8PubMed Central. Lipodystrophy in HIV: Evolving Challenges and Unresolved Questions
The facial wasting can be dramatic. Cheeks become deeply hollowed, the temples sink, and the overall appearance changes enough that people sometimes describe it as looking like they’ve aged decades overnight. A review of the condition’s management notes that it encompasses both lipoatrophy and lipohypertrophy along with dyslipidemia and insulin resistance.9PubMed Central. Lipodystrophy in HIV patients: its challenges and management approaches Newer antiretroviral regimens carry a lower risk, but the problem has not vanished entirely, and people who started treatment with older drugs may still live with visible facial wasting.
Beyond HIV medications, facial lipoatrophy can also be a complication of connective tissue diseases. Conditions like lupus erythematosus profundus and morphea can cause localized fat loss in the face.10PubMed Central. Acquired facial lipoatrophy: pathogenesis and therapeutic options Local corticosteroid injections, used widely for joint pain and inflammatory conditions, can also cause subcutaneous fat atrophy and even muscle atrophy at the injection site.11PubMed Central. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection If you’ve had steroid injections near your face or jaw for conditions like TMJ pain, a resulting dent could be from localized fat loss at the injection site.
Parry-Romberg Syndrome and Scleroderma
When a dent appears on just one side of the face and gradually worsens over months or years, two rare but important conditions deserve consideration. Parry-Romberg syndrome is a degenerative disorder of unknown cause that produces slow, progressive atrophy on one side of the face. It typically begins in childhood and advances gradually, with stabilization sometimes taking up to 20 years.12PubMed Central. Parry Romberg Syndrome: A Case Report and an Insight Into Etiology The wasting can affect skin, fat, muscle, and sometimes even bone on the affected side, producing a progressively asymmetric face.
A related condition, scleroderma en coup de sabre, produces a characteristic atrophic lesion that usually runs along the forehead and scalp area, sometimes looking like a linear indentation or scar. The atrophic lesion in the frontoparietal area is considered the hallmark of this condition.13PubMed Central. Neurologic involvement in scleroderma en coup de sabre Both conditions are rare enough that many general practitioners have never seen a case, which can delay diagnosis. If you have a progressive, one-sided indentation that’s deepening over time, particularly if it started in childhood or adolescence, these possibilities are worth raising with a specialist.
Infections That Leave Depressed Scars
Certain infections can leave behind permanent dents in the skin after they heal. Chickenpox is probably the most familiar example in Western countries, but globally, cutaneous leishmaniasis is a significant cause of disfiguring depressed scars, particularly on the face. Leishmaniasis lesions typically heal on their own over time, but the scar they leave behind is characteristically depressed.14PubMed Central. Cutaneous leishmaniasis: A neglected disfiguring disease for women Severe bacterial skin infections and certain fungal infections can also destroy enough underlying tissue to leave a visible depression, particularly when treatment is delayed.
The mechanism is similar to what happens with acne scars: infection triggers inflammation, inflammation destroys subcutaneous tissue, and the body replaces lost volume with scar tissue that sits lower than the surrounding skin. The deeper the infection and the longer it persists, the more pronounced the resulting dent tends to be.
Congenital Dents and Dimples
Not every dent in the face is a problem. Dimples are permanent depressions that many people are born with, and they result from a quirk of facial muscle anatomy rather than any tissue loss. The cheek dimple, specifically, appears to be caused by a split or doubled zygomaticus major muscle. In people with this variant, the inferior bundle of the muscle has an attachment to the skin along its mid-portion, tethering the overlying skin so that smiling pulls it inward and creates a visible dimple.15PubMed. Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation
Preauricular pits are another congenital variant. These tiny openings or dents appear just in front of the ear and are a common incidental finding on routine examinations. They’re usually harmless, though they can occasionally become infected or, in rare cases, may be associated with hearing or kidney anomalies when part of a broader syndrome.16PubMed Central. Ectopic Unilateral Ear Pit in an Otherwise Well-Appearing Child: A Case Report and Literature Review If you’ve had a small pit near your ear your entire life, it’s almost certainly a preauricular pit and nothing to worry about unless it becomes red, swollen, or painful.
Idiopathic Localized Lipoatrophy
Sometimes a small dent appears in the face with no obvious cause: no history of acne, no injection, no injury, no systemic disease. This can be idiopathic localized involutional lipoatrophy, a condition defined as focal loss of subcutaneous fat without any signs of inflammation. A retrospective study of 12 cases noted that the condition can resolve on its own over time.17PubMed Central. Idiopathic Localized Involutional Lipoatrophy: A Retrospective Study of 12 Cases The condition is poorly understood, and it’s diagnosed mainly by ruling out other causes. If imaging and blood work come back normal and the dent isn’t progressing, this diagnosis may apply. The encouraging part is the tendency toward spontaneous regression, meaning the dent may partially or fully fill back in without treatment.
