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Delivery Method Of Hyaluronic Acid In Infraorbital Region Affects Adverse Events Outcome


Study authors found that injection with a needle resulted in a higher incidence of ecchymosis.

Hyaluronic acid (HA) injections in the infraorbital region are a popular non-surgical treatment to address hollowing in the area. Researchers compared use of the needle to the cannula for infraorbital HA injections to assess incidence ofecchymosis and edema.1 



The systematic review and meta-analysis included 16 prospective clinical trials with participants aged 18 and over. Studies were taken from the databases of PubMed, (United States National Library of Medicine, Bethesda, Maryland), MEDLINE (via Ovid), Scopus (Elsevier, Amsterdam, the Netherlands), the Cochrane Central Register of Controlled Trials (Ovid CENTRAL; Wiley, Hoboken, New Jersey), and Google Scholar.

A meta-regression analysis revealed that study participants treated with a needle (M: 0.228, Std. error: 0.010) experienced a significantly higher rate of ecchymosis, compared to those treated with a cannula (M: 0.016, Std. error: 0.027). Participants treated with a cannula (M: 0.547, Std. error: 0.030) experienced a significantly higher incidence rate of edema, compared to those treated with a needle (M: 0.217, Std. error: 0.010).

Study authors found that in the infraorbital region overall, edema is a more common adverse event than ecchymosis, regardless of whether a needle or cannula is used. Also, the infraorbital region is more prone to chronic or recurrent edema before HA injections due to many factors, including allergies, genetics, and diet. This should factor into a treatment plan.

Study authors also suggest that some of the other factors to consider when deciding on treatment include the quantity of product to be used, the quality and color of the skin envelope, the amount and extension of intra- versus extra-orbital fat, and the differences between the chronological changes of the superficial and deep fat pad. 

One factor that is frequently underestimated is clinician experience. Authors state, “[T]he use of cannulas is more frequent in the novice injector, yet it may lead to more tissue destruction as planes are less respected, and multiple passes lead to a greater incidence of edema, whereas the use of a needle in less experienced hands may lead to a substantially greater incidence of ecchymosis.”1


  1. Nikolis A, Enright KM, Berros P, Sampalis JS. Safety of infraorbital hyaluronic acid injections: Outcomes of a meta-analysis on prospective clinical trials. J Cosmet Dermatol. 2023;00:1-9.doi:10.1111/jocd.15925 

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