A scoping review of modifications of the transconjunctival approach for maxillofacial fracture management and proposal of evidence-based algorithm for incision selection

Abstract

Background The transconjunctival (TC) approach is widely utilized for orbital fracture repair due to its superior cosmetic outcomes compared to cutaneous incisions. However, concerns about limited surgical exposure, prolonged operative times, and lower eyelid complications have prompted several modifications of this technique. Purpose This scoping review aimed to systematically map and analyze the various modifications of the transconjunctival (TC) approach used for orbital and adjacent midface (infraorbital rim and zygomaticomaxillary complex) fracture repair, focusing on technical descriptions, clinical outcomes, and complications. Study selection A systematic search of electronic databases was performed following PRISMA-ScR guidelines to identify studies reporting modifications of the TC approach. Inclusion criteria encompassed clinical studies, retrospective analyses, and case reports or series that described surgical techniques and reported outcomes. Studies describing TC approach modifications for orbital, infraorbital rim, or zygomatic fractures were included. Studies without specific details on modifications or outcomes were excluded. Of the initially identified articles, 22 studies met the inclusion criteria after independent screening by two reviewers. Results Twenty-two studies describing TC approach modifications were included, describing eight major categories of TC modifications. Reported variations included lateral paracanthal extensions, sutureless TC incisions, cutaneous Y-modifications, extended TC approaches, stair-step incisions, modified lateral canthotomy and aesthetic variations, lateral skin extensions and canthal-sparing techniques. These techniques were designed to improve surgical access and minimise complications such as ectropion, entropion, and scleral show. Some modifications prioritized enhanced exposure, while others focused on reducing morbidity and optimizing aesthetic results. Due to the heterogeneity of study designs and outcome measures, quantitative synthesis was not performed. Conclusions and relevance The TC approach continues to evolve through multiple technical refinements that balance exposure and aesthetics. Awareness of these variants enables surgeons to individualise incision choices based on fracture patterns and risk profiles. The current evidence is largely descriptive and lacks standardised outcome measures, which limits direct comparisons. Prospective, well-designed studies are needed to establish the optimal modification for specific clinical contexts.