Accepted Manuscript

Subciliary vs. transconjunctival approach for the management of orbital floor and
periorbital fractures: a systematic review and meta-analysis

Essam Ahmed Al-Moraissi, Ph.D, Seth R. Thaller, MD, DMD FAC, Edward Ellis, III,
DDS

PII: S1010-5182(17)30242-1
DOI: 10.1016/j.jcms.2017.07.004
Reference: YJCMS 2727

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 14 May 2017

Revised Date: 1 June 2017
Accepted Date: 14 July 2017

Please cite this article as: Al-Moraissi EA, Thaller SR, Ellis III E, Subciliary vs. transconjunctival
approach for the management of orbital floor and periorbital fractures: a systematic review and meta-
analysis, Journal of Cranio-Maxillofacial Surgery (2017), doi: 10.1016/j.jcms.2017.07.004.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

Subciliary vs. transconjunctival approach for the management of

orbital floor and periorbital fractures: a systematic review and meta-
analysis

Essam Ahmed Al-Moraissi 1, Ph.D , Seth R. Thaller, MD, DMD, FAC2 ,

PT
Edward Ellis III, DDS 3

RI
1Assistant Professor, Dept. of Oral and Maxillofacial Surgery Faculty of

SC
Dentistry, Thamar University, Yemen

2. Professor, Department of Surgery, Division of Plastic Surgery, University

of Miami, Miller school of medicine
U
AN
3Professor and Chair, Dept. of Oral and Maxillofacial Surgery University of
M

Texas Health Science Center at San Antonio

Department or institution to which the work should be attributed :

D
TE

Dept. of Oral and Maxillofacial Surgery Faculty of Dentistry, Thamar

University, Thamar, Yemen
EP

Dr. Essam Ahmed Al-Moraissi

C

Corresponding author:
AC

Dr Essam Ahmed Al-Moraissi

Dept. of Oral and Maxillofacial Surgery Faculty of Dentistry, Thamar
University, Thamar, Yemen
Email: dressamalmoraissi@gmail.com; dr_essamalmoraissi@yahoo.com
Phone: 00967777788939
Source of funding: none
 ACCEPTED MANUSCRIPT

Subciliary vs. transconjunctival approach for the management of

orbital floor and periorbital fractures: a systematic review and meta-
analysis

PT
Essam Ahmed Al-Moraissi 1, PhD, Seth R. Thaller, MD, DMD, FAC2 ,

RI
Edward Ellis III, DDS 3

SC
1Assistant Professor, Dept. of Oral and Maxillofacial Surgery Faculty of
Dentistry, Thamar University, Yemen

U
AN
2. Professor, Department of Surgery, Division of Plastic Surgery, University
of Miami, Miller school of medicine
M

3 Professor and Chair, Dept. of Oral and Maxillofacial Surgery University of

Texas Health Science Center at San Antonio
D
TE
C EP
AC

1
 ACCEPTED MANUSCRIPT

ABSTRACT

Purpose: This study compared complications between subciliary and

transconjunctival approaches to the infraorbital rim/orbital floor using
systematic review and meta-analysis.

PT
Methods and Methods: A systematic review with meta-analysis was

RI
conducted according to the PRISMA guidelines. An electronic search in
PubMed, Embase and Cochrane Library was performed. Randomized

SC
controlled and controlled (retrospective or prospective) clinical studies with
aims of comparing subciliary to transconjunctival approaches in the

U
management of infraorbital rim/orbital floor fractures were included.
AN
Outcomes variables were lower lid malposition including ectropion,
entropion, scleral shows, canthal malpositions and others complications. An
M

Odds ratio (OR) using Mantel-Haenszel (M-H) test with 95% confidence
intervals (95% CIs) of outcomes variables was calculated using a
D

Comprehensive Meta-analysis software. A descriptive analysis of

TE

postoperative complications was also presented.

Results: Subciliary approach had a significantly higher incidence of

EP

ectropion and scleral show when compared to the subconjunctival approach

(p<0.001). The subconjunctival approach had a significantly higher
C

incidence of entropion than the subciliary approach (p<0.001).

AC

Conclusions: Both the subciliary and the transconjunctival approaches are

associated with specific complications. Overall, the transconjunctival
approach showed the lowest incidence of complications.

