What surgical approach has the lowest risk of the lower lid complications in the treatment of orbital floor and periorbital fractures? A frequentist network meta-analysis

Purpose: Evidence on the best surgical approach with the lowest lower lid complications (LLCs) in the treatment of orbital floor (OF) and periorbital fractures (POFs) is limited because of the absence of head-to-head studies. We performed this network meta-analysis (NMA) to compare various surgical approaches in treatment of OFs and POFs, with respect to LLCs. Materials and methods: This NMA based on PRIMSA guidelines studied the incidence of the LLCs among various surgical approaches in the treatment of the OFs and POFs. We searched several databases from 1970 to March 2018. All clinical studies comparing different surgical approaches in treatment of OFs and POFs were included. Outcome variables were ectropion, entropion, scleral show and other complications. Predictor variables were transconjunctival approach (TCA), subciliary approach (SCA), subtarsal approach (STA) and infraorbital approach (IOA). Frequentist NMA was performed using STATA software. Results: A total of 47 studies with 5267 cases of the OFs and POFs received ORIF using 4 surgical approaches with 6 comparisons were included. TCA significantly reduces the prevalence of ectropion than SCA (OR = 3.54, CI1.28-9.84), but no significant difference was found between TCA and, STA or TCA and IOA. SCA and STA significantly reduce the prevalence of entropion than TCA (OR = 5.02, CI, 1.79-14.06, OR = 0.11, CI, 0.02-0.57) respectively. We found no significant difference between the 6 comparisons with respect to other complications. Conclusion: This NMA shows that the application of various surgical approaches leads to different incidences of LLCs. While TCA appears to have the lowest overall LLCs rate, STA has lowest rate among the transcutaneous approaches. The choice of an appropriate surgical approach for a given fracture should take these among other factors into consideration. Owing to the limitations of this study, we suggest that the results be interpreted with caution. (C) 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.