Document Type: Original Article


1 Fellowship of Maxillofacial Trauma, Dept. of Oral and Maxillofacial Surgery, Sina Hospital, Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.

2 Fellowship of Facial Cosmetic and Reconstructive Surgery, Dept. of Oral and Maxillofacial Surgery, Sina hospital, Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.

3 Dept. of Oral and Maxillofacial Surgery, Zahedan University of Medical Sciences, Zahedan, Iran. Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.

4 Resident Dept. of Oral and Maxillofacial Surgery, Sina hospital, Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.


Statement of the Problem: Treating zygomaticomaxillary complex fractures (ZMC Fx) can result in postoperative complications that should be minimized by choosing the best surgical approach.
Purpose: This study compared incidence rates of some common postoperative complications with emphasis on ectropion (an outward curling of the lower eyelid) and entropion (an inward curling of the lower eyelid) occurring with transconjunctival or subciliary approaches for the treatment of ZMC fractures.
Materials and Method: This prospective study enrolled 80 patients with ZMC Fx who had been surgically treated. Patients were visited within one month and five months postoperatively by the same surgeon, and an information checklist was completed for each patient to clinically assess postoperative complications.
Results: There was no significant difference between the two groups in the type of trauma (simple or comminuted) (p = 0.1) or the frequency of ectropion and entropion one month and five months postoperatively, respectively (p > 0.05). The same results were observed for history of massage under the eye or around the field of surgery (p = 0.151), scleral show (p = 0.414), history of post-surgical epiphora (overflow of tears and accumulation of tear) (p = 0.059), duration of the use of suspension/frost sutures (used to prevent eyelid distortion secondary to wound injury applied at the skin inferior to the incision to help elevate the lid) (p = 0.057), and the use of porex (an alloplastic material over the defect in the orbital floor) (p = 0.91).
Conclusion: There is no significant difference between the transconjunctival approach and the subciliary approach in terms of common postoperative complications such as ectropion and entropion.


[1]  Sadda RS. Maxillofacial war injuries during the Iraq-Iran War: an analysis of 300 cases. Int J Oral Maxillofac Surg. 2003; 32: 209-214.

[2]  Mohajerani H, Esmaeelinejad M, Sabour S, Aghdashi F, Dehghani N. Diagnostic factors of odontogenic cysts in Iranian population: A retrospective study over the past two decades. Iran Red Crescent Med J. 2015; 17: e21793.

[3]  Strong EB, Gary C. Management of Zygomaticomaxillary Complex Fractures. Facial Plast Surg Clin North Am. 2017; 25: 547-562.

[4]  Peretti N, MacLeod S. Zygomaticomaxillary complex fractures: diagnosis and treatment. Curr Opin Otolaryngol Head Neck Surg. 2017; 25: 314-319.

[5]  Chrcanovic BR, Freire-Maia B, Souza LNd, Araújo VdO, Abreu MHNGd. Facial fractures: a 1-year retrospective study in a hospital in Belo Horizonte. Braz Oral Res. 2004; 18: 322-328.

[6]  Al*Ahmed HE, Jaber MA, Fanas SHA, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004; 98: 166-170.

[7]  Singaram M, Sree*Vijayabala G, Udhayakumar RK. Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2016; 42: 174-181.

[8]  Damasceno RW, Osaki MH, Dantas PEC, Belfort Jr*R. Involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population. Ophthalmic Plast Reconstr Surg. 2011; 27: 317-320.

[9]  Brucoli M, Boffano P, Broccardo E, Benech A, Corre P, Bertin H, et al. The "European zygomatic fracture" research project: The epidemiological results from a multicenter European collaboration. J Craniomaxillofac Surg. 2019; 47: 616-621.

[10]          Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M. Toward CT-based facial fracture treatment. Plast Reconstr Surg. 1990; 85: 202-212.

[11]          Heckler FR, Songcharoen S, Sultani FA. Subciliary incision and skin-muscle eyelid flap for orbital fractures. Ann Plast Surg. 1983; 10: 309-313.

[12]          Manson P, Ruas E, Iliff N. Deep orbital reconstruction for correction of post-traumatic enophthalmos. Clin Plast Surg. 1987; 14: 113-121.

[13]          Lacy M, Pospisil O. Lower blepharoplasty post-orbicularis approach to the orbit- a prospective study. Brit J Oral Max Surg. 1987; 25: 398-401.

[14]          Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg. 1993; 119: 1000-1007.

[15]          Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr., et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. 1990; 30: 1356-1365.

[16]          Clark DE, Ryan LM. Modeling injury outcomes using time-to-event methods. J Trauma. 1997; 42: 1129-1134.

[17]          Chalya PL, Mchembe M, Mabula JB, Kanumba ES, Gilyoma JM. Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital. J Trauma Manag Outcomes. 2011; 5: 7.

[18]          Furtado LM, Rocha FS, Silva CJ, Marquez IM, Zanetta-Barbosa D. Retrospective analysis of maxillofacial fractures: a 7-year study of 748 patients. Int J Dent. 2010; 8: 9.

[19]          Motamedi MHK. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg. 2003; 61: 61-64.

[20]          Ansari MH. Maxillofacial fractures in Hamedan province, Iran: a retrospective study (1987–2001). J Craniomaxillofac Surg. 2004; 32: 28-34.

[21]          Tenzel RR, Miller GR. Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol. 1971; 71: 1141.

[22]          Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Oral Maxillofac Surg. 1973; 1: 3-8.

[23]          Converse JM, Firmin F, Wood-smith D, Friedland JA, Converse JM. The conjunctival approach in orbital fractures. Plast Reconstr Surg. 1973; 52: 656-657.

[24]          Wray Jr RC, Holtmann B, Ribaudo JM, Keiter J, Weeks PM. A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg. 1977; 30: 142-145.

[25]          Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. 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.

[26]          Giraddi GB, Syed MK. Preseptal transconjunctival vs. subciliary approach in treatment of infraorbital rim and floor fractures. Ann Maxillofac Surg. 2012; 2: 136.

[27]          De*Melo*Crosara J, da*Rosa ELS, e*Silva MRMA. Comparison of cutaneous incisions to approach the infraorbital rim and orbital floor. Braz J Oral Sci. 2009; 8: 88-91.

[28]          Bartsich S, Yao CA. Is frosting effective? The role of retention sutures in posttraumatic orbital reconstruction surgery. J Plast Reconstr Aesthet Surg. 2015; 68: 1683-1686.