2
 ACCEPTED MANUSCRIPT

Introduction

Reconstructive surgeons can obtain access to both the infraorbital rim and
orbital floor using either transcutaneous or transconjunctival approach
(Kushner, 2006 ; Wilson and Ellis,2006 ; Converse,1944) When performing

PT
surgery in this area, cosmesis is the major factor ( Rohrich et al.,2003).

RI
Three surgical approaches through the external skin of the lower eyelid have
been employed: subciliary, subtarsal, and infraorbital (Wilson and

SC
Ellis,2006).

The most common complication following surgical approaches to the orbital

U
floor and the periorbital area is lower lid malposition (Ridgway et al.,2009).
AN
Lower lid malposition is comprised of several functional and cosmetic
problems.These encompass palpebral asymmetries, ectropion, entropion,
M

lower lid retraction and scleral show.

Proponents of the transconjunctival approach state it allows adequate

D

exposure of the orbital floor has a low complication rate and results in better
TE

cosmetic results because the incision is hidden within the inferior fornix of
the eyelid (Kushner, 2006 ; Bourquet, 1924 ; Habal and Chaset,1974 ; Habal
EP

,1979 ; Sailer, 1977 ; Jacono and Moskowitz, 2001). Opponents for

transconjunctival approach claim that it provides very limited access to the
C

orbit unless accompanied by a lateral canthotomy and inferior cantholysis.

AC

This maneuver substantially complicates the incision because the inferior

canthus has to be properly resuspended during closure to prevent eyelid
malpositions ( Wilson and Ellis,2006). Proponents of the transcutaneous
approaches claim that they provide excellent access as far laterally as needed
without infringement on the lateral canthal ligament. Additionally, medial

3
 ACCEPTED MANUSCRIPT

access to the frontal process of the maxilla and nasal bones can also be
easily obtained (Wilson and Ellis,2006).

Over the past three decades, both subcutaneous and transconjunctival

approaches have been widely used in the management of orbital fractures.

PT
However, there is still controversy regarding which is the best surgical
approach associated with the lowest rate of lower lid malposition.

RI
Currently, no systematic review and meta-analysis have compared the

SC
subcillary to the transconjunctival approach with respect to lower lid
complications. Thus, authors of this study hypothesize that there is no

U
difference in the rate of LLM between subcillary and transconjunctival
AN
approaches to the infraorbital rim/orbital floor used for the treatment of
orbitozygomatic fractures.
M

MATERIALS AND METHODS

A systematic review and meta-analysis was performed according to the

D

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

TE

(PRISMA) statement for reporting systematic reviews (Liberati et al.,2009).

Focused Question
EP

The clinical research question of this study was “Is there a difference in
C

lower eyelid complications between the subciliary and transconjunctival

AC

approaches when used for the surgical reconstruction of orbital floor and
periorbital fractures?”

Search Strategy

4
 ACCEPTED MANUSCRIPT

All pertinent articles published from 1977 to March 2016 were located that
followed the PRISMA guidelines (http://www.prisma-statement.org).
Electronic search and the PICO strategy is shown in Table 1.

Inclusion Criteria

PT
The following inclusion criteria were adopted by the PICOS criteria:

RI
(Liberati et al.,2009). (P) Patients with the orbital floor, orbitozygomatic and
periorbital fractures who underwent OIRF. (I) Patients who received

SC
transconjunctival approaches (prespetal or retrospetal); (C) patients who
received the subcillary approach; (O) Outcomes include lower eyelid

U
malposition: ectropion, entropion, scleral show, canthal malposition. (S)
AN
Clinical human studies, including randomized controlled trials, controlled
clinical trials, retrospective studies and case series with the purpose of
M

comparing transconjunctival to subcillary approaches for orbital floor and

periorbital surgery.
D

Exclusion Criteria
TE

The following exclusion criteria were applied: (1) case reports, (2) technical
reports, (3) animal or in vitro studies, (4) review papers, and 5) studies that
EP

do not report the appropriate information (surgical and postsurgical changes)

required for performing a meta-analysis.
C

Data Extraction
AC

Data was extracted independently by two researchers using a previously

prepared data extraction form. The following information was extracted
from each study: authors, year of publication, study design, patient’s age
(average), male/female ratio, the number of patients, type of managed
fractures, follow-up period and author’s conclusions.
5
 ACCEPTED MANUSCRIPT

Quality Assessment of the Studies Included

A methodological quality rating was performed by combining the proposed

criteria of the Meta-Analysis of Observational Studies in Epidemiology
statement (MOSES),(Stroup et al.,2001) the Strengthening the Reporting of

PT
Observational Studies in Epidemiology statement (SROSES),(von wt
al.,2007) and the Preferred Reporting Items for Systematic Reviews and

RI
Meta-Analyses (PRISMA) (Moher et al.,2009) to verify the strength of

SC
scientific evidence in clinical decision-making. A study that had all the
domains was classified as having a low risk of bias, a study that did not have
one of these domains was classified as having a moderate risk of bias. When

U
two or more domains were missing, the report was considered to have a high
AN
risk of bias.
M

Summary Measures

Predictor variables were those patients with periorbital fractures who

D

underwent subcillary and transconjunctival approaches. Primary outcome

TE

variables were ectropion, entropion, scleral shows, canthal malposition.

Secondary outcomes were lid edema and conjunctival granulomas.
EP

Meta-Analysis

Lower lid malposition and postoperative complications were pooled and

C

reported as an odds ratio (OR) using Mantel-Haenszel (M-H) test with

AC

corresponding 95% confidence intervals (95% CIs). Significant

heterogeneity among the studies included in this analysis was formally
assessed by Cochran's x2 test and the I2 index. A p-value < 0.1 by the x2 test
and I2 value < 0.75 indicate a low degree of heterogeneity. A fixed-effect
model was used. Otherwise, a random effects model with 95% confidence

6
 ACCEPTED MANUSCRIPT

intervals [CI] was performed. ( Borenstein et al.,2009) Significance level

(null hypothesis) was rejected at the 5% level (P<0.05). Meta-analysis was
performed using Comprehensive Meta-analysis Software (Biostat Inc,
Englewood, NJ). ( Borenstein et al.,2009) Additionally, event rate

PT
(percentage) for all complications was tabulated and calculated by dividing
the number of a reported complication on the total number of patients.

RI
Sensitivity analysis

SC
A sensitivity analysis was conducted to assess if complications associated
with the transconjunctival approach were due to the lateral canthotomy and

U
cantholysis. Thus, the analysis was repeated by including only patients who
AN
underwent a transconjunctival approach without lateral a canthotomy.

RESULTS
M

Results of Literature Search

D

Figure 1 shows the process of screening articles for inclusion in the review
TE

and meta-analysis. The search strategy resulted in a total of 330 articles from
all databases. Of the 330 articles, 90 were duplicates and removed,105
articles were excluded after reading the titles and abstracts. Full-text articles
EP

of the remaining 136 studies were reviewed independently by two authors

for eligibility, and 124 studies were elminated because they did not meet the
C

inclusion criteria. Finally, a total of 12 studies met the inclusion criteria and
AC

et al.
were processed for critical review (Ridgway ,2009; Wray et al.,1977 ;
Patel et al.,1998; Appling et al.,1993 ; Salgarelli et al.,2010; Raschke et
al.,2012; Giraddi and Syed, 2012; Vaibhav et al.,2015; Kesselring et
al.,2016; Pausch et al.,2016; Ishida, 2016; Neovius et al.,2017 )

Description of Studies Included

7
 ACCEPTED MANUSCRIPT

A full description of the details of included studies is presented in Table 1.

Descriptive analysis for complications occurring with the two approaches
using a percentage for each outcome variables was tabulated (Table 2).

Risk of Bias Within Included Studies

PT
Two randomized controlled clinical studies had a low risk of bias. (Giraddi

RI
and Syed,2012 ; Vaibhav et al.,2015 23) Eight studies had a moderate risk
of bias ( Ridgway et al.,2009; Appling et al.,1991; Salgarelli et al.,2010

SC
;Raschke et al.,2012 ; Kesselring et al. 2016 ; Pausch et al,.2016 ; Kunihiro
Ishida, 2016 ; Neovius et al.,2017 ). Two studies had a high risk of bias

U
(Wary et al,1977 ; Patel et al.,1989). A detailed of critical appraisal of
AN
included studies is showed in Table 3.

Results of Outcome Variables

M

1. Ectropion
D

A total of 1719 patients enrolled in twelve studies they compared the

TE

frequency of ectropion in patients who had undergone subcillary (n = 922),

and transconjunctival (n =797) approaches (Ridgway et al.,2009; Wray et
EP

al.,1977 ; Patel et al.,1998; Appling et al.,1993 ; Salgarelli et al.,2010;

Raschke et al.,2012; Giraddi and Syed, 2012; Vaibhav et al.,2015;
C

Kesselring et al.,2016; Pausch et al.,2016; Ishida, 2016 ; Neovius et

AC

al.,2017). Mean follow-up period varied from to 13 months.

