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 our study was to examine lower lid malposition associated with these incisional approaches at our 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 post-operative 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%), subciliary (31%), and transconjunctival (25%). The risk of ectropion was highest in subciliary incisions (12.5%, 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 (14%), entropion in transconjunctival (1.5%), and hypertrophic scarring in subtarsal incisions (3.4%). 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 our findings we favor the subtarsal approach for zygomaticomaxillary fractures and the transconjunctival incision for isolated orbital floor fractures.