AESXXX10.1177/1090820X14534680Aesthetic Surgery JournalBook Review
IBUTION
TR
AL CON
ON
ERN
INT ATI
534680
research-article2014
Book Review
Aesthetic Surgery Journal
2014, Vol. 34(8) NP91­–NP93
© 2014 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
journalsPermissions.nav
www.aestheticsurgeryjournal.com
Malcolm D. Paul, ed. Clinics in Plastic Surgery: Necklift. New
York: Elsevier, 2013.
ISBN-10: 0323227376
Reviewed by: James D. Frame, FRCS, FRCS (PLAS)
DOI: 10.1177/1090820X14534680
Introduction
It is often hard to be critical of a book written in good faith
and with every good intention by surgeons invited from
different parts of the world, by a single editor himself with
a strong reputation as an international speaker. I have to
say, though, that this book, Clinics in Plastic Surgery:
Necklift, edited by Malcolm D. Paul, is not one to get too
excited about. It is not actually exclusively about lifting the
neck: it is about methods to nonsurgically tighten the
superficial skin and to surgically rejuvenate the aging neck
but mostly at a level above the hyoid only. At first glance,
the book is disappointingly small in size but not small
enough to put in a pocket. It is rather unattractively color
mismatched and could be easily lost behind a cupboard or
under a short table leg. It is a thin book, deficient in pages,
sometimes with blank sheets, yet it is supposed to contain
substance and exciting tips and tricks from all of its 16
invited authors (presumably with major contributions
from some junior doctor coauthors). It is not set out in
chapters per se, and this adds to the somewhat difficult-tofollow and confused lack of flow to the book. It is really a
collection of anecdotes and personal preferences. Some
authors clearly understand what we, as readers, want to
know. Others, unfortunately, say very little of interest and
stick to some pre-thought-out questions presented by the
editor. I will expand upon these later. On balance, I think
this book may be useful to some young plastic surgeons
engaging in the concept of facial aesthetic surgery and
perhaps as guidance to those wanting ideas to improve
their current outcomes. There are apparently some good
operative videos that accompany certain chapters. I would
be surprised if the publishers had exclusive copyright
because the surgical techniques are often referenced in
publications elsewhere.
Strengths
It was difficult to find many strengths to this book. The
preface really intended to systematically address anatomy,
then topical treatments, and finally surgical treatments.
The latter confusingly starts with aggressive surgery and
ends with a minimalist lower risk procedure. The book
begins with a chapter on anatomy, but I would prefer to
direct the reader to any undergraduate anatomy textbook
to get a much clearer understanding of the anatomical relationships within the neck. Simply listing contents within
triangles and levels of lymph node levels is not of interest,
and the small pictures and line drawings are pretty poor.
There are interesting and surgically important points made,
though—for example, on the platysmal anatomical variance, the digastrics, the anterior veins, and the marginal
mandibular nerve—but these are learned at the undergraduate anatomy level. I would have liked more on the anatomy of aging (eg, the ribbon-like platysmal fibers and how
they are held together or loosen or fall medially to create
the jowl and turkey neck of aging), why surgery reconstitutes the correct angulation of the platysma crossing the
mandible, and so forth.
Joseph’s chapter follows this one, but actually could
have been omitted, due to redundancy with Mulhollands’s
20-page chapter on nonexcisional, minimally invasive rejuvenation of the neck. I was a little confused by the comment that the physician should be aware of what the
Dr Frame is a Consultant Plastic Surgeon at Springfield Hospital,
Chelmsford, Essex, United Kingdom, and Professor of Aesthetic
Plastic Surgery at the Post Graduate Medical Institute, Anglia Ruskin
University, Chelmsford, Essex, United Kingdom.
NP92
surgeons can do and the surgeon should be aware of what
the physician can do. I thought patient safety was about
the plastic surgeons leading, engaging, and gaining knowledge in nonsurgical techniques supervised by surgeons. As
mentioned by several of the later authors, this is not surgery for the inexperienced, and simply reading this book is
not a license to practice without caution and consideration.
Similarly, there are considerable downsides to nonsurgical
management not addressed in this chapter—for example,
color changes, hair loss, and risks and inconveniences of
Botox, particularly the duration of action, frequency of
retreatment, repetitive costs of treatments, and patient dissatisfaction rates. To its credit, it is one of the few chapters
that discusses outside of the apparent remit, though.
The Dilson Luz wand technique is something that Paul
has adopted in his own practice, apparently. Those who
influenced Paul’s ideology on the neck are all included
within the book’s authorship. But, there are glaring omissions. The idea of lipocutaneous mobilization is all Brazilian
and not confined to the face. As Luz alludes, the technique
has reduced the risk, particularly of seroma, in abdominoplasty approximately 20-fold. It clearly works to allow safer
mobilization of the neck superficial to the platysma.
I remain unclear and confused about a number of issues
surrounding each surgeon’s view on submandibular gland
excision, anterior digastric corset suturing, or medial or
lateral tightening of the platysma, and I don’t agree with
the surgeons that say you need to drain necks. It depends
on what surgery you are performing.