There was a significant reduction in the incidence of ectropion for those

patients who underwent transconjunctival approaches compared with
subcillary approaches. OR was 5.143 (OR, M-H, 95% CI, 2.757 to 9.593 ; p

8
 ACCEPTED MANUSCRIPT

< 0.001 [fixed-effects model]). There was no heterogeneity among studies

(I2= 18.3 %; P = 0.254) (Fig 2).

2. Entropion

PT
A total of 609 patients enrolled in six studies compared the frequency of
entropion in patients who had undergone subcillary (n =328) and

RI
transconjunctival (n =281) approaches (Ridgway et al.,2009; Wray et
al.,1977 ; Giraddi and Syed, 2012; Vaibhav et al., 2015; Kesselring et al.,

SC
2016; Ishida, 2016). Mean follow-up period varied from 6 months to 4 years.

There was a significant reduction in the incidence of entropion for those

patients who underwent
U
subcillary approaches compared with
AN
transconjunctival approaches. OR was 0.185 (RR, M-H, 95% CI, 0.052 to
0.664; P < 0.010 [fixed-effects model]). There was no heterogeneity among
M

studies (I2= 000 %; p = 0.967) (Fig 3).

3. Scleral show
D
TE

A total of 1322 patients enrolled in seven studies compared the frequency of

scleral show in patients who had undergone subcillary (n = 638) and
transconjunctival (n =684) approaches (Patel et al.,1998; Appling et al.,1993
EP

; Salgarelli et al.,2010; Raschke et al.,2012; Pausch et al.,2016; Ishida, 2016;

Neovius et al.,2016). Mean follow-up period varied from 6 months to 4
C

years.
AC

There was a significant reduction in the incidence of the scleral show for
those patients who underwent transconjunctival compared with subcillary
approaches. OR was 3.904 (OR, M-H, 95% CI, 2.246 to 6.777; p < 0.001
[fixed-effects model]). There was no heterogeneity among studies (I2= 48 %;
p = 0.070) (Fig 4).
9
 ACCEPTED MANUSCRIPT

4. Canthal malposition

A total of 394 patients enrolled in three studies compared the frequency of

canthal malposition in patients who had undergone subcillary (n = 91) and
transconjunctival (n =303) approaches. (Appling et al.,1993 ; Neovius et

PT
al.,2016; Ishida, 2016). Mean follow-up period varied from 6 months to 4
years.

RI
There was no significant difference in the incidence of canthal malposition

SC
for those patients who underwent subcillary compared with
transconjunctival approaches. OR was 0.423 (OR, M-H, 95% CI, 0.075 to

U
2.398; p = 0.331 [fixed-effects model]). There was no heterogeneity among
AN
studies (I2= 48 %; P = 0.070) (Fig 5).

5. Others complications
M

A total of 1250 patients/incisions enrolled in ten studies (transconjunctival =

564, subcillary = 686) compared the frequency of other complications
D

caused by the surgical approaches (including lid edema, visible scar,

TE

trichiasis, chemosis, conjunctival granulation, symblepharons, lacrimal

canaliculus avulsion and lagophthalmos), in patients who had undergone
EP

subcillary (n = 597) and transconjunctival approaches (n =422). (Ridgway

et al.,2009; Wray et al.,1977 ; Patel et al.,1998; Appling et al.,1993 ;
C

Salgarelli et al.,2010; Raschke et al.,2012; Giraddi and Syed, 2012; Vaibhav

AC

et al.,2015; Pausch et al.,2016; Ishida, 2016). Mean follow-up period varied

from 6 months to 4 years.

There was no significant difference in the incidence of other complications

for those patients who underwent transconjunctival compared with the
subcillary approaches. OR was 0.876 (OR, M-H, 95% CI, 0.240 to 3.215; p

10
 ACCEPTED MANUSCRIPT

= 0.846 [fixed-effects model]). There was heterogeneity among studies (I2=

62%; P = 0.002). So the random effect model was used. (Fig 4).

Sensitivity analysis

PT
After exclusion of those patients who underwent transconjunctival approach
with lateral canthotomy and cantholysis, ORs for entropion and ectropion

RI
were 0.126 and 3.5 respectively. Thus, no change in the main results was
detected for the outcomes of ectropion and entropion.

SC
Discussion

U
AN
The key to skeletal surgery is having sufficient exposure. To facilitate the
bony surgery, the most direct route through the soft tissues to the bone is
M

often taken, especially in orthopedic surgery. When working in the face,

another significant consideration is cosmetics. Incisions to expose the facial
D

skeleton are usually made in inconspicuous or hidden areas. Often this may
TE

be at the expense of ease of exposure of the bones. This is certainly the case
with surgical approaches to the infraorbital rim and orbital floor. The most
direct route would be an incision placed at the infraorbital rim. This is rarely
EP

done, however, because the scar is readily seen. Instead, incisions made just
below the eyelashes (subciliary) or behind the eyelid (transconjunctival) are
C

used to hide the scars. The price one pays for using such incisions, however,
AC

is less direct access to the bones. That means that dissection of the soft
tissues, often in different surgical planes, must be used to expose the bone.
Such dissection can occasionally lead to functional and esthetic
complications such as ectropion, entropion, scleral show, palpebral
asymmetries, etc.

11
 ACCEPTED MANUSCRIPT

The traditional transcutaneous approach to the infraorbital rim and floor is

the subciliary. The location of the incision through the skin of the lower
eyelid is the same as what one might do for a cosmetic blepharoplasty.
Unfortunately, when used for skeletal surgery, the subciliary approach has a

PT
significant rate of complications. These involve ectropion, scleral show,
palpebral asymmetries, etc. (Ridgway et al.,2009 ; Wary et al,1977 ;

RI
Kunihiro Ishida, 2016 ; Neovius et al.,2017; 29. Pospisil et al.,1984).

SC
Because of that, alternative surgical approaches have gained popularity.

The transconjunctival approach to the orbit was introduced by Bourguet in

U
1928 and has gained popularity over the past 20 years ( Bourguet, 1924). It
AN
has the advantage of hiding the scar behind the lower eyelid, so it is
invisible. Also, it has the advantage of being capable of exposing not only
M

the infraorbital rim and floor of the orbit but with the medial extension, it
can readily expose the medial wall of the orbit. Many studies have shown
D

that the rate of complications with the transconjunctival approach is minimal

TE

(Ridgway et al.,2009 ; Wary et al,1977; Raschke et al.,2012 ; Kesselring et

al. 2016; Kunihiro Ishida, 2016) However, when a complication occurs, it
can be more difficult to correct and more troubling to the patient because it
EP

is often entropion, with the eyelashes contacting the cornea.

C

This is the first systematic review and meta-analysis comparing the

AC

subciliary and the subconjunctival approaches on complications. The results

of this study indicate that there is a statistically significant increase in the
rate of ectropion and scleral show with the subciliary approach when
compared with the subconjunctival approach (p<0001). Conversely, there
was a statistically significant increase in the rate of entropion with the
subconjunctival approach when compared with the subciliary approach

12
 ACCEPTED MANUSCRIPT

(p<0.001). While both of the complications are distressing, entropion is

more so because patients have severe pain when the lower eyelashes invert
and contact the cornea. Further, most surgeons agree that treating entropion
is more difficult than treating ectropion. Whether or not these factors should

PT
be considered when selecting a surgical approach to the infraorbital rim and
orbital floor is a personal decision that must be made by each surgeon.

RI
When assessing the incidence of ectropion, entropion and scleral show that

SC
might occur with either surgical approach, it becomes clear that the
transconjunctival approach has a slight advantage over the subciliary
approach. For instance, 14.5% of patients that undergo subciliary approaches

U
showed ectropion and/or scleral show, whereas 8.8% of patients undergoing
AN
a transconjunctival approach showed ectropion, entropion, or scleral show.
M

In addition to the rate of potential complications that accompany the two

surgical approaches, there are other reasons why one surgical approach
D

might be selected over the other. For instance, if exposure of both the orbital
TE

floor and the medial wall is required, far better access can be obtained using
a transconjunctival approach with medial extension. One can easily expose
the frontoethmoidal suture using this approach. Using a subciliary approach
EP

for medial orbital fractures only provides access to approximately the height
of the medial canthus. However, most medial orbital wall fractures extend
C

much higher, often to the frontoethmoidal suture. A subciliary approach

AC

would therefore not be as useful for such fractures as would a

transconjunctival.

