Necklifts, time management, and building a successