Eyelid Complications in Subciliary Versus Transconjunctival Approaches to Orbital and Zygomaticofacial Fractures: A Meta-Analysis
1
Department of Ophthalmology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
2
Doctoral Program in Translational Medicine, National Chung Hsing University, Taichung 402202, Taiwan
3
School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
4
Program of Biomedical Informatics and Data Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
5
School of Medicine, Chung Shan Medical University, Taichung 402306, Taiwan
6
Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou 545402, Taiwan
7
Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei 112303, Taiwan
8
School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
9
Section of Infectious Diseases, Taipei City Hospital, Heping Fuyou Branch, Taipei 100058, Taiwan
10
Institute of Public Health, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2025, 14(18), 6431; https://doi.org/10.3390/jcm14186431
Submission received: 31 July 2025
/
Revised: 1 September 2025
/
Accepted: 10 September 2025
/
Published: 12 September 2025
(This article belongs to the Section Ophthalmology)
Abstract
Background/Objectives: Eyelid complications such as ectropion, entropion, scleral show, and visible scarring can lead to significant cosmetic and functional concerns following orbital and zygomaticofacial fracture repair. The subciliary and transconjunctival approaches are commonly used, but their relative complication risks remain debated. This study aimed to compare the risk of postoperative eyelid complications between these two approaches. Methods: A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines. The study protocol was registered with PROSPERO (CRD420251089460). PubMed, EMBASE, and the Cochrane Library were searched for studies published between 1 January 1990 and 15 June 2025. Data on study design, patient demographics, and complication rates were extracted following the PRISMA guidelines. The Newcastle–Ottawa scale was used for quality assessment. A random effects meta-analysis was performed using Comprehensive Meta-Analysis software (v4.0), and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: Nineteen studies involving 2103 patients (1062 subciliary; 1041 transconjunctival) were included for analysis. The subciliary approach was associated with significantly higher risks of ectropion (OR = 2.94; 95% CI: 1.63–5.31), scleral show (OR = 2.33; 95% CI: 1.12–4.84), and visible scar (OR = 5.62; 95% CI: 1.65–19.18). In contrast, the transconjunctival approach carried a higher risk of entropion (OR = 0.17; 95% CI: 0.07–0.42). Between-study heterogeneity and publication bias were minimal. Conclusions: As compared with the transconjunctival approach, the subciliary incision is associated with higher risks of ectropion, scleral show, and scarring, whereas the transconjunctival approach carries a greater risk of entropion. These findings may help guide surgical decision-making and patient counseling regarding postoperative outcomes.
1. Introduction
Orbital and zygomaticofacial fractures are common in high-energy trauma, such as motor vehicle accidents, physical assault, and industrial incidents [1]. Surgical intervention is frequently required to restore the anatomical integrity, orbital function, and cosmetic appearance of these fractures. The infraorbital rim, orbital floor, and zygomatic bone are typically accessed via external or internal surgical approaches, among which the subciliary and transconjunctival techniques are the most widely used [2].
Although both the subciliary and transconjunctival approaches have long been used to manage orbital or zygomatic fractures, there is an ongoing debate regarding which technique is associated with superior surgical outcomes [3,4]. The subciliary approach, introduced in the mid-20th century, provides excellent exposure but might be associated with a risk of postoperative ectropion, visible scarring, and scleral show [5]. In contrast, the transconjunctival approach has gained popularity due to its hidden incision, which minimizes visible scarring. However, concerns remain regarding entropion, limited exposure, and technical complexity, particularly in the context of extensive zygomaticomaxillary complex fractures [2,6].
Postoperative eyelid complications can result not only in cosmetic concerns but also in an increased risk of ocular surface diseases, such as conjunctivitis or corneal ulcers, which require medical or surgical intervention [7,8]. Previous studies have compared the risk of postoperative eyelid complications between the subciliary and transconjunctival approaches [3,6,9,10,11,12,13,14]. However, most of these studies included fewer than 50 patients per group, which makes it difficult to determine accurately the incidence or relative risk of eyelid complications. Although published review articles or meta-analyses have suggested that the transconjunctival approach is associated with a lower risk of ectropion and visible scarring but a potentially higher risk of entropion, several studies published in the past two years were not included in those analyses [5,15,16,17].
Given the clinical importance of minimizing postoperative eyelid deformities, we conducted this meta-analysis to systematically compare the incidence of eyelid complications. We evaluated specific complications of interest including ectropion, entropion, scleral show, and visible scars. This study integrates the latest available evidence to help surgeons better understand the risks associated with each surgical approach. This information can support more informed, evidence-based discussions with patients during preoperative planning for maxillofacial and oculoplastic surgery.
2. Materials and Methods
2.1. Search Strategy
We conducted this study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines provided in PRISMA 2020 checklists. The study was registered in PROSPERO on 7 July 2025 and the protocol including amendments can be accessed in the PROSPERO database (CRD420251089460). The ethical review board approval or participant informed consent was waived. We searched PubMed, EMBASE, and Cochrane databases for studies published from 1 January 1990 to 15 June 2025, using the following keywords: (zygomatic OR zygomaticomaxillary OR facial) AND fracture AND ectropion. We screened studies by first examining the titles and abstracts and then scrutinizing the full texts. We also manually searched the relevant literature in the bibliographies.