Conversely, if access to the frontal process of the maxilla and its articulation
with the nasal bones is required, for instance with a nasal-orbit-ethmoid
fracture, the subciliary approach has an advantage over the transconjunctival
13
 ACCEPTED MANUSCRIPT

approach. Because of the medial inferior position of the lacrymal drainage

system, it is not possible to reach the external face of the frontal process of
the maxilla using a transconjunctival approach. With such injuries, a
transcutaneous approach would be a better option.

PT
Conclusion

RI
In summary, the subciliary and transconjunctival approaches to the orbit
each have their own advantages, disadvantages, and complications which

SC
may be weighed when considering a surgical approach to the infraorbital rim
and orbital floor.

U
AN
M
D
TE
C EP
AC

14
 ACCEPTED MANUSCRIPT

Figure legends

PT
Figure 1: screening process of studies based on PRISMA

Figure 2: Subciliary vs. transconjunctival approach, ectropion, risk ratio

RI
Figure 3: Subciliary vs. transconjunctival approach, entropion, risk ratio

SC
Figure 4: Subciliary vs. transconjunctival approach, scleral show, risk ratio

U
Figure 5: Subciliary vs. transconjunctival approach, canthal malposition, risk
ratio
AN
Figure 6. Subciliary vs. transconjunctival approach, others complications,
M

risk ratio

Table captions
D

Table 1: Characteristics of included studies

TE

Table 2: Rate of complications as reported in the included studies

EP

Table 2: Critical appraisal of included studies

C
AC

15
 ACCEPTED MANUSCRIPT

References

Appling, D., Patrinely, J. R., & Salzer, T. A. Transconjunctival Approach vs

PT
Skin-Muscle Flap Approach for Orbital Subciliary Fracture Repair. Arch
Otolaryngol Head Neck Surg. Sep;119(9):1000-7,1993.

RI
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to

SC
Meta-Analysis. Wiley, Chichester, 2009.

U
Bourquet J: Les hernies graisseuse de l’orbite: Notre traitment chirurgical.
AN
Bull Acad Med (Paris) 92:1270, 1924.
M

Converse JM: Two plastic operations for repair of orbit follow- ing severe
trauma and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944.
D
TE

Girish B. Giraddi and Moinuddin K. Syed. Preseptal transconjunctival vs.

subciliary approach in treatment of infraorbital rim and floor fractures. Ann
Maxillofac Surg. Jul Dec; 2(2): 136–140,2012,2012.
EP

Habal MB, Chaset RB: Infraciliary transconjunctival approach to the orbital

C

floor for correction of traumatized lesions. Surg Gynecol Obstet 139:420,

AC

1974.
Habal MB: Experience in the application of the transconjunctival route to
surgical exposure in the orbital region. Surg Gynecol Obstet 143:437, 1976

16
 ACCEPTED MANUSCRIPT

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. 69(4):497-505,2016 .

PT
Jacono AA, Moskowitz B: Transconjunctival versus transcutaneous
approach in upper and lower blepharoplasty. Facial Plast Surg 17:21, 2001.

RI
Kesselring AG, Promes P, Strabbing EM, van der Wal KGH, Koudstaal MJ.

SC
Lower Eyelid Malposition Following Orbital Fracture Surgery: A
Retrospective Analysis Based on 198 Surgeries. Craniomaxillofac Trauma
Reconstr. 9(2):109-112., 2016.
U
AN
Kushner, G. M. Surgical Approaches to the Infraorbital Rim and Orbital
M

Floor : The Case for the Transconjunctival Approach. J Oral Maxillofac

Surg 108–110, 2006.
D
TE

Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Loannidis JP,

et al. The PRISMA statement for reporting systematic reviews and meta-
EP

analyses of studies that evaluate health care interventions: explanation and

elaboration. PLoS Med 6:1–6, 2009.
C
AC

Moher D, Liberati A, Tetzlaff J, The ADG, Group P. Preferred reporting

items for systematic reviews and meta-analyses: the PRISMA statement.
PLoS Med 6:e1000097,2009.

17
 ACCEPTED MANUSCRIPT

Neovius, Erik, Sophie Clarliden, Filip Farnebo, and Tor Kalle Lundgren.
“Lower Eyelid Complications in Facial Fracture Surgery. J Craniofac Surg
Mar;28(2):391-393,2017.

