Introduction: What Is Endomidface? ENDOMIDFACE® by Direct Vision is a midface elevation surgical technique developed by Dr. Robério Brandão since 2006. The name derives from “Endo” (internal, referring to the subperiosteal approach) + “midface” (middle third of the face).
⚠️ Fundamental Clarification
Despite the “Endo” prefix, Endomidface is NOT an endoscopic technique. The name refers to the anatomical approach (internal access to the midface), not to the use of cameras. The technique uses Direct Vision** — surgical loupes and frontal illumination — completely eliminating the need for endoscopic towers. This distinction is critical because it represents the central proposal of the technique: achieving superior or equivalent results to traditional endoscopy without the costs, complexity, and equipment risks.
Historical Context
The technique was born from practical necessity. Working in Natal, Brazil, Dr. Brandão did not have access to the $100,000-$150,000 endoscopic towers that were the standard for midface surgery at the time. This forced him to develop approaches that achieved the same objectives with available resources. In 2007, Dr. Brandão became a pioneer in facial video-endoscopy in Rio Grande do Norte. Paradoxically, this experience with endoscopic technique validated his suspicions: the equipment added cost and complexity without necessarily improving results. Direct vision, when properly optimized, offered equal or superior control. Over 18 years and more than 1,500 surgeries, the technique was refined to the current protocol that forms the basis of the [Modern Face Institute training program.
Anatomical Foundations
Endomidface works in a specific anatomical plane: the subperiosteal space of the midface. This is the virtual space between the periosteum (membrane covering the bone) and the maxillary, zygomatic, and frontal bones.
Why the Subperiosteal Plane?
Avascular plane: Virtually no significant vessels between periosteum and bone, minimizing bleeding
Anatomically defined: Clear boundaries facilitate spatial orientation during dissection
Nerve protection: The facial nerve is superficial to this plane, protected throughout dissection
Resistant to biostimulators: Rarely affected by fibrosis from previous treatments
Key Structures
Must Preserve
- • Infraorbital nerve (sensation)
- • Temporal branch of facial nerve (motor)
- • Zygomatic branch of facial nerve (motor)
- • Facial artery and vein
Must Mobilize
- • Malar fat pad
- • Orbicularis oculi (malar portion)
- • Malar retaining ligaments
- • Periosteum (elevated en bloc)
Surgical Technique: Step by Step The following protocol represents the standardized sequence taught at the Modern Face Institute. Variations may be necessary according to individual anatomy and specific objectives.
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💡 Technical Note: Official Terminology
The Modern Face protocol uses standardized terminology: Platysmaplasty (midline platysma suture), Digastric Shaving** (controlled anterior belly reduction), Glandular Loop (repositioning without removal of submandibular gland). This nomenclature is taught in the mentorship programs.
Advantages Over Other Techniques
Endomidface vs Traditional Deep Plane
Aspect Endomidface Deep Plane
Anatomical focus Midface (malar) SMAS/jowl/neck
Main vector Vertical ↑ Oblique-lateral ↗
Dissection plane Subperiosteal Sub-SMAS
Special equipment Loupes + headlight None or endoscope
Facial nerve risk Minimal (plane deep to nerve) Moderate (crosses nerve plane)
Ideal indication Malar ptosis, nasolabial fold Severe jowl, SMAS redundancy
Modern Face (biostim.) Excellent Plane may be altered
Important: Endomidface and Deep Plane are not competing techniques — they are complementary. A patient with significant malar ptosis AND severe jowl can benefit from both. The question is: which problem are you solving? For detailed analysis, see our article: Endomidface vs Deep Plane: Complete Technical Analysis
Indications and Contraindications
Indications
- ✓ Malar fat pad ptosis (malar bags)
- ✓ Deep nasolabial fold
- ✓ Hollow tear trough
- ✓ Lower eyelid with skin show
- ✓ Patients 45-65 years old
- ✓ History of biostimulators
- ✓ Desire for natural result
- ✓ Preference for fast recovery
Contraindications
- ✗ Patients 70+ with severe redundancy
- ✗ Primary problem is jowl (use Deep Plane)
- ✗ Significant skin excess
- ✗ Unrealistic expectations
- ✗ Uncontrolled coagulopathies
- ✗ Active facial infection
- ✗ Psychological instability
Frequently Asked Questions
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For surgeons: Learn the Endomidface technique in our mentorship program.