Hyaluronic acid fillers and autologous fat grafting for periocular volume restoration: a systematic review and indirect comparison.

PURPOSE: To synthesize patient satisfaction and complication rates reported in separate hyaluronic acid (HA) filler and autologous fat grafting (AFG) cohorts, and to explore indirect differences between modalities.
METHODS: A systematic review was conducted according to PRISMA guidelines and registered with PROSPERO (CRD42025636742). MEDLINE, EMBASE, Cochrane CENTRAL, and Web of Science were searched from inception through January 2025, with an updated search in April 2026. Randomized trials, cohort studies, and case series evaluating HA or AFG in adults were included. Complication proportions were pooled separately for HA and AFG using inverse-variance random-effects models, followed by exploratory cross-modality risk-ratio comparisons when both modalities met the minimum five-cohort threshold. Categorical satisfaction responses and heterogeneous patient-reported outcomes were synthesized descriptively.
RESULTS: Thirty-one studies involving 2,573 patients were included. Swelling was pooled from 23 HA cohorts (21.9%; 95% CI, 12.9%-34.9%; I2 = 92.2%) and six AFG cohorts (60.9%; 95% CI, 20.1%-90.6%; I2 = 89.2%), yielding an exploratory indirect RR of 0.36 (95% CI, 0.15-0.89; p = 0.027). However, the swelling comparison was no longer statistically significant after either 100% AFG swelling cohort was removed. Among patient-level categorical responses, 96.2% of 367 HA responses and 83.6% of 213 AFG responses were satisfied or very satisfied.
CONCLUSIONS: Both HA and AFG were associated with high reported satisfaction, but the available single-arm evidence did not establish a robust difference in complication risk between modalities. These heterogeneous, unanchored findings should be considered hypothesis-generating. Treatment selection should remain individualized, and direct comparative studies using standardized complication definitions, validated patient-reported outcomes, and longer follow-up are needed.