PT
Patel, P. C., Sobota, B. T., Patel, N. M., Greene, J. S., & Millman, B.
Comparison of transconjunctival versus subciliary approaches for orbital

RI
fractures: a review of 60 cases. Journal of Cranio-Maxillofacial Trauma,
4(1), 17–21,1998.

SC
Pausch NC, Sirintawat N, Wagner R, Halama D, Dhanuthai K. Lower eyelid
complications associated with
Utransconjunctival versus subciliary
AN
approaches to orbital floor fractures. Oral Maxillofac Surg. 20(1):51-
55,2016.
M

Pospisil, O. A., and T. D. Fernando. “Review of the Lower Blepharoplasty

D

Incision as a Surgical Approach to Zygomatic-Orbital Fractures. Br J Oral

TE

Maxillofac Surg. Aug;22(4):261-8,1984.

EP

Raschke GF, Rieger UM, Bader R. Transconjunctival versus subciliary

approach for orbital fracture repair — an anthropometric evaluation of 221
C

cases. Clin Oral Investig. Apr;17(3):933-42,2013, 2012.

AC

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. Plastic and Reconstructive Surgery, 124(5),
1578–1586, 2009.
18
 ACCEPTED MANUSCRIPT

Rohrich RJ, Janis JE, Adams WP: Subciliary versus subfascial approaches to
orbitozygomatic fractures. Plast Reconst Surg 111:1708, 2003.

Sailer HF: Osteosynthesis of orbital margin via transconjunctival approach

PT
using staples. J Maxillofac Surg 5184, 1977.

RI
Salgarelli AC, Bellini P, Landini B, Multinu A, Consolo U. A comparative
study of different approaches in the treatment of orbital trauma: An

SC
experience based on 274 cases. Oral Maxillofac Surg. 14(1):23-27,2010.

U
Spencer Wilson, Edward Ellis. Surgical Approaches to the Infraorbital Rim
AN
and Orbital Floor : The Case for the Subtarsal Approach. J Oral Maxillofac
Surg Jan;64(1):104-7, 2006.
M

Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D,
D

Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational

TE

studies in epidemiology: a proposal for reporting. Meta-analysis of

Observational Studies in Epidemiology (MOOSE) group. JAMA 283:2008-
EP

12,2000.
C

Vaibhav N, Madan RK, Ashwin NDP. Comparison of “ sutureless ”

AC

Transconjunctival and Subciliary Approach for Treatment of Infraorbital

Rim Fractures : a Clinical Study. J Maxillofac Oral Surg. Sep;15(3):355-
362,2016.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,

Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of
19
 ACCEPTED MANUSCRIPT

Observational Studies in Epidemiology (STROBE) statement: guidelines for

reporting observational studies. Lancet 370:1453-7,2007.

Wray, R. C., Holtmann, B., Ribaudo, J. M., Keiter, J., & Weeks, P. M. A

PT
comparison of conjunctival and subciliary incisions for orbital fractures.
British Journal of Plastic Surgery, 30(2), 142–145, 1977.

RI
U SC
AN
M
D
TE
C EP
AC

20
Table 1: Characteristics of included studies

Authors Study design Male to female

ratio ACCEPTED
Age
MANUSCRIPT
Number of patients Type of managed fractures Follow
up

Transcjnjuctival Subcillary Transcinjuctival Subcilairy 3

Wary et Retrospective 62:19 11- 45 : retrospetal 45 85 Le Fort II and/or trimalar fractures, 3 months
al,1977 cohort study 65 (25 with lateral blowout fractures of the orbital floor,
canthotomy) and 2 isolated fractures of the
infraorbital rim.
Patel et Retrospective NM NM 30 : (25 with 30 Orbital fractures
al.,1989 study lateral subcillary
canthotomy
Appling et Retrospective 41:18 11- 36: presptal 27: 14 isolated blowout 9 isolated 6weeks
al.,1991 60 lateral with subcillary 11 floor and rims 15 floor and rim –5
canthotomy and Skin- fractures years
cantholysis muscle

PT
flap

Salgarelli et Retrospective 169:105 37.1 55 : 23 with 219 Orbital fractures 6-48

al.,2010 cohort study lateral subcillary months
canthotomy

RI
Ridgway et Retrospective 72:28 39 45 (2 47 53 isolated orbital fractures 6
al.,2009 cohort study retrospetal and subtarsal 59 isolated zygomaticomaxillary months
43 preseptal ) 56 fractures, and 68 combined
subcillary orbitozygomatic fractures

