In an adult without active skin infection, coagulopathy, recent nasal surgery, or hyaluronic‑acid (HA) filler allergy, what is the safest first‑line dermal filler type, volume, and injection technique for aesthetic augmentation of the pyriform aperture?

Pyriform Aperture Augmentation with Dermal Fillers

First-Line Recommendation

For aesthetic augmentation of the pyriform aperture, use large-particle hyaluronic acid (LP-HA) filler as the first-line agent, injecting 0.3–0.5 mL per side at the periosteal level using a 30-gauge needle with slow, retrograde technique to correct bony resorption in this region. 1

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Product Selection: Why Large-Particle HA is Superior

• Large-particle HA demonstrates significantly better efficacy for correcting bony resorption in the nasal pyriform region compared to small-particle formulations. 1
• LP-HA requires 61% less volume than small-particle HA to achieve equivalent correction (one-grade WSRS improvement), making it more efficient for structural augmentation. 1
• The pyriform aperture represents a bony deficiency that requires a filler with high elasticity, cohesiveness, and good adaptability—properties characteristic of LP-HA products designed for deep structural support. 2
• HA fillers provide volumizing effects lasting 6–18 months in nasal applications, with established safety profiles across multiple anatomic regions. 3, 4

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Injection Technique: Critical Safety Protocol

Depth and Placement

• Inject at the periosteal or perichondrial level—this deep placement minimizes risk of intravascular injection in the complex nasal vasculature. 2
• The injection must be above the orbicularis oris muscle to avoid vascular complications, particularly given the proximity to facial arterial branches. 3
• Use visible blanching or resistance as tactile feedback confirming proper periosteal placement. 2

Needle Selection and Approach

• Use a 30-gauge, 4–8mm needle inserted at a shallow angle with the bevel facing upward. 5, 6
• A 25-gauge cannula may be considered as an alternative to reduce bruising risk, though needle technique allows more precise periosteal placement. 3

Volume and Injection Dynamics

• Inject 0.3–0.5 mL per side of the pyriform aperture, using small aliquots (0.05–0.1 mL per pass). 3, 2
• Use slow, low-pressure, low-volume injections in a retrograde fashion to minimize vascular compression and allow early detection of complications. 2
• Aspirate before each injection to detect intravascular placement, though negative aspiration does not guarantee extravascular positioning. 5

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Alternative Option: Autologous Platelet Concentrates

When to Consider APCs

• APCs (including PRF and Bio-Filler formulations) offer superior biocompatibility and eliminate risks of allergic reactions or prolonged vascular occlusion associated with cross-linked HA fillers. 7, 8
• However, APCs provide rejuvenation effects rather than significant structural volumization—the 3D volumizing effect does not persist beyond 3–4 months, compared to 6–18 months for HA fillers. 3, 8

APC Limitations for Pyriform Augmentation

• The pyriform aperture requires structural support to correct bony resorption, making LP-HA the superior choice for this specific indication. 1
• APCs are better suited for superficial skin quality improvement (texture, color, moisture) rather than deep structural augmentation. 7, 3
• If APCs are used, inject 0.2–0.5 mL per quadrant using 27–30 gauge needles, though expect limited volumizing persistence. 3

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Safety Considerations and Adverse Events

Expected Treatment-Related Effects

• Warn all patients about bruising, swelling, and tenderness—these are the most frequent treatment-related effects and are mild to moderate, resolving within days to weeks. 3
• Pain during injection is common but self-limited. 3

Serious Complications

• Serious adverse events with HA fillers are uncommon (8 events in 4,605 patients across multiple studies), with most considered unrelated to treatment. 4
• The nasal region carries elevated risk due to complex vasculature, but proper deep periosteal injection technique minimizes intravascular placement. 2
• No serious complications were reported in over 250 patients treated with HA for nasal reshaping over a 15-year period when proper technique was employed. 9

Emergency Recognition and Management

• Visual changes or eye pain represent ophthalmic artery involvement and constitute a medical emergency requiring immediate hyaluronidase administration. 5
• Have hyaluronidase immediately available: inject 0.1–0.2 mg/kg (up to 10 mg diluted in 10 mL of 0.9% sodium chloride) intradermally at the affected site if vascular occlusion is suspected. 5

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Clinical Outcomes and Retreatment

• The aesthetic effect of HA in the nasal region persists for >1 year in most patients, with some patients maintaining results for >5 years, though individual variation exists. 9
• Retreatment rates of approximately 43% are reported for nasal HA applications, typically for additional refinement rather than loss of all correction. 9
• Patient satisfaction rates exceed 84% for nasal HA augmentation when proper technique and product selection are employed. 6
• Touch-up treatments may be needed in 44% of patients, typically performed 2 weeks after initial treatment. 6

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Critical Pitfalls to Avoid

• Do not inject superficially in the pyriform region—this increases vascular complication risk and fails to address the underlying bony deficiency. 2, 1
• Do not use small-particle HA for pyriform augmentation—it requires 61% more volume and demonstrates inferior efficacy for bony resorption correction. 1
• Do not use APCs when structural volumization is the primary goal—their volumizing effect is inadequate for correcting pyriform aperture deficiency. 3, 8
• Do not inject large boluses—use incremental small aliquots to allow early complication detection and minimize tissue distortion. 5, 2
• Do not proceed without discussing realistic expectations about bruising and swelling, which are nearly universal in nasal filler treatments. 3