2.2. Inclusion and Exclusion Criteria
We included only peer-reviewed journal articles. The inclusion criteria were original prospective or retrospective clinical studies that compared eyelid complications after subciliary and transconjunctival approaches for orbital or zygomaticofacial fractures. We excluded reviews, meta-analyses, or studies with fewer than ten cases in either group. Two researchers (Y.-Y. Chen and T.-Y. Chen) independently assessed the articles. A third researcher (Y.-J. Lai) was consulted if consensus was not reached.
2.3. Quality Assessment
We applied the Newcastle–Ottawa scale as the evaluation tool for methodological quality, which included cohort adequacy selection, study comparability, and outcome assessment. Two researchers (Y.-Y. Chen and T.-Y. Chen) independently evaluated the quality of the included articles. When discrepancies occurred, a third researcher (Y.-J. Lai) reassessed the data and made the final decision.
2.4. Data Extraction
The following data were tracked from each included article: first author, year of publication, number/age of participants, and duration of follow-up. We also recorded the percentage of postoperative complications, including ectropion, entropion, scleral show, and scar.
2.5. Statistical Analysis
We performed the meta-analysis using the Comprehensive Meta-Analysis software, version 4.0 (Biostat, Englewood, NJ, USA). First, we calculated the odds ratios (ORs) for each complication (ectropion, entropion, scleral show, and scar) between the subciliary and transconjunctival groups in each study. Then, we pooled the ORs from each study to obtain the overall ORs. Thus, we could then identify the surgery that was favored. We determined the heterogeneity among the studies using the I2 statistic, with an I2 statistic of ≥50% representing high heterogeneity. Funnel plots and Egger’s test were used to assess publication bias. We also conducted a sensitivity analysis to assess whether the exclusion of any single study would alter the statistical significance of our findings.
3. Results
3.1. Search Results
Figure 1 shows the PRISMA flow diagram. The PRISMA 2020 checklists is presented in Supplementary Table S1. We initially identified 160 studies. After eliminating duplicated articles (n = 63), we removed nonrelevant studies by screening titles and abstracts (n = 69). We then performed a full-text review. Review articles (n = 2), meta-analysis (n = 3), and studies with fewer than 10 cases in each group (n = 1) were excluded. The excluded studies and reasons are presented in Supplementary Table S2. We also excluded papers that were not written in English (n = 3). Finally, we included 19 studies in our meta-analysis [3,9,10,11,12,13,16,18,19,20,21,22,23,24,25,26,27,28,29].
3.2. Evaluation of the Quality of Included Studies
As shown in Table 1, quality assessment using the Newcastle–Ottawa scale indicated that all included studies had high methodological quality, with six studies achieving the maximum score of nine stars and the remaining receiving eight stars. The most critical item was comparability evaluation, which is a weak point of retrospective studies without randomization. The high score achieved by all included studies ensures the robustness and reliability of our meta-analysis.
3.3. Characteristics of the Included Studies
Table 2 summarizes the characteristics of the included studies. Of the included studies, 13 were retrospective, 5 were randomized, and 1 was a prospective nonrandomized clinical study. A total of 2103 patients were enrolled, with 1062 patients in the subciliary group and 1041 in the transconjunctival group.
3.4. Outcome Assessment
Table 3 presents the complications according to the subciliary and transconjunctival approaches in each study. The main complications were ectropion, entropion, scleral show, and scar. The majority of the included studies (15 of 19) involved orbital floor reconstruction [3,9,10,11,12,13,16,19,20,21,22,23,24,25,26]. Figure 2 shows the pooled analyses comparing the risk of these complications between the subciliary and transconjunctival approaches. All p values were less than 0.05.
3.4.1. Ectropion
Seventeen studies reported postoperative ectropion [3,9,10,11,12,13,16,20,21,22,23,24,25,26,27,28,29]. There was a significant increase in the pooled risk of ectropion in patients who underwent the subciliary approach compared with the transconjunctival approach (OR = 2.94, 95% confidence interval [CI]: 1.63–5.31).
3.4.2. Entropion
We included ten studies in the analysis of postoperative entropion [9,10,12,16,18,20,21,26,27,29]. The pooled results showed a significantly lower risk of entropion in patients who underwent the subciliary approach compared with those who received the transconjunctival approach (OR = 0.17, 95% CI: 0.07–0.42).
3.4.3. Scleral Show
3.4.4. Scar
Standardized evaluation scales commonly used for assessing lower eyelid scars include the Visual Analog Scale (VAS), the Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale (VSS), and the Manchester Scar Scale (MSS). Table 4 summarizes the scar assessment methods applied in the included studies. Among them, only one study utilized an internationally standardized scale (VAS) [28]. One study relied on a patient-reported satisfaction scale [18], which is subjective and presents outcomes as either satisfactory or unsatisfactory. The studies by Patel, Ridgway, and Salgarelli employed a binary visible scar assessment, reporting solely the presence or absence of a scar [3,16,19]. Mohamed’s study adopted the simplified Feldman scar esthetic score, which is a non-standardized, single-dimension tool that evaluates scar visibility only [10].
3.5. Heterogeneity and Publication Bias
All analyses revealed low between-study heterogeneity, with I2 values of 3.54%, <0.001%, 43.19%, and <0.001%, corresponding to ectropion, entropion, scleral show, and scar, respectively. All p values were greater than 0.05.
With regard to publication bias, Figure 3 shows the funnel plots of all analyses. The p values of Egger’s test were 0.33, 0.24, 0.91, and 0.16, corresponding to ectropion, entropion, scleral show, and scar, respectively; therefore, there were no significant publication biases.
