The New Normal: Treated Faces
20 years ago, patients came to facial surgery with “virgin” faces — never treated with minimally invasive aesthetic procedures. Today, this reality has changed drastically.
📊 Clinical Reality Data
• 90% of patients seeking facelift have already used biostimulators
- • 75% have had multiple treatment sessions
- • 60% combined different types of products
- • Average age for starting treatments: 35-40 years This means facial surgeons need to know how to operate on faces that no longer have virgin anatomy. The question is not “if” you’ll encounter fibrosis — it’s “where” and “how much”.
“Refusing patients because they have biostimulators means refusing 90% of current demand. The answer is not to refuse — it’s to adapt the technique.”
- — Dr. Robério Brandão
Why Do Biostimulators Complicate Surgery? Biostimulators work by stimulating collagen production. This collagen creates tissue fibrosis — scar tissue that permanently alters local anatomy.
Poly-L-Lactic Acid (Sculptra)
Creates diffuse fibrosis in treated areas. Multiple sessions = cumulative fibrosis. Peak fibrosis: 6-12 months
Calcium Hydroxyapatite (Radiesse)
More localized but intense fibrosis. Microspheres may be palpable. Peak fibrosis: 3-6 months
Polycaprolactone (Ellansé)
Most intense and lasting fibrosis. Can create “blocks” of scar tissue. Fibrosis: can last years
Hyaluronic Acid
Less fibrosis, but high volume can compress structures. Can be dissolved. Duration: 12-18 months
⚠️ Risks in Traditional Techniques
• Altered anatomical planes — traditional surgical plane may not exist
- • “Trapped” nerves — fibrosis can involve nerve branches
- • Increased bleeding — fibrosed tissue is more vascularized
• Difficult dissection — loss of tactile feedback in blind techniques
• Unpredictable results — tissue responds differently to traction
The Solution: Direct Vision on Injected Face Endomidface by Direct Vision solves the central problem: unpredictability. When you see and feel simultaneously, you can adapt the technique to the real conditions of each patient. This approach is detailed in our [Endomidface section.
✓ Visual Identification of Fibrosis
Under direct vision, fibrosed areas are visually identifiable — they have a whiter color, different texture and increased consistency. The surgeon can literally see where the problem is.
✓ Simultaneous Tactile Feedback
While visualizing, the surgeon feels tissue resistance. Fibrosis offers different resistance from normal tissue — this allows adjusting force and direction of dissection in real time.
✓ Adaptive Navigation
Instead of following a predetermined plane (which may not exist), the surgeon navigates through spaces that effectively exist in that specific face. Each surgery is personalized to the altered anatomy.
✓ Preservation of Structures
Nerves, vessels and other critical structures are identified before being approached. If a nerve is involved in fibrosis, it’s possible to see and bypass it safely.
Practical Protocol: Modern Face Approach
1. Detailed History
Identify all previous treatments: product type, volume, number of sessions, approximate dates, treated areas.
2. Clinical Mapping
Careful palpation to identify fibrosis areas. Mark zones of greatest consistency in preoperative planning.
3. Adequate Timing
Ideally, operate after peak fibrosis (6-12 months after last application) when planes have already been defined.
4. Direct Vision Technique
Dissection under direct visualization, identifying and bypassing fibrosed areas. Use of available planes, not theoretical planes.
5. Realistic Expectations
Explain that treated faces may have slightly different results from virgin faces — but still excellent.
Results on Injected Faces
Of the 212 documented cases in Dr. Robério Brandão’s series, a significant percentage were patients with previous biostimulators. Results demonstrate that it’s possible to: 0% Permanent Nerve Injury 7-10d Social Recovery These numbers are especially significant because they include exactly the population that other techniques consider “high risk” or even contraindicated.
Frequently Asked Questions
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Related Articles
Direct Vision Technique
Learn why seeing what you’re doing is the ultimate safety feature.
Biostimulators Guide
A broader look at how different products affect facial tissues.
Fibrosis Management
How we navigate through scar tissue during rejuvenation.
For surgeons: Learn to master the [Endomidface technique through our education programs.
Master the Technique for Injected Faces
Learn to operate safely on patients with previous biostimulators.
Learn About Training Program