During skeletal surgery sufficient exposure is key, often a direct approach through the overlying tissues is the easiest route. In the face, however, as the scar would be readily visible so approaches are designed to hide this. Surgical access to the orbital floor when required is via a transcutaneous or transconjunctival approach. The transcutaneous approach can be subciliary, subtarsal or infraorbital. These are variously employed to ensure the best exposure with postoperative cosmesis in mind. The commonest and most worrisome complication is lower lid malposition. The main advantage claimed for the transcutaneous approach is better exposure without damaging the lateral canthal attachments. Extended approach to the maxilla and nasal bones is also possible. The main drawback of the transconjunctival approach is limited access to the orbital floor and disruption of the canthal attachments, especially with extended approaches. Both approaches are however widely accepted and used. The usual complications of both are ectropion, entropion, scleral show and obvious malpositioning of the eyelid. This paper by a group from the USA is a systematic review with meta-analysis on the best approach with least complications. They searched all pertinent articles from 1977 to March 2016 but did not include case reports, technical reports, review papers or reports with animal and in vitro studies. The question examined was whether one approach had more complications than the other. The incidence of ectropion and the scleral show was significantly reduced with the transconjunctival approach whereas entropion was reduced with the subciliary approach. There was no significant difference in the incidence of other complications. This is a good paper with sufficient discussion to learn about some of the complications of these approaches. There is no description of surgical techniques but the authors only set out to examine the complications. There is still discussion about the best approach and, like many other surgical procedures, operator variability and personal preference. It is however good to quantify the risks for either approach. 

Subciliary vs transconjunctival approach for the management of Orbital floor and periorbital fractures: a systematic review and meta-analysis.
Al-Moraissi EA, Thaller SR, Ellis E.
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Sunil K Bhatia

Royal Shrewsbury Hospital, Shrewsbury, UK.

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