The Incidence of Lower Eyelid Malposition after Facial Fracture Repair: A
Retrospective Study and Meta-Analysis Comparing Subtarsal, Subciliary, and
Transconjunctival Incisions
Emily B. Ridgway, MD, Chen Chen, Bernard T. Lee, MD
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 treated
operatively at the Beth Israel Deaconess Medical Center from 1998 to 2008 was
performed. In each case, the surgical approach- specifically the lower eyelid incision and
all post-operative lower eyelid complications were noted. A literature review and metaanalysis were 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 zygomatic and/or orbital fractures were treated operatively via at least one
lower eyelid incision. Of these cases identified, the lower eyelid incisions employed
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 lower eyelid incisional approaches
to facial fracture repair, often resolving with conservative management. Based on our
findings we favor the subtarsal approach for zygomaticomaxillary fractures and the
transconjunctival incision for isolated orbital floor fractures.
None of the authors have a financial interest in any of the products, devices, or drugs
mentioned in this article.
Table: Entropion and Ectropion Incidence by Approach
Complications
n (% by approach)
Subtarsal
n= 74
Subciliary
n= 56
Transconjunctival
n= 45
Laceration
n= 5
Total
n=180
P-Value*
2 (2.7%)
7 (12.5%)
0
0
9 (5.0%)
0.018
2 (2.7%)
6 (10.7%)
0
0
8 (4.4%)
0
1 (1.8%)
0
0
1 (0.5%)
0
0
2 (4.4%)
0
2 (1.1%)
Conservatively managed
0
0
0
0
0
Operatively managed
0
0
2 (4.4%)
0
2 (1.1%)
Lid Edema
1 (1.4%)
5 (8.9%)
0
1 (20%)
7 (3.9%)
.016
Hypertrophic Scar
1 (1.4%)
2 (3.6%)
0
0
3 (1.7%)
.545
Total
4 (5.4%)
14 (25%)
2 (4.4%)
1 (20%)
21 (11.7%)
Total Ectropion
Conservatively managed
Operatively managed
Total Entropion
* Fisher’s Exact Test
0.108
Table: Meta-Analysis of Entropion and Ectropion Incidence by Approach
Complications
n (% by approach)
Subtarsal
n= 238
Subciliary
n= 470
Transconjunctival
n= 1378
Total
n=2086
P-Value*
9 (3.8%)
68 (14%)
20 (1.5%)
97 (4.7%)
<0.001
Conservatively managed
8 (3.4%)
54 (11%)
4 (0.3%)
66 (3.2%)
Operatively managed
1 (0.4%)
14 (3.0%)
16 (1.2%)
31 (1.5%)
0
1 (0.2%)
9 (0.7%)
10 (0.5%)
Conservatively managed
0
0
4 (0.3%)
4 (0.2%)
Operatively managed
0
1 (0.2%)
5 (0.4%)
6 (0.3%)
Lid Edema
6 (2.5%)
17 (3.6%)
0
23 (1.1%)
<0.001
Hypertrophic Scar
8 (3.4%)
4 (0.9%)
0
12 (0.6%)
<0.001
Total
23 (9.7%)
90 (19.1%)
29 (2.1%)
142 (6.8%)
Total Ectropion
Total Entropion
* Fisher’s Exact Test
0.42
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