# Comparison of Lower Eyelid Complications Among Surgical Approaches for Orbital and Zygomaticomaxillary Fractures: A Network Meta-Analysis

## TL;DR

This study compares surgical approaches for facial fractures and their risks of eyelid complications to help surgeons make better choices.

## Contribution

A network meta-analysis comparing four surgical approaches for their risks of lower eyelid complications.

## Key findings

- The subciliary approach had the highest risk of ectropion and scleral show.
- The transconjunctival approach had the lowest risk of ectropion and scarring but the highest risk of entropion.
- The infraorbital approach had the highest risk of postoperative scarring.

## Abstract

Background/Objectives: This network meta-analysis aimed to evaluate and compare the risks of lower eyelid complications—ectropion, entropion, scleral show, and postoperative scarring—associated with four surgical approaches (subciliary, subtarsal, infraorbital, and transconjunctival) for orbital and zygomaticomaxillary fracture repair. Methods: A systematic search of PubMed, Embase, and Cochrane databases identified relevant studies published between 1 January 1990 and 10 January 2026. Twenty-seven eligible studies involving 2790 patients were included. Direct pairwise meta-analyses and network meta-analyses were conducted to compare complication risks among the approaches. Sensitivity analyses were performed to assess the influence of individual studies, and inconsistency tests were applied to evaluate model robustness. Results: The subciliary approach was associated with the highest risk of ectropion and scleral show. The transconjunctival approach had the lowest risk of ectropion and scarring but the highest risk of entropion. The subtarsal approach had the lowest risk of scleral show, while the infraorbital approach had the highest risk of postoperative scarring. Sensitivity analyses confirmed consistent rankings, and no significant inconsistency was detected. Conclusions: This study provides updated, comprehensive evidence to guide the choice of surgical approach for orbital and zygomaticomaxillary fracture repair. Surgeons should balance operative exposure, cosmetic outcomes, and complication risk, and communicate these trade-offs clearly with patients to optimize decision-making.