The Silent Change in Facial Surgery There’s a reality that few plastic surgery textbooks address: most patients who come to the office seeking surgical rejuvenation have already received injectable treatments. Fillers, biostimulators, support threads — years of treatments that have fundamentally modified facial anatomy. This isn’t a problem when you’re doing more filling. But when the scalpel enters, everything changes. Anatomical planes that should glide easily are adherent. Tissues that should have predictable consistency have areas of irregular fibrosis. Landmarks you memorized may be displaced. The [Modern Face® was born from this reality. It’s a surgical philosophy developed for the contemporary patient — one whose facial tissue has history.
“Operating the Modern Face with techniques developed for virgin tissue is like using a 1950 map to navigate a city that has grown exponentially.”
- — Dr. Robério Brandão
What Do Biostimulators Do to Tissue? To understand the surgical impact, we need to understand the mechanism of action of biostimulators:
Basic Mechanism
1 Injection: Particles are deposited in subcutaneous or subdermal tissue
2 Inflammatory reaction: The body recognizes particles as foreign body
3 Encapsulation: Fibroblasts deposit collagen around particles
4 Neocollagenesis: Continuous collagen production creates sustained volume
This process is desirable for non-surgical rejuvenation. But surgically, it means:
Fibrosis
Scar tissue that adheres anatomical planes. The sub-SMAS that should glide easily may be “welded”.
Granulomas
Inflammatory nodules around particles. Can be confused with anatomical structures or tumors.
Altered Planes
Neocollagenesis can create “false planes” that seem correct but lead to dangerous structures.
Irregular Consistency
Areas of normal tissue interspersed with fibrosis areas make uniform dissection difficult.
Impact by Product Type
Not all injectables have the same surgical impact. Here’s an analysis by category: Mechanism: Duration: Surgical impact: Recommendation: )) }
Technical Adaptations for the Modern Face The Modern Face philosophy incorporates several adaptations to deal with tissue modified by injectables:
- Preference for Subperiosteal Plane The subperiosteal plane (between periosteum and bone) is rarely affected by biostimulators, which remain more superficial. The Direct Vision Endomidface technique works in this plane, offering predictable dissection even in treated faces.
- Direct Vision over Endoscopy Direct vision allows identifying and bypassing areas of fibrosis in real time. Traditional endoscopy may have difficulty distinguishing correct plane from pseudoplane created by fibrosis.
- Careful and Deliberate Dissection Instead of rapid, aggressive dissection, Modern Face advocates deliberate dissection with constant structure identification. This is especially important when landmarks may be displaced.
- Detailed Preoperative Evaluation Complete history of injectables, palpation of fibrosis/nodule areas, and in selected cases, ultrasound to map biostimulator deposits.
💡 Modern Face Preoperative Protocol
- • List ALL injectables: type, amount, date, location
- • Request pre-procedure photos (when available)
- • Systematic palpation seeking nodules/fibrosis
- • Consider preoperative HA dissolution
- • Wait adequate time post-biostimulator
- • Plan adapted technique (subperiosteal preference)
Frequently Asked Questions
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Conclusion: Adapting to the New Reality The Modern Face patient isn’t the exception — it’s the rule. Surgeons who insist on techniques developed for virgin tissue will encounter increasing difficulties. Adaptation isn’t optional; it’s a requirement for consistent and safe results. The Modern Face Institute programs were specifically developed for this reality, teaching techniques that work on both virgin tissue and treated faces.
Learn to Operate the Modern Face
Techniques adapted for the contemporary patient. Mentorship with Dr. Robério Brandão.
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