3.6. Sensitivity Analysis
The results showed that removing any single study did not affect the significance of our findings.
4. Discussion
In this meta-analysis, we included 19 studies focusing on the comparison of eyelid complications between the subciliary and transconjunctival approaches for orbital and zygomaticofacial fractures. The group undergoing the subciliary approach had a significantly higher risk of postoperative ectropion, scleral show, and scar as compared with the transconjunctival group. Conversely, patients who received the transconjunctival approach had a significantly higher risk of entropion than those who underwent the subciliary approach did.
With regard to the forest plot of ectropion, 15 of 17 studies reported higher odds of ectropion in the subciliary group than in the transconjunctival group [3,9,10,11,12,13,16,18,19,21,22,23,24,25,26,27,29]. However, only one study reported a marginal statistically significant result (p value = 0.04) [20]. The insignificant OR might be due to the wide confidence interval, which covers the OR point equal to one. This emphasizes the strength of the meta-analysis. Because we pooled all of the studies in this research, we were able to obtain a large number of cases, thus increasing the power of our statistics. Our meta-analysis revealed a significantly increased risk of postoperative ectropion with the subciliary approach compared with the transconjunctival approach. The pooled OR was 2.94 (1.63–5.31), which was similar to that reported in the meta-analysis conducted by AI-Moraissi et al., who found an OR of 3.54 (1.28–9.83) [30].
With regard to postoperative entropion, all included studies showed a lower risk of entropion in the subciliary group than in the transconjunctival group, although none of these results were statistically significant. The OR in our study was 0.17 (0.07–0.42), which is significant, as was shown in a previous meta-analysis conducted by Zhang and AI-Moraissi [2,17]. There are several reasons why the transconjunctival approach induces entropion [6,13,23,31]. First, making an incision in the conjunctiva increases the risk of conjunctival scar, shortens the posterior lamella, and inverts the eyelid. In addition, disrupting or shortening the retractors can cause inward rotation of the eyelid margin. Furthermore, anterior migration or overriding of the orbicularis muscle results in eyelid inversion.
When the lower eyelid rests too low, the white sclera is exposed, which results in scleral show. The scleral show was not significantly different between the subciliary and transconjunctival approaches in every included study. However, when we pooled the results of all these studies, scleral show was marginally significantly higher in the subciliary group. A subciliary incision often extends through or near the orbicularis oculi muscle and septum, which are critical for eyelid tone and position. In addition, healing after surgery causes fibrosis contracture in the deeper tissues, leading to eyelid retraction that exposes the inferior sclera.
Our meta-analysis also revealed a significantly higher risk of scarring in the subciliary group than in the transconjunctival group. This is similar to the findings of previous meta-analyses conducted by AI-Moraissi and Zhang [2,17]. It is noteworthy that the included studies used the subjective descriptions of surgeons or patients to define scar severity [3,10,16,18,19]. Strictly speaking, we need a standardized and objective method to evaluate scar severity. In the study conducted by Haghighat et al. in 2017, the authors applied the 10-unit visual analog scale (VAS) to quantify the appearance of the scar [25]. In Haghighat’s study, zero indicated no scar and ten was considered the worst scar possible. The use of the VAS in more research in the future would improve the comparability among studies.
When assessing the overall risk of eyelid malposition, including ectropion, entropion, scleral show, and scar, the transconjunctival approach has an advantage over the subciliary approach. Ectropion is the most common eyelid complication after the subciliary approach. Predisposing factors for postoperative ectropion in the subciliary group include old age and lower eyelid laxity. For example, in the study by Ridgway et al. conducted in 2009, only 1 of 56 patients in the subciliary group required surgery for correction of postoperative ectropion, and that patient was the oldest in the subciliary group. Ridgway et al. also suggested in that older patients with lower-lid laxity, preventative measures should be adopted to reduce the risk of ectropion, such as cheek suspension, frost/tarsorrhaphy suture, or tarsal strip procedures. In addition, conservative, postoperative management with taping and massage is generally effective in improving ectropion [16].
To the best of our knowledge, no studies have specifically examined the correlation between postoperative ectropion and visible scarring. Ectropion is commonly attributed to contracture of the anterior lamella, suggesting that scarring and ectropion may share similar underlying mechanisms. However, clinical evidence indicates that the presence of one does not necessarily imply the occurrence of the other. For example, Vaibhav and Salgarelli reported that in their subciliary groups, the rate of postoperative ectropion was zero, whereas the rates of visible scarring were 10% and 17.5%, respectively. Similarly, Hasan et al. observed that postoperative ectropion tended to resolve over time, while scarring persisted, further implying that the two complications do not always co-occur [32]. Consequently, most studies report these outcomes separately, without testing their statistical association. Future research should include both scar assessments and ectropion, followed by regression analysis to clarify their potential correlation.
It is noteworthy that reconstruction of the orbital floor likely involves greater tissue exposure and tension, which may increase the risk of eyelid complications compared with surgeries limited to the infraorbital rim. Consequently, inclusion of patients with or without orbital floor reconstruction could confound complication rates. In our analysis, however, the majority of included studies (15 of 19) involved orbital floor reconstruction. Importantly, exclusion of the four studies without orbital floor reconstruction did not alter the overall results.
The limitation of our research is that we included only six randomized clinical studies. Most of the published studies had a retrospective design and might have confounding variables in the decision as to which surgical approach to perform. Prospective, randomized clinical studies are needed in the future; therefore, meta-analysis including more randomized studies could result in more objective conclusions. The strengths of our research are its completeness, as we pooled a large number of cases to provide convincing evidence. Our results can serve to remind surgeons to be aware of the risks of various eyelid complications before surgery and communicate meticulously with patients during the decision-making process.
5. Conclusions
This meta-analysis demonstrated that the subciliary approach for orbital and zygomaticofacial fracture repair carries significantly higher risks of postoperative ectropion, scleral show, and visible scarring, whereas the transconjunctival approach is associated with a greater risk of entropion. These findings underscore that no single approach is without complications, and surgical decisions should balance the advantages of exposure with the potential for eyelid malposition. Importantly, most of the included studies involved orbital floor reconstruction, and excluding those without such procedures did not alter the results, suggesting robustness of the findings. Nevertheless, the predominance of retrospective studies highlights the need for additional prospective, randomized trials using standardized outcome measures, particularly for scar assessment. Until such evidence is available, our results can serve to guide surgeons in selecting the most appropriate surgical approach and in counseling patients regarding expected postoperative outcomes.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/jcm14186431/s1, Table S1: PRISMA 2020 Checklist; Table S2: Excluded studies and reasons.
Author Contributions
Conceptualization, Y.-Y.C. and Y.-J.L.; methodology, Y.-Y.C. and T.-Y.C.; validation, Y.-F.Y.; formal analysis, Y.-Y.C. and T.-Y.C.; investigation, Y.-J.L. and Y.-F.Y.; resources, Y.-Y.C.; writing—original draft preparation, Y.-Y.C. and T.-Y.C.; writing—review and editing, T.-Y.C.; visualization, Y.-J.L. and T.-Y.C.; funding acquisition, Y.-Y.C. All authors have read and agreed to the published version of the manuscript.
Funding
This work was supported by the Taichung Veterans General Hospital TCVGH-1136901B and TCVGH-1142201B.
Institutional Review Board Statement
This is a meta-analysis study. The Taichung Veterans General Hospital Research Ethics Committee have confirmed that no ethical approval is required.
Informed Consent Statement
This is a meta-analysis study. Informed consent is not applicable.
Data Availability Statement
Data analyzed in this study were a re-analysis of existing data openly available in works cited in the reference section.
Acknowledgments
We would like to acknowledge the Taichung Veterans General Hospital for their database resources.
Conflicts of Interest
The authors declare no conflicts of interest. The funders had no role in the design of the study, nor in the collection, analyses, or interpretation of the data. Neither did they have a role in the writing of the manuscript, nor in the decision to publish the results.
Abbreviations
The following abbreviations are used in this manuscript:
| Ors | Odds Ratios |
| Cis | Confidence Intervals |
| VAS | Visual Analog Scale |
References
- Zingg, M.; Chowdhury, K.; Lädrach, K.; Vuillemin, T.; Sutter, F.; Raveh, J. Treatment of 813 zygoma-lateral orbital complex fractures. New aspects. Arch. Otolaryngol.-Head Neck Surg. 1991, 117, 611–620. [Google Scholar] [CrossRef]
- Al-Moraissi, E.A.; Thaller, S.R.; Ellis, E. Subciliary vs. Transconjunctival approach for the management of orbital floor and periorbital fractures: A systematic review and meta-analysis. J. Cranio-Maxillo-Facial Surg. 2017, 45, 1647–1654. [Google Scholar] [CrossRef]
- Patel, P.C.; Sobota, B.T.; Patel, N.M.; Greene, J.S.; Millman, B. Comparison of transconjunctival versus subciliary approaches for orbital fractures: A review of 60 cases. J. Cranio-Maxillofac. Trauma 1998, 4, 17–21. [Google Scholar]
- Gooris, P.J.J.; Jansen, J.; Bergsma, J.E.; Dubois, L. Evidence-based decision making in orbital fractures: Implementation of a clinical protocol. Atlas Oral Maxillofac. Surg. Clin. N. Am. 2021, 29, 109–127. [Google Scholar] [CrossRef]
- Palavalli, M.H.; Huayllani, M.T.; Gokun, Y.; Lu, Y.; Janis, J.E. Surgical approaches to orbital fractures: A practical and systematic review. Plast. Reconstr. Surg. Glob. Open 2023, 11, e4967. [Google Scholar] [CrossRef]
- Ridgway, E.B.; Chen, C.; Lee, B.T. Acquired entropion associated with the transconjunctival incision for facial fracture management. J. Craniofacial Surg. 2009, 20, 1412–1415. [Google Scholar] [CrossRef]
- Liu, S.H.; Chen, Y.Y.; Nurmatov, U.; van Schayck, O.C.P.; Kuo, I.C. Antibiotics versus placebo for acute bacterial conjunctivitis: Findings from a cochrane systematic review. Am. J. Ophthalmol. 2024, 257, 143–153. [Google Scholar] [CrossRef]
- Thevi, T.; Abas, A.L.; Dua, H.S. Amniotic membrane graft (amg) for persistent epithelial defects following infective corneal ulcers and keratitis— A systematic review. Indian J. Ophthalmol. 2025, 73, S361–S368. [Google Scholar] [CrossRef] [PubMed]
- Bronstein, J.A.; Bruce, W.J.; Bakhos, F.; Ishaq, D.; Joyce, C.J.; Cimino, V. Surgical approach to orbital floor fractures: Comparing complication rates between subciliary and subconjunctival approaches. Craniomaxillofacial Trauma Reconstr. 2020, 13, 45–48. [Google Scholar] [CrossRef]
- Mohamed, F.I.; Reda, H.M.; Khalifa, G.A. Anthropometric changes in the morphology of the lower eyelid after using three different approaches in patients with orbital fractures. J. Cranio-Maxillo-Facial Surg. 2020, 48, 985–993. [Google Scholar] [CrossRef] [PubMed]
- Appling, W.D.; Patrinely, J.R.; Salzer, T.A. Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair. Arch. Otolaryngol.-Head Neck Surg. 1993, 119, 1000–1007. [Google Scholar] [CrossRef]
- Mehrnoush, M.R.; Amir, J.A.; Hamed, Z.; Narges, H. The incidence of common complications, including ectropion and entropion, in transconjunctival and subciliary approaches for treatment of zmc fractures. J. Dent. 2021, 22, 76–81. [Google Scholar]
- Trevisiol, L.; D’Agostino, A.; Gasparini, S.; Bettini, P.; Bersani, M.; Nocini, R.; Favero, V. Transconjunctival and subciliary approach in the treatment of orbital fractures: A study on oculoplastic complication. J. Clin. Med. 2021, 10, 2775. [Google Scholar] [CrossRef]
- Raschke, G.; Djedovic, G.; Peisker, A.; Wohlrath, R.; Rieger, U.; Guentsch, A.; Gomez-Dammeier, M.; Schultze-Mosgau, S. The isolated orbital floor fracture from a transconjunctival or subciliary perspective-a standardized anthropometric evaluation. Med. Oral Patol. Oral Cir. Bucal 2016, 21, e111–e117. [Google Scholar] [CrossRef]
- Pandya, R.P.; Deng, W.; Hodgson, N.M. Current guidelines and opinions in the management of orbital floor fractures. Otolaryngol. Clin. N. Am. 2023, 56, 1101–1112. [Google Scholar] [CrossRef]
- Ridgway, E.B.; Chen, C.; Colakoglu, S.; Gautam, S.; Lee, B.T. The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast. Reconstr. Surg. 2009, 124, 1578–1586. [Google Scholar] [CrossRef]
- Zhang, J.; He, X.; Qi, Y.; Zhou, P. The better surgical timing and approach for orbital fracture: A systematic review and meta-analysis. Ann. Transl. Med. 2022, 10, 564. [Google Scholar] [CrossRef]
- Vaibhav, N.; Keerthi, R.; Nanjappa, M.; Ashwin, D.P.; Reyazulla, M.A.; Gopinath, A.L.; Ghosh, A. Comparison of ‘sutureless’ transconjunctival and subciliary approach for treatment of infraorbital rim fractures: A clinical study. J. Maxillofac. Oral Surg. 2016, 15, 355–362. [Google Scholar] [CrossRef]
- Salgarelli, A.C.; Bellini, P.; Landini, B.; Multinu, A.; Consolo, U. A comparative study of different approaches in the treatment of orbital trauma: An experience based on 274 cases. Oral Maxillofac. Surg. 2010, 14, 23–27. [Google Scholar] [CrossRef] [PubMed]
- Raschke, G.; Rieger, U.; Bader, R.D.; Schaefer, O.; Guentsch, A.; Schultze-Mosgau, S. Outcomes analysis of eyelid deformities using photograph-assisted standardized anthropometry in 311 patients after orbital fracture treatment. J. Trauma Acute Care Surg. 2012, 73, 1319–1325. [Google Scholar] [CrossRef] [PubMed]
- Pausch, N.C.; Sirintawat, N.; Wagner, R.; Halama, D.; Dhanuthai, K. Lower eyelid complications associated with transconjunctival versus subciliary approaches to orbital floor fractures. Oral Maxillofac. Surg. 2016, 20, 51–55. [Google Scholar] [CrossRef] [PubMed]
- Neovius, E.; Clarliden, S.; Farnebo, F.; Lundgren, T.K. Lower eyelid complications in facial fracture surgery. J. Craniofacial Surg. 2017, 28, 391–393. [Google Scholar] [CrossRef]
- Kesselring, A.G.; Promes, P.; Strabbing, E.M.; van der Wal, K.G.; Koudstaal, M.J. Lower eyelid malposition following orbital fracture surgery: A retrospective analysis based on 198 surgeries. Craniomaxillofacial Trauma Reconstr. 2016, 9, 109–112. [Google Scholar] [CrossRef]
- Ishida, K. Evolution of the surgical approach to the orbitozygomatic fracture: From a subciliary to a transconjunctival and to a novel extended transconjunctival approach without skin incisions. J. Plast. Reconstr. Aesthetic Surg. 2016, 69, 497–505. [Google Scholar] [CrossRef]
- Haghighat, A.; Moaddabi, A.; Soltani, P. Comparison of subciliary, subtarsal and transconjunctival approaches for management of zygomaticoorbital fractures. Br. J. Med. Med. Res. 2017, 20, 1–9. [Google Scholar] [CrossRef]
