The growing popularity of injectable biostimulators like Sculptra® and Radiesse® has transformed the facial anatomy we encounter in the operating room. What was once predictable territory now frequently presents itself as a minefield of fibrosis, requiring new approaches and techniques to ensure the safety and efficacy of a facelift. This complete guide for 2025 offers a detailed overview of how to navigate these challenges, focusing on the techniques of the Modern Face philosophy, led by Dr. Robério Brandão.
With over 18 years of experience and more than 1,500 facial surgeries performed, Dr. Robério Brandão, creator of the Modern Face philosophy and the Endomidface by Direct Vision technique, offers a protocol validated by 212 documented cases, with 0% permanent nerve injury. This guide is essential for surgeons seeking predictable and safe results in the era of biostimulators.
The Problem: Fibrosis Induced by Biostimulators
Biostimulators, although effective for stimulating collagen production, induce a fibrotic process in the Superficial Musculoaponeurotic System (SMAS) layer. This fibrosis, often described as a “biological superglue”, can adhere to surrounding tissues, making surgical dissection more challenging and increasing the risk of nerve injuries.
[Image: Illustration showing the distribution of fibrosis in the SMAS after injection of biostimulators]
Where Fibrosis is Most Common
Fibrosis tends to concentrate in the fixed lateral SMAS, the area of the cheek closest to the ear. This is a critical zone, as it is traversed by important branches of the facial nerve.
The Risks of Ignoring Fibrosis
When performing a traditional facelift on an injected face, the surgeon may face:
- Difficulty in dissection: Fibrosis makes SMAS detachment more difficult and time-consuming.
- Increased risk of nerve injury: Tissue adhesion to the facial nerve increases the probability of injuries during dissection.
- Unpredictable results: Fibrosis can distort facelift results, leading to asymmetries and irregularities.
The Solution: Modern Face Philosophy and Endomidface by Direct Vision
The Modern Face philosophy, developed by Dr. Robério Brandão, offers an innovative and safe approach for facelifts in injected faces. The central pillar of this philosophy is the prioritization of safety and the minimization of surgical trauma.
[Video: Dr. Robério Brandão explaining the Modern Face philosophy]
Endomidface by Direct Vision: A Safe Anatomical Shortcut
The Endomidface by Direct Vision technique is a key component of Modern Face. It offers an anatomical shortcut that bypasses the zone of fibrosis, minimizing the risk of nerve injury.
How It Works:
- Superior Access: Instead of approaching the SMAS laterally (as in traditional deep plane), Endomidface uses a temporal incision, allowing access to the SMAS from top to bottom.
- Bypassing Fibrosis: This superior access allows the surgeon to bypass the area of fibrosis, working in a more superficial plane and avoiding direct dissection in the adhesion zone.
- Direct Vision: Unlike endoscopic techniques, Endomidface is performed under direct vision, without the need for cameras or complex equipment. This allows better visualization of anatomical structures and more precise control of dissection.
[Image: Comparison between the lateral access of Deep Plane and the superior access of Endomidface, showing the avoided fibrosis zone]
Benefits of Endomidface in Injected Faces:
- Reduced Risk of Nerve Injury: By bypassing fibrosis, Endomidface minimizes the risk of damage to facial nerve branches.
- Natural and Long-Lasting Results: The technique allows precise tissue repositioning, restoring volume and facial harmony naturally and lastingly.
- Faster Recovery: The minimally invasive approach results in less edema and bruising, allowing a faster return to normal activities.
- Less Reliance on Grafts and Fillers: By repositioning tissues structurally, Endomidface reduces the need for fat grafts or fillers to restore facial volume.
The Modern Face Protocol: Step-by-Step for Lifting in Injected Face
Success in lifting an injected face depends on careful planning and precise execution of a proven protocol. The Modern Face protocol, developed by Dr. Robério Brandão, offers a step-by-step guide to ensure procedure safety and efficacy.
1. Detailed Pre-Operative Evaluation: Mapping Fibrosis Anatomy
Pre-operative evaluation is crucial to identify the presence and extent of fibrosis in the SMAS.
- Patient history: Record all previous aesthetic procedures, including the type and amount of biostimulators injected.
- Physical exam: Palpate the face to identify areas of fibrosis and tissue adhesion.
- Ultrasound: Use ultrasound to map the depth and extent of fibrosis in the SMAS.
[Image: Ultrasound example showing fibrosis in the SMAS]
2. Precise Surgical Marking: Planning the Access Route
Surgical marking should take into account the location of fibrosis and the dissection plane.
- Temporal incision: Mark the temporal incision, following the hairline and avoiding areas of alopecia.
- Dissection plane: Define the dissection plane, which should be sub-SMAS and as superficial as possible in the area of fibrosis.
- Nerve marking: Identify and mark facial nerve branches to avoid injuries during dissection.
3. Refined Surgical Technique: Navigating Safely in the Sub-SMAS Plane
Dissection should be performed with care and precision, using delicate instruments and minimally invasive techniques.
- Access to SMAS: Perform the temporal incision and access the SMAS, avoiding direct dissection in the fibrosis area.
- Release of ligaments: Release SMAS retaining ligaments, such as the zygomatic ligament and masseteric ligament, to allow tissue repositioning.
- SMAS repositioning: Reposition the SMAS in a higher position, using sutures and appropriate fixation techniques.
[Infographic: Step-by-step illustration of the Endomidface by Direct Vision technique]
4. Modern Deep Neck: Harmonizing Cervical Contour
Often, a facelift in an injected face is combined with Modern Deep Neck to harmonize the cervical contour.