SC
Raschke et Prospective 171:50 44.76 129 retrospetal 92 skin- ZMC 9
al.,2012 cohort study muscle months
stepped y

Giraddi and
Syed,2012
RCT 25:5 28.4
U
10 presetal with
lateral
subciliary
10 skin-
muscle
infraorbital floor and rim fractures 3
months
AN
cathotomy flap
subcillary
Vaibhav et RCT 3:36 37 20 preseptal 20 skin- infra-orbital rim Up to 3
al.,2015 (1 with lateral muscle months
canthotomy) stepped
M

subcillary
Kesselring et Retrospective 115:60 37.5 26 trasconj. 47: orbital floor fractures requiring NM
al. 2016 cohort study alone subcillary
3 with lateral
Pausch et Retrospective 248:98 42.7 121 225 Isolated orbital floor fracture 156 (45.1) 6
D

al,.2016 cohort study subcillary Associated with zygomatic months

fracture
141 (40.7)
TE

Associated with other facial

fracture(s)
49 (14.2)
Kunihiro Retrospective 179 (44 with 29 Orbital floor/medial orbital wall 401
Ishida, 2016 cohort study lateral subcilary fractures days
EP

canthotomy )
Neovius et Retrospective 249:68 41 91presptal ( 72 37 skin- Facial fractures 6
al.,2017 cohort study with lateral muscle months
canthotomy ) flap -
subcillary
C

ZMC- zygomaticomaxillary fractures, RCT- randomized controlled clinical trial, NM- not mentioned
AC
 ACCEPTED MANUSCRIPT

Table 2 : Rate of complications as reported in included studies

PT
Subgroups Subciliary Transconjunctival
Ectropion 65/922 = 7.04 % 9/797 = 1.12 %
entropion 0/281 = 0 % 15/328 = 4.57 %

RI
Scleral 51/684 = 7.45 % 20/638 = 3.14 %
shows
Canthal 0/91 = 0 % 6/ 303 = 1.98 %
malposition

SC
Chemosis 20/45 = 44 % 37/53 = 69 %
Conjunctival 0/66 = 0 5/270 = 1.85 %
granuloma
Visible scar 42/305 = 13.7 % 5/130 = 3.8 %
Trichiasis 0/49 = 0 % 5/130 = 1.5 %
U
Lacrimal 0/29 = 0 % 2/179 = 1 %
canaliculus
AN
avulsion
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Table 3 : Characteristics of included studies

3Authors, year of Random Defined Loss of follow- Validated Statistical Estimated potential
publication selection in inclusion/exclusion up measuremen analysis risk of bias
population criteria t
Wary et al,1977 No Yes Yes Yes No High
Patel et al.,1989 No Yes Yes Yes No High

PT
Appling et al.,1991 No Yes Yes Yes Yes Moderate
Salgarelli et al.,2010 No Yes Yes Yes Yes Moderate
Ridgway et al.,2009 No Yes Yes Yes Yes Moderate
Raschke et al.,2012 No Yes Yes Yes Yes Moderate

RI
Giraddi and Syed,2012 Yes Yes Yes Yes Yes Low
Vaibhav et al.,2015 Yes Yes Yes Yes Yes Low
Kesselring et al. 2016 No Yes Yes Yes Yes Moderate

SC
Pausch et al,.2016 No Yes Yes Yes Yes Moderate
Kunihiro Ishida, 2016 No Yes Yes Yes Yes Moderate
Neovius et al.,2017 No Yes Yes Yes Yes Moderate
U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

330 of records retrieved through electronic

PT
database
Identification

(PubMed, Embase and Cochrane Library)

RI
SC
90 articles for screening after duplicate
eliminated
Screening

U 105 articles excluded after

AN
assessment of title and abstract
M

136 articles of full text screened for

Eligibility

eligibility
D
TE

124 of records excluded due to

they did not meet inclusion
criteria
EP
Included

12 articles included in critical appraisal and

C

meta-analysis
AC

Figure 1 : Selecting screening process

 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

Highlights

This is the first systematic review and meta-analysis comparing the

PT
subciliary and the subconjunctival approaches on postoperative
complications.

RI
Subciliary approach had a significantly higher incidence of ectropion and

SC
scleral show when compared to the subconjunctival approach (p<0.001).

The subconjunctival approach had a significantly higher incidence of

U
entropion than the subciliary approach (p<0.001).
AN
M
D
TE
C EP
AC