- Giraddi, G.B.; Syed, M.K. Preseptal transconjunctival vs. Subciliary approach in treatment of infraorbital rim and floor fractures. Ann. Maxillofac. Surg. 2012, 2, 136–140. [Google Scholar] [CrossRef]
- Bhatti, M.A.; Riaz, E.; Razi, A.; Ahmed, S.; Ahsan, F.; Nadeem, R. Incidence of complication of ectropion and entropion in transconjunctival and subciliary approach for treatment of zmc fracture. Pak. J. Med. Health Sci. 2022, 16, 693–695. [Google Scholar] [CrossRef]
- Subramanian, B.; Krishnamurthy, S.; Suresh Kumar, P.; Saravanan, B.; Padhmanabhan, M. Comparison of various approaches for exposure of infraorbital rim fractures of zygoma. J. Maxillofac. Oral Surg. 2009, 8, 99–102. [Google Scholar] [CrossRef] [PubMed]
- El-Anwar, M.W.; Elsheikh, E.; Hussein, A.M.; Tantawy, A.A.; Abdelbaki, Y.M. Transconjunctival versus subciliary approach to the infraorbital margin for open reduction of zygomaticomaxillary complex fractures: A randomized feasibility study. Oral Maxillofac. Surg. 2017, 21, 187–192. [Google Scholar] [CrossRef] [PubMed]
- Al-Moraissi, E.; Elsharkawy, A.; Al-Tairi, N.; Farhan, A.; Abotaleb, B.; Alsharaee, Y.; Oginni, F.O.; Al-Zabidi, A. What surgical approach has the lowest risk of the lower lid complications in the treatment of orbital floor and periorbital fractures? A frequentist network meta-analysis. J. Cranio-Maxillo-Facial Surg. 2018, 46, 2164–2175. [Google Scholar] [CrossRef]
- Wagh, R.D.; Naik, M.; Bothra, N.; Singh, S. Lower eyelid entropion following transconjunctival orbital fracture repair: Case series and literature review. Saudi J. Ophthalmol. 2023, 37, 154–157. [Google Scholar] [CrossRef] [PubMed]
- Hasan, M.Z.; Rabbani, F.; Hasnat, A.; Imam, F.; Saddam, M.M.R. Aesthetic Outcome of Transconjunctival versus Subciliary Approach for Infra-Orbital Rim and Orbital Floor Fractures. J. Dent. Allied Sci. 2025, 7, 19–25. [Google Scholar] [CrossRef]
Figure 1.
Preferred reporting items for systemic reviews and meta-analyses (PRISMA) flow diagram for searching and identifying included studies.
Figure 1.
Preferred reporting items for systemic reviews and meta-analyses (PRISMA) flow diagram for searching and identifying included studies.
Figure 2.
Forest plots comparing the risk of eyelid complications between the subciliary and transconjunctival approaches: (A) ectropion, (B) entropion, (C) scleral show, and (D) scar formation [3,9,10,11,12,13,16,18,19,20,21,22,23,24,25,26,27,28,29].
Figure 3.
Funnel plots demonstrating no significant publication bias based on Egger’s test for: (A) ectropion (p value = 0.33), (B) entropion (p value = 0.24), (C) scleral show (p value = 0.91), and (D) scar (p value = 0.16).
Figure 3.
Funnel plots demonstrating no significant publication bias based on Egger’s test for: (A) ectropion (p value = 0.33), (B) entropion (p value = 0.24), (C) scleral show (p value = 0.91), and (D) scar (p value = 0.16).
Table 1.
Risk of bias and quality assessment of included studies.
| Study | Selection | Comparability | Outcomes | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Representativeness of Cohort | Selection of Nonexposed Cohort | Ascertainment of Exposure | Outcome Lacking at the Beginning | Main Factor | Additional Factor | Outcome Assessment | Sufficient Follow-Up Time | Follow Up Adequacy | Score a | |
| Bronstein [9] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Mohamed [10] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
| Appling [11] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Patel [3] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Mehrnoush [12] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
| Ridgeway [16] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Trevisiol [13] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Neovius [22] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Giraddi [26] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
| Haghighat [25] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Vaibhav [18] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
| Pausch [21] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Kesselring [23] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Ishida [24] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Salgarelli [19] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Raschke [20] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Bhatti [27] | ★ | ★ | ★ | ★ | ★ | ☆ | ★ | ★ | ★ | 8 |
| Subramanian [28] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
| EI-Anwar [29] | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | ★ | 9 |
a The total score of Newcastle-Ottawa scale is 9 points; ★ represents that the item has received a score, while ☆ represents that it has not.
Table 2.
Demographic characteristics of patients in studies included in meta-analysis.