- Submental Access: Make a small incision under the chin to access the submental region.
- Platysmaplasty: Suture the edges of the platysma muscle to create better jawline definition.
- Liposuction: Perform liposuction of submental fat to reduce neck volume.
[Image: Before and after of a patient undergoing Endomidface and Modern Deep Neck]
5. Closure and Post-Operative Care: Optimizing Recovery
Incision closure should be performed with techniques that minimize skin tension and promote proper healing.
- Sutures: Use absorbable sutures to close deep layers and non-absorbable sutures for the skin.
- Dressings: Apply compressive dressings to reduce edema and bruising.
- Instructions: Provide detailed instructions on post-operative care, including rest, wound hygiene, and medication use.
Dr. Robério Brandão’s Tips and Tricks for Lifting in Injected Face
Based on his vast experience, Dr. Robério Brandão shares some tips and tricks to optimize results of lifting in injected face:
- Use Ultrasound: Ultrasound is a valuable tool to map fibrosis and plan surgery.
- Be Conservative in Liposuction: Avoid aggressive liposuction, as it can remove natural skin support and lead to unwanted results.
- Do Not Fear Correcting Asymmetries: Facial lifting can be used to correct existing facial asymmetries or those caused by previous procedures.
- Communicate Clearly with Patient: Explain risks and benefits of procedure, as well as realistic expectations of results.
Relevant Anatomy for This Procedure
Anatomical knowledge is fundamental to understand how results are achieved safely and effectively.
Key Structures
The face is composed of layers that must be understood together:
- Skin: most superficial layer, reflecting aging through wrinkles and sagging
- Subcutaneous tissue: contains fat that redistributes with age
- SMAS (Superficial Musculoaponeurotic System): fundamental layer connecting muscles to skin
- Facial muscles: responsible for expression and dynamic support
- Retaining ligaments: anchor skin to facial skeleton
- Facial nerves: control movement and sensitivity
Surgical Planes
In Modern Face philosophy, we work in specific planes:
- Superficial plane: above SMAS, used in less invasive procedures
- Deep plane (sub-SMAS): below SMAS, allows longer-lasting results
- Subcutaneous plane: used for fat grafting and fat treatment
Why This Matters
Understanding anatomy explains:
- Why certain procedures last longer than others
- How natural results are achieved
- Why surgeon experience is crucial
- How complications can be avoided
“Respect for anatomy is what separates natural result from artificial result. In Modern Face, each structure has its role and must be preserved or repositioned with precision.” — Dr. Robério Brandão
Conclusion: Mastering the Art of Lifting in Modern Face
Facelift in injected face presents unique challenges, but with appropriate knowledge and techniques, it is possible to obtain safe, effective, and natural results. By following Modern Face protocol and Endomidface by Direct Vision, you will be prepared to face challenges of modern face and offer your patients rejuvenation they desire.
Remember: The key to success is combination of technical knowledge, surgical skill, and patient-centered approach.
[CTA: Download complete checklist of Modern Face protocol for lifting in injected face]
Related Content
- Endomidface: Complete Guide to the Innovative Technique
- Endomidface vs Deep Plane: Which is the Best Option?
- Modern Face: The Revolutionary Concept in Facial Surgery
- SMAS Anatomy: Essential Guide for Facial Surgeons
- Facelift: What to Expect from Recovery
Frequently Asked Questions (FAQ)
What are biostimulators and why do they complicate a facelift?
Biostimulators, like Sculptra and Radiesse, are injectable substances that stimulate collagen production in skin. However, this process can also lead to formation of fibrosis in SMAS (Superficial Musculoaponeurotic System), tissue layer supporting face. This fibrosis can make surgical dissection more difficult and increase risk of nerve injuries during facelift.
What is main advantage of Endomidface in faces with biostimulators?
Endomidface by Direct Vision offers safer approach in faces with biostimulators, as it allows bypassing fibrosis area, accessing SMAS from above and avoiding direct dissection in adhesion zone.
Is it necessary to remove submandibular gland in a Deep Neck?
In Modern Face, removal of submandibular gland is not routine practice. Instead, technique focuses on repositioning fat and platysma muscle to improve neck contour, minimizing risks associated with gland removal.
What is recovery time after a facelift in injected face?
With minimally invasive techniques, such as Endomidface, recovery time can be 7 to 10 days, compared to weeks necessary to recover from more invasive traditional techniques.
How to know if dissection plane is correct?
Tactile sensation is important guide. Correct sub-SMAS plane should offer little resistance, with sensation described as “separating pages of wet book”.
What areas of face can be treated with facelift?
Facelift can treat forehead, midface, and neck, depending on technique used and individual patient needs. Endomidface focuses mainly on midface, while Deep Neck treats neck.
What are risks of operating on face with fibrosis?
Main risk is injury to facial nerve due to greater difficulty of dissection and tissue adhesion to nerve area.
Conclusion
Lifting in injected face demands new look at traditional techniques. Modern Face philosophy, with its focus on safety, naturalness, and optimized recovery, offers promising path for surgeons seeking exceptional results in era of biostimulators.
Remember: Mastery lies in combination of technical knowledge, surgical skill, and patient-centered approach.
⚠️ Disclaimer
This content is educational and represents author’s technical opinion based on documented clinical experience. Surgical decisions must be individualized.
Author: Dr. Robério Brandão, CRM-CE 8596 Last update: January 2026