Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned from Functional Anatomy

Background The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying fascial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments. Objectives To evaluate the location and function of the angular vein in the tear trough in three different facial expressions: repose, smiling, and max. orbicularis oculi contraction. Methods Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m 2 were investigated via functional ultrasound imaging. The diameter of the angular vein, the velocity, and direction of venous blood flow were analyzed in repose, smiling and during max. orbicularis oculi contraction. Results The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (= intra-muscular course) within the tear trough whereas the angular artery was not identified in this location. The distance between the angular vein the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/sec and was 7.3 cm/sec at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling. Conclusions The diameter and the venous blood flow of the angular vein varied between the three tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein