**Background:** Zygomaticomaxillary complex (ZMC) fractures are common maxillofacial injuries, accounting for 23-42% of such fractures. Surgical management often requires open reduction and internal fixation via approaches to the inferior orbital rim. Transcutaneous approaches (e.g., subtarsal) provide good access but risk visible scarring, while transconjunctival approaches avoid external scars but may have limited exposure. The Y-modification of the transconjunctival approach aims to improve access to the frontozygomatic region. This study compared the subtarsal, conventional transconjunctival, and Y-modified transconjunctival approaches in terms of operative time, accessibility, pain, edema, complications, and esthetics.
**Methods:** This randomized clinical trial enrolled 24 patients (19 males, 5 females; mean age 31.82 ± 9.23 years) from the Emergency Ward of Alexandria University teaching hospital (August–October 2022). Inclusion criteria: ZMC fractures requiring open reduction and internal fixation, age 20–50 years. Exclusion criteria: existing periorbital laceration, infection, comminuted fracture with bone loss, conjunctival diseases. Patients were randomly allocated into three equal groups (n=8 each): Group A (subtarsal approach), Group B (conventional transconjunctival approach with lateral canthotomy if needed), Group C (transconjunctival approach with Y-modification). All surgeries were performed under general anesthesia. Parameters evaluated: exposure duration (minutes from incision to field exposure), accessibility to fracture site, postoperative pain (VAS at 24h and 1 week), postoperative edema (subjective at 24h, 1 week, 4 weeks), ocular complications (ectropion, entropion, scleral show, etc.), wound healing, sensory nerve function (at 3 months), and scarring (at 6 weeks). Statistical analysis used ANOVA, Chi-square, and post-hoc tests.
**Key Results:** Exposure duration was significantly different among groups (p<0.001): Group B had the shortest (mean 8.75 ± 1.28 min), followed by Group A (13.50 ± 1.77 min), and Group C the longest (23.38 ± 1.41 min). Accessibility to the fracture site was 100% in all groups with no significant difference. Pain at 24h was significantly higher in Group A (mean 9.0 ± 0.76) vs Group B (7.75 ± 1.04, p=0.031); at 1 week, pain was significantly higher in Groups A (6.63 ± 0.92) and C (5.75 ± 1.39) compared to Group B (4.0 ± 0.76, p<0.001). Edema at 24h: Group B had 100% mild-to-moderate edema, while Group A had 100% moderate-to-severe and Group C had 50% moderate-to-severe and 50% severe (p<0.001). At 1 week, Group B had 100% mild edema; Group A had 100% mild-to-moderate; Group C had 25% mild-to-moderate, 37.5% moderate, 37.5% moderate-to-severe (p<0.001). At 4 weeks, Group B had 100% no edema; Groups A and C had 100% mild edema (p<0.001). Ocular complications occurred in 37.5% of Group A (ectropion/scleral show), 25% of Group B (entropion, transient diplopia), and 12.5% of Group C (mild scleral show), with no significant difference (p=0.836). Wound healing disturbances (infection) occurred in 25% of Group A, 0% of Group B, and 12.5% of Group C (wound dehiscence), not significant (p=0.302). Sensory nerve function was affected in 25% of Group A, 0% of Group B, and 12.5% of Group C (numbness), not significant (p=0.747). Scarring was present in 100% of Group A vs 0% in Groups B and C (p<0.001). Radiographically, all cases showed adequate reduction.
**Clinical Implications:** The conventional transconjunctival approach (Group B) offers the shortest operative time, least postoperative pain and edema, and no visible scarring, making it an excellent choice for ZMC fractures requiring access to the infraorbital rim and orbital floor. The Y-modified transconjunctival approach (Group C) provides superior access to the frontozygomatic region without an additional lateral brow incision, but with longer operative time and more edema than the conventional approach. The subtarsal approach (Group A) results in visible scarring in all patients and higher early pain, though it provides adequate exposure. Surgeons should consider the Y-modification when frontozygomatic fixation is needed, while the conventional transconjunctival approach is preferable for isolated infraorbital rim fractures. All approaches had comparable low rates of ocular complications and sensory nerve dysfunction.