Evidence-Based Pyriform Fossa Filler Injection Techniques

Learn how we treat the deep pyriform space, with this Global Evidence Matrix pyriform fossa injection technique case study. 

Addressing maxillary recession in this way restores deep structural support and can soften nasolabial folds. It may not be one of the first filler treatments patients ask for, but it’s a useful one for aesthetic practitioners to have in their toolkit. 

In this article we’ll explore how to treat it with injection techniques based on the latest evidence set out in the Global Evidence Matrix. You’ll learn the optimal tool and filler product selections, based on research, and gain practical tips from Harley Academy’s Founder.

We also use a live GEM© Clinic case study video demonstration, which you can scroll down to watch, to bring these methods to life. A great asset for all you visual learners!

Read on to find out more or skip straight to the end to watch the video which is extracted from a broader case study that’s exclusively available to Harley Pro subscribers to watch in full at HarleyAcademy.ai.

Molly’s Pyriform Fossa Treatment Video Case Study

For the latest in our GEM© Clinic video case study series, showcasing injection technique guidance from the Global Evidence Matrix, we saw Molly, 32. She was treated live on camera at Harley Academy London by Dr Tristan Mehta, Founder and CEO.

Dr Tristan shares, “In our early 30s we start to get reduction in the deep cheek fat, in the anterior cheek and also in the maxilla. So we lose some of this projection and, when assessing Molly, I noticed a bit of maxillary recession that I wanted to focus on.”

Part of a full face treatment plan

Although the extracted video clip shared below focuses on the pyriform fossa, Molly’s full treatment plan also included:

• Temple filler
• Cheek filler, treating the apex and zygomatic arch
• Palpebromalar groove and tear trough filler
• Lip filler.

You can watch her complete case in 4K HD, along with many more, at HarleyAcademy.ai with a Harley Pro subscription. This also unlocks instant access to the full GEM© suite of content, which includes our self-paced online aesthetics course, Certificate in Advanced Filler Techniques. 

Fun fact: Healthcare professionals receive a free 12-month subscription to Harley Pro when signing up for any of our JCCP-approved and Ofqual-regulated Level 7 Diploma aesthetics courses. This includes our Level 7 Diploma in Cosmetic Injectables, our Fast Track Level 7 Diploma and our combined Level 7+.

Pyriform fossa treatments are not for complete novices so you won’t be injecting them from day one. They are covered in our Level 7 courses, however, as well as on HarleyAcademy.ai. 

Needle or Cannula: Which is Best for Pyriform Fossa Filler?

You’ve completed your full consultation, assessed your patient and gained informed consent. The scene is set and you’re ready to start your pyriform fossa treatment. 

First, prepare the face properly

You carry out a full clinical cleanse, including the nose, to ensure all traces of makeup are removed. As you’ll hear Dr Max Greenfield, Head of Clinical Training at Harley Academy, share in the video below, remembering to clean the sides of the nose thoroughly is vital. Should a vascular event occur after treating the pyriform fossa, pallor can be seen in the nose wall, so this needs to be unobscured by makeup.

Next you map the landmarks for your injections. We’ve previously written about how to locate the pyriform fossa if you need a reminder. 

Needle vs cannula 

Now, what’s your tool of choice? Is a needle or a cannula better when treating the pyriform fossa? The answer is, you can use either. Research backs use of a 25G needle in layer 5 or using a 22G cannula in layer 4 when injecting hyaluronic acid-based filler products.

How you choose which to go with depends largely on your own personal preference and cannula confidence. 

You should also consider precision. Using a needle allows for a direct perpendicular “hit” onto the periosteum, which is great for exact bolus placement.

A 22G cannula is often selected to reduce the risk of arterial penetration given the angular artery’s depth is highly variable in this region. This is something Dr Tristan explains in this case study clip, and which we touch on below.

What’s the Best Filler Product for This Treatment?

The deep pyriform space requires a high Gprime filler product to address bony recession. For Molly’s case study, Dr Tristan uses Revanesse Shape.