Some of the clinical results shown in this book are
amazing. Very few pictures highlight complications, but it
was nice to see a seroma resolve in the chapter by
Matarassos and residual prominent submandibular glands
after surgery in the chapter by Oscar Ramirez. No author
offered hard statistics on clinical outcomes, complications,
reoperation rates, and how to treat anything other than
noncomplicated men and women.
I thought the chapters by Ramirez, Gonzales, and
Giampapa, in particular, were extremely well thought out,
and I would have preferred more from them. In many
respects, this book would have been better by limiting the
number of authors but adding more specifics and detail.
Unfortunately, the editor and the other authors did not
mention the IGuide platysmaplasty, the neck-defining
IGuide suture suspension technique, or the IGuide Gigli
procedure developed commercially by Greg Mueller
(Implicitcare, Los Angeles, California). I guess they are
similar concepts to a few of this book’s authors, and they
appear to have all developed independently as part of the
“theory of nultiples” over a period of a few years. No one
really should claim “a first,” since suture suspension, fat
grafting, and other techniques have never been specific to
the face or neck, and all were around before these authors
presented their ideas. I have to say also that the use of
Aesthetic Surgery Journal 34(8)
braided suture platysmal band division, which I call the
“Gigli procedure” after the Gigli saw action to cut bone, as
mentioned by several of the authors, is not, as inferred,
universally successful over time. Also, no author mentioned the importance of the use of a cervical collar to help
prevent recurrence of these divided bands by keeping the
neck at least in a nonflexed position for 2 weeks.
Additionally, no author mentioned direct excision of the
loose neck that defies all lifting and tightening procedures.
We all see them, and there is a place to do this type of
surgery. Direct neck skin excision with platysmal work is
simple, safe, and satisfactory surgery and is an important
exit strategy. As explained by several of the authors,
though, the patient must be fully informed and consented
and be realistic in expectations. I tend to agree with
Malcolm Paul’s final chapter, in which he has decided that
minimalistic surgery is safer. I disagree with his use of long
threads and the use of terms such as lifestyle lift. The public is easily misled by such trivialization of grammar, and I
believe that all plastic surgeons should be aware of Jones’s
Plastic and Reconstructive Surgery Journal paper (referenced in Trevidics’s chapter), which shows that the neck
after facelift is not as responsive to long-term results as we
once thought. It seems no one has the complete answer,
except it seems in Dr Ristow’s hands, and we all proceed
using our own personal experience but with direction from
our teachers, trainers, and mentors.
Weaknesses
As I was reading the chapters, I was surprised with the
amount of awkwardness in some of the sentences in the
early chapters. Aside from the actual meaning being
wrongly interpreted (Elsevier is usually extremely good at
translating and rewriting into the correct grammar), some
chapters could have made better reading. It didn’t enhance
my opinion of the book during the first surgical chapters.
The difficult neck was not addressed, and actual complication rates, including how to approach redo surgery,
were not adequately discussed.
I felt that some authors were too set on answering
what Paul wanted answering, but I suspect this isn’t what
the rest of us want to know. Who is bothered about fibrin
glue or pulmonary embolism? The readers need to see
preference of technique, as well as short- and long-term
outcomes.
There appears to be a preoccupation with the submandibular gland, with few authors advocating partial excision
and most relying on platysmal slings to hide prominent
glands.
Surprisingly, only 1 author mentioned surgically treating the lower neck, and this was by modifying the Fogli
mobilization and using the triple cable suture technique
(Darryl Hodgkinson). Even then, the results still showed
Book ReviewNP93
mild central submental looseness in an otherwise very
acceptable series of results.
No one mentioned the posterior cervical tightening procedure for treating lower cervical laxity. Perhaps there
needed to be a more diverse group of surgical authors to
fully cover the ground.
neck in case of resultant paralysis, treat with antihypertensives to avoid hematoma, or leave drains in situ for over 48
hours, the readers will note that there must be fairly risky
problems not adequately described in this book. The message of this book has to be a warning directed at the inexperienced surgeon that this surgery is not easy.
Summary
Rating: 2 of 5
I would not buy the book, and I would not recommend it
to my trainees. It would easily sit unread on the shelf. I
would, however, take a note of the authors and reference
peer-reviewed articles to their name. Some of these authors
have well-deserved reputations within this field, and an
opportunity has been lost, in my view. As an eminent surgeon told me the other day, he has 4 sides on A4 paper
listing the different ways to tighten a loose neck. Not any
one method can treat all patients and yield consistently
excellent results. Whether it be in this book’s chapters that
mention the need to secondarily divide platysmal bands,
inject Botox into submandibular glands to reduce prominence, be careful to avoid injecting Botox into the deeper
To purchase, visit: http://www.us.elsevierhealth.com/plas
tic-surgery/clinics-in-plastic-surgery-journal/00941298/
Disclosures
The author declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.