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
Background Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral peri-orbital region underscoring the versatility of neuromodulator treatments. Objective To analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. Methods Seventy-five study participants (8 males, 67 females) with a mean age of 37.5 (8.5) years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement using 3-dimensional imaging at baseline, day 14 and day 30. Results 3-dimensional volume analysis revealed an increase in midfacial volume by 0.46 cc, and a decrease of the lower facial volume by 0.30 cc compared to baseline. Additionally, an improvement of midfacial fullness (change of 0.13) and jawline contour (change of 0.44) was reported on clinical rating scales at day 30 compared to baseline. Conclusions Facial soft tissues can be repositioned during the 30 days follow-up period following a neuromodulator treatment; this was reflected through an increase in middle facial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.
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