| Authors | Year | Study Design | Age | Groups | Number of Pts | Follow-Up |
|---|---|---|---|---|---|---|
| Bronstein et al. [9] | 2020 | Retrospective | 34.8 ± 12.4 | Subciliary | 82 | at least 6 months |
| 35.3 ± 11.9 | Transconjunctival | 102 | ||||
| Mohamed et al. [10] | 2020 | Randomized clinical study | 30.9 ± 12.6 | Subciliary | 15 | 6 months |
| 37.4 ± 9.0 | Transconjunctival | 15 | ||||
| Appling et al. [11] | 1993 | Retrospective | 11–60 | Subciliary | 25 | 6 weeks–5 years |
| Transconjunctival | 33 | |||||
| Patel et al. [3] | 1998 | Retrospective | 12–63 | Subciliary | 30 | at least 8 months |
| Transconjunctival | ||||||
| Mehrnoush et al. [12] | 2021 | Randomized clinical study | 34.6 ± 14.2 | Subciliary | 42 | 5 months |
| 29.0 ± 9.0 | Transconjunctival | 38 | ||||
| Ridgeway et al. [16] | 2009 | Retrospective | 39 | Subciliary | 56 | 6 weeks |
| Transconjunctival | 45 | |||||
| Trevisiol et al. [13] | 2021 | Retrospective | 44 | Subciliary | 36 | 12–74 months |
| Transconjunctival | 33 | |||||
| Neovius et al. [22] | 2017 | Retrospective | 41 | Subciliary | 37 | at least 6 months |
| Transconjunctival | 91 | |||||
| Giraddi et al. [26] | 2012 | Randomized clinical study | 28.4 | Subciliary | 10 | 3 months |
| Transconjunctival | 10 | |||||
| Haghighat et al. [25] | 2010 | Prospective clinical study | 26.7 ± 6.5 | Subciliary | 17 | 4 weeks |
| Transconjunctival | 17 | |||||
| Vaibhav et al. [18] | 2016 | Randomized clinical study | 20–60 | Subciliary | 20 | 3 months |
| Transconjunctival | 20 | |||||
| Pausch et al. [21] | 2016 | Retrospective | 42.7 ± 21.1 | Subciliary | 225 | 6 months |
| Transconjunctival | 121 | |||||
| Kesselring et al. [23] | 2016 | Retrospective | 37.5 | Subciliary | 47 | NR |
| Transconjunctival | 26 | |||||
| Ishida et al. [24] | 2016 | Retrospective | NR | Subciliary | 29 | 6 weeks–6.8 years |
| Transconjunctival | 179 | |||||
| Salgarelli et al. [19] | 2010 | Retrospective | 37.1 | Subciliary | 219 | 6–48 months |
| Transconjunctival | 32 | |||||
| Raschke et al. [20] | 2012 | Retrospective | 43.3 ± 19.0 | Subciliary | 114 | 9 months |
| Transconjunctival | 197 | |||||
| Bhatti et al. [27] | 2022 | Prospective clinical study | 32.8 | Subciliary | 28 | 5 months |
| Transconjunctival | 22 | |||||
| Subramanian [28] | 2009 | Randomized clinical study | NR | Subciliary | 10 | at least 6 months |
| Transconjunctival | 10 | |||||
| EI-Anwar et al. [29] | 2017 | Randomized clinical study | 31.3 ± 9.2 | Subciliary | 20 | 6 weeks |
| 31.6 ± 7.7 | Transconjunctival | 20 |
Pts, patients; NR, not reported; age is presented as mean ± SD, mean, or range.
Table 3.
Complications in studies included in meta-analysis.
| Study | Groups | Num of pts | Orbital Floor Reconstruction | Types of Complication (%) |
|---|---|---|---|---|
| Bronstein, 2020 [9] | Sub ciliary | 82 | Yes | ectropion (2.4), entropion (1.2), lagophthalmos (1.2), corneal injury (7.3), keratoconjunctivitis sicca (3.7) |
| Transconjunctival | 102 | ectropion (2.0), entropion (3.9), lagophthalmos (1.0), corneal injury (6.9), keratoconjunctivitis sicca (3.9) | ||
| Mohamed, 2020 [10] | Subciliary | 15 | Yes | ectropion (20), entropion (0), scleral show (26.7), visible scar (13.3) a |
| Transconjunctival | 15 | ectropion (6.7), entropion (20), scleral show (13.3), visible scar (0) a | ||
| Appling, 1993 [11] | Subciliary | 25 | Yes | ectropion (12.0), scleral show (28.0), canthal malposition (0) |
| Transconjunctival | 33 | ectropion (0), scleral show (3.0), canthal malposition (9.1) | ||
| Patel, 1998 [3] | Subciliary | 30 | Yes | ectropion (6.7), entropion (0), scleral show (20), visible scar (6.7) b |
| Transconjunctival | 30 | ectropion (0), entropion (0), scleral show (3.3), visible scar (0) b | ||
| Mehrnoush, 2021 [12] | Subciliary | 42 | Yes | ectropion (2.4), entropion (0), epiphora (7.1), scleral show (11.9) |
| Transconjunctival | 38 | ectropion (13.2), entropion (5.3), epiphora (23.7), scleral show (18.4) | ||
| Ridgeway, 2009 [16] | Subciliary | 56 | Yes | Ectropion (12.5), entropion (0), scar (3.6) c, lid edema (8.9) |
| Transconjunctival | 45 | Ectropion (0), entropion (4.4), scar (0) c, lid edema (0) | ||
| Trevisiol, 2021 [13] | Subciliary | 36 | Yes | ectropion (8.3), entropion (0) |
| Transconjunctival | 33 | ectropion (0), entropion (0) | ||
| Neovius, 2017 [22] | Subciliary | 37 | Yes | ectropion (8.1), entropion (0), scleral show (11.0), canthal malposition (0) |
| Transconjunctival | 91 | ectropion (2.2), entropion (0), scleral show (4.4), canthal malposition (2.2) | ||
