Best Practices for the Use of High-Frequency Ultrasound to Guide Aesthetic Filler Injections—Part 2: Middle Third of the Face, Nose, and Tear Troughs

The midface is a key area in facial aesthetics, highly susceptible to age-related changes such as fat pad absorption, bone resorption, and loss of skin elasticity. These changes lead to the formation of prominent folds, such as the nasolabial fold. In addition, critical vascular structures and non-vascular components, such as the facial artery, angular artery, and parotid gland, make this region prone to complications during filler injections. High-frequency ultrasound (HFUS) offers real-time, radiation-free visualization of facial anatomy, enabling injectors to accurately target the desired treatment planes and avoid critical structures. This article is the second in a series of articles on ultrasound-guided facial injections and focuses on the midface. It provides a detailed overview of the sonographic anatomy of key areas, including the nose, tear trough, nasolabial fold, zygomatic, and preauricular regions. Step-by-step techniques for ultrasound-guided filler injections are described, emphasizing the importance of scanning both before and during injections to ensure safe filler placement. By using ultrasound in this area, injectors can possibly minimize risks such as vascular occlusion and other complications, such as the Tyndall effect and intra-parotid injection. With ongoing advancements, ultrasound-guided injections are expected to become more refined, enhancing both aesthetic outcomes and patient safety.