Trauma and Fat Necrosis
A blow to the face, even one you might not remember clearly, can cause fat necrosis: the death of fat cells from trauma. When fat cells die and are eventually reabsorbed, the area can be left with a visible depression. This is particularly true in areas with a thin layer of soft tissue over bone, such as the forehead or the area around the eye socket. Post-traumatic fat necrosis can sometimes be difficult to diagnose initially because the inflammation can mimic other conditions.18PubMed Central. Posttraumatic fat necrosis presented as cellulitis of the leg Surgical procedures on the face, including cosmetic ones, can sometimes leave behind localized depressions if fat is unevenly removed or if healing doesn’t proceed smoothly.
How Doctors Evaluate Facial Dents
If a facial dent is new, worsening, or accompanied by other symptoms, your doctor will typically start with a thorough history. When the dent appeared, whether it’s progressing, whether you’ve had acne, surgery, injections, or facial injuries, and whether you’re taking medications that could cause fat atrophy are all relevant details. A physical exam can often distinguish between a scar (which involves the skin surface) and deeper tissue loss (which suggests fat or bone involvement).
When the cause isn’t clear from examination alone, imaging comes into play. CT and MRI are the tools most commonly used for evaluating the face and can help distinguish bone resorption from fat loss, tumor-related changes, or inflammatory processes.19PubMed Central. Dental findings on face and neck imaging For suspected autoimmune conditions like Parry-Romberg syndrome or scleroderma, blood tests for autoantibodies and sometimes skin biopsies are part of the workup. The key clinical question is whether the dent is stable or progressing, because a stable dent is usually a cosmetic concern while a progressive one may signal an active underlying disease.
Treatment Options for Facial Dents
Treatment depends entirely on the cause, but for the most common scenarios, several approaches exist.
For atrophic acne scars, the standard treatments include laser resurfacing, chemical peels, microneedling, subcision (breaking up the fibrous bands that tether scars downward), and dermal fillers. A newer technique, autologous nanofat grafting, has shown promise for depressed facial scars. A case series evaluating nanofat grafting found that scar measurements were minimized, color and texture improved, and patients reported high satisfaction with the results.20PubMed Central. Evaluating the Efficacy of Facial Scar Treatment Techniques Using Nanofat Grafting: A Case Series The appeal of nanofat grafting is that it uses your own fat, processed into a very fine form, which may help restore both volume and some degree of skin quality.
For age-related volume loss, hyaluronic acid fillers (brands you’d recognize from advertisements) and fat transfer are the workhorses. These don’t stop the underlying bone and fat changes, but they can restore contour by replacing lost volume. The effects of hyaluronic acid fillers typically last six months to two years depending on the product and the area treated, while fat grafting can produce longer-lasting results but involves a surgical harvesting step.
For HIV-associated facial wasting, poly-L-lactic acid injections have become a mainstay treatment. This biostimulatory filler works by prompting your body to produce new collagen over a series of treatment sessions, gradually rebuilding facial volume. For conditions like Parry-Romberg syndrome, treatment focuses on halting the underlying disease process (often with immunosuppressive medications) before addressing the cosmetic deficit, typically through fat grafting or implants once the condition has stabilized.
When a Dent Needs Urgent Attention
Most facial dents are either cosmetic concerns or signs of slow-moving processes that allow time for thoughtful evaluation. A few situations, though, warrant faster action. A dent that appears suddenly after a facial injury, especially with swelling, numbness, or difficulty opening your mouth, could indicate a fracture. A rapidly progressive indentation on one side of the face, particularly in a child or teenager, should be evaluated for Parry-Romberg syndrome or related conditions, because early treatment may limit the extent of tissue loss. And any dent accompanied by changes in skin color, new lumps, or unexplained pain deserves a dermatology or surgical consultation to rule out an underlying mass or inflammatory process.
For everyone else with a facial dent that has been stable for a while, the first step is an honest inventory. If you had acne as a teenager, that’s your most likely answer. If you’re noticing new hollows in your forties or fifties without any history of skin disease, age-related volume change is the probable explanation. And if you’ve had a small dimple near your mouth or ear your entire life, you can stop worrying: you were simply born with an anatomical variant that plenty of people consider attractive.