| Giraddi, 2012 [26] | Subciliary | 10 | Yes | ectropion (30.0), entropion (0), laceration of tarsal plate (0), buttonhole laceration of lower eyelid (10.0) |
| Transconjunctival | 10 | ectropion (10.0), entropion (30.0), laceration of tarsal plate (10.0), buttonhole laceration of lower eyelid (0) | ||
| Haghighat, 2017 [25] | Subciliary | 17 | Yes | ectropion (17.6), scar (3.7 ± 0.6) d |
| Transconjunctival | 17 | ectropion (0), scar (0.0 ± 0.0) d | ||
| Vaibhav, 2016 [18] | Subciliary | 20 | No | ectropion (0), entropion (0), unsatisfactory scar (10) e |
| Transconjunctival | 20 | ectropion (0), entropion (5), unsatisfactory scar (0) e | ||
| Pausch, 2016 [21] | Subciliary | 225 | Yes | ectropion (3.6), entropion (0), eyelid retraction (0) |
| Transconjunctival | 121 | ectropion (0), entropion (2.5), eyelid retraction (0) | ||
| Kesselring, 2016 [23] | Subciliary | 47 | Yes | ectropion (2.1), entropion (0) |
| Transconjunctival | 26 | ectropion (0), entropion (0) | ||
| Ishida, 2016 [24] | Subciliary | 29 | Yes | ectropion (6.9), scleral show (6.9) |
| Transconjunctival | 179 | ectropion (0.6), entropion (3.4), symblepharon (1.7), trichiasis (1.1), lacrimal canaliculus avulsion (1.1), conjunctival granulation (2.2), canthal malposition (0.6) | ||
| Salgarelli, 2010 [19] | Subciliary | 219 | Yes | ectropion (0), visible scar (17.5) f, scleral show (1.3) |
| Transconjunctival | 32 | ectropion (0), visible scar (3) f, scleral show (0) | ||
| Raschke, 2012 [20] | Subciliary | 114 | Yes | ectropion (5.3), entropion (0), scleral show (21.8) |
| Transconjunctival | 197 | ectropion (1.0), entropion (1.0), scleral show (6.6) | ||
| Bhatti, 2022 [27] | Subciliary | 28 | No | ectropion (14.2), entropion (0), scleral show (11.0), epiphora (21.0) |
| Transconjunctival | 22 | ectropion (13.5), entropion (9.1), scleral show (17.0), epiphora (20.0) | ||
| Subramanian, 2009 [28] | Subciliary | 10 | No | ectropion (0), scar (1.55) g |
| Transconjunctival | 10 | ectropion (10), scar (1.00) g, prolonged edema (20) | ||
| EI-Anwar, 2017 [29] | Subciliary | 20 | No | ectropion (10), entropion (0), scleral show (15), intolerable pain (10) |
| Transconjunctival | 20 | ectropion (0), entropion (20), scleral show (0), intolerable pain (15) |
pts patients; a visible scar scale (5-point ordinal scale) created by Feldman; b visible scar scale (binary). c hypertrophic (or visible) scar scale (binary); d VAS score for scar; e patient-reported satisfaction scale (binary); f visible scar scale (binary); g visible scar scale (3-point grading) created by the authors—1 point for invisible scar, 2 for barely visible scar, and 3 for visible scar.
Table 4.
Summary of Scar Evaluation Methods in Studies.
| Study | Scar Assessment Method | Score Range |
|---|---|---|
| Mohamed, 2020 [10] | Feldman scar esthetic score | 0–4 (0 = Scar not visible, 1 = Barely visible, 2 = Noticeable, 3 = Very noticeable, 4 = Extremely noticeable |
| Patel, 1998 [3] | visible scar scale (binary) | yes/no |
| Ridgway, 2009 [16] | hypertrophic (or visible) scar scale | yes/no |
| Vaibhav, 2016 [18] | patient-reported satisfaction scale (binary) | satisfactory/unsatisfactory |
| Salgarelli, 2010 [19] | visible scar scale (binary) | yes/no |
| Subramanian, 2009 [28] | VAS (3-point visibility score) | custom; 1 = invisible, 2 = barely visible, 3 = visible |
Vas, visual analog scale.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
MDPI and ACS Style
Chen, Y.-Y.; Lai, Y.-J.; Chen, T.-Y.; Yen, Y.-F. Eyelid Complications in Subciliary Versus Transconjunctival Approaches to Orbital and Zygomaticofacial Fractures: A Meta-Analysis. J. Clin. Med. 2025, 14, 6431. https://doi.org/10.3390/jcm14186431
AMA Style
Chen Y-Y, Lai Y-J, Chen T-Y, Yen Y-F. Eyelid Complications in Subciliary Versus Transconjunctival Approaches to Orbital and Zygomaticofacial Fractures: A Meta-Analysis. Journal of Clinical Medicine. 2025; 14(18):6431. https://doi.org/10.3390/jcm14186431
Chicago/Turabian StyleChen, Yu-Yen, Yun-Ju Lai, Tai-Yuan Chen, and Yung-Feng Yen. 2025. "Eyelid Complications in Subciliary Versus Transconjunctival Approaches to Orbital and Zygomaticofacial Fractures: A Meta-Analysis" Journal of Clinical Medicine 14, no. 18: 6431. https://doi.org/10.3390/jcm14186431
APA StyleChen, Y.-Y., Lai, Y.-J., Chen, T.-Y., & Yen, Y.-F. (2025). Eyelid Complications in Subciliary Versus Transconjunctival Approaches to Orbital and Zygomaticofacial Fractures: A Meta-Analysis. Journal of Clinical Medicine, 14(18), 6431. https://doi.org/10.3390/jcm14186431
Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.
