The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions

Background: Many incisional techniques have been described for access to the craniofacial skeleton for traumatic fracture repair, including subciliary, subtarsal, and transconjunctival approaches. Each is associated with a distinct set of complications. The goal of the authors' study was to examine lower lid malposition associated with these incisional approaches at the authors' institution and in the literature. Methods: A retrospective chart review of all operative orbital and/or zygomatic fractures at the Beth Israel Deaconess Medical Center from 1998 to 2008 was performed. The surgical approach and postoperative lower eyelid complications were noted. A literature review was performed of all peer-reviewed studies in the English language examining the incidence of complications of lower eyelid incisions in operative facial trauma. Results: A total of 180 cases were treated with a lower eyelid incision; these were identified as subtarsal (41 percent), subciliary (31 percent), and transconjunctival (25 percent). The risk of ectropion was highest in subciliary incisions (12.5 percent, p = 0.018); however, only two cases required operative management. Entropion was found in two cases after transconjunctival incisions; both required operative management. Seventeen studies were included in the meta-analysis, representing 2086 patients. The risk of ectropion was highest in subciliary incisions (14 percent), the risk of entropion was highest in transconjunctival incisions (1.5 percent), and the risk of hypertrophic scarring was highest in subtarsal incisions (3.4 percent). A majority of these complications resolved with conservative management. Conclusions: Lower eyelid complications can be seen with all three incisional approaches to facial fracture repair. Based on their findings, the authors favor the subtarsal approach for zygomaticomaxillary fractures and the transconjunctival incision for isolated orbital floor fractures.