The reason the research favours this particular viscosity is because you’re depositing the filler directly onto or adjacent to the maxilla. A stiffer, high Gprime filler can give the mechanical lift you need to soften the nasolabial fold closest to the nasal ala from a deep plane.

Want to know more about Gprime? Create a free account at HarleyAcademy.ai and ask our Assistant. This AI-powered tool draws exclusively from Harley Academy’s own knowledge bank and published research to answer all your queries. Just look for the purple circle with a white star to activate the Assistant and start learning!

You may also find our article on knowing your Gprime helpful.

Pyriform Fossa Filler Injection Techniques

As we’ve mentioned above, there are two different approaches you can take to treating the deep pyriform space. Each requires a high Gprime filler and both require staying medial to the infraorbital foramen to avoid nerve injury or vascular trauma.

One is in layer 4 with a 22G cannula, the other, which we’re showcasing in this case study, is injecting down onto bone using an unprimed 25G needle. 

Watch Dr Tristan using a TSK needle to soften Molly’s nasolabial fold and address the maxilla which, he notes, “slightly retrudes and resorbs with the ageing process”.

Aspirate first

“We find where the bone is closest to the surface of the skin,” says Dr Tristan. “Then, with our bevel facing upwards, we make a 45° angle, touch down on bone. And then keep it very, very still”. You then aspirate.

As we’ve mentioned, vessels in the nasolabial fold and pyriform fossa region are unpredictable. “On ultrasound studies they've been shown to be just under the skin generally, but they can be down on bone,” he warns. 

Because of this, some aesthetic practitioners are using ultrasound to image these regions. However, you need to be skilled in reading this imaging before you decide to go down this route. Ultrasound is just one precaution you can take to manage the heightened unpredictability of the vasculature in this region.

Injecting the pyriform fossa

“When I'm injecting the pyriform fossa, I’m using a supraperiosteal bolus injection technique. I'm also looking at the side wall of the nose,” reiterates Dr Tristan. “I'm just checking for any blanching because that's where the angular artery will show if there's been any complication.”

Avoiding the angular artery

As he injects, he stays medial to the infraorbital foramen, given the riskiness of this area. Whilst the infraorbital neurovascular bundle and facial artery are considerations, it is the angular artery that's the primary concern.

In the minority of cases, this connects to the ophthalmic artery. Intravascular injection can lead to retrograde embolisation and blindness, which is why beginners should avoid injecting the deep pyriform space. 

This is considered a ‘Stage 2’ treatment in the Global Evidence Matrix. The criteria for each of these levels - Stages 1 to 3 - are backed by published research which Harley Academy was involved with alongside a team of esteemed anatomists, researchers and educators. Stage 2 relates to a clinician who can demonstrate:

• Advanced anatomical understanding. A detailed grasp of "danger zones," including the depth and variability of specific neurovascular structures such as the angular artery
• Tactile proficiency. This relates to techniques which often require the ability to feel for specific tissue resistance or "pops" when transitioning between layers. For example, perforating the orbicularis oculi muscle to reach the deep interlaminar fat
• Specific device mastery. Stage 2 often involves the use of cannulas in delicate areas or needles in deep supraperiosteal planes (Layer 5) where aspiration and precise bone contact are mandatory
• Risk mitigation skills. The aesthetic practitioner must be able to identify and manage more complex medical risks, such as vascular compromise or glandular trauma, and aesthetic risks including the Tyndall effect or malar oedema
• Prerequisite completion. It’s generally expected that a clinician has mastered Stage 1 foundational filler injection techniques, such as basic midface volumisation, before progressing to Stage 2 areas including the tear trough or pre-auricular region.

Watch the Case Study Video

As you’ll see, both Dr Tristan and, most importantly, his patient, were pleased with the outcome. Molly felt she looked “refreshed” with “way less shadows”. These are the small details your patients will pick up on. 

We hope you enjoy this learning opportunity and case observation. If you have any questions, feel free to put them in the chatbot in the corner of this screen. Alternatively, if you’re looking for guidance on the best medical aesthetics training courses for you, or how to access our wealth of digital resources, WhatsApp our team now.

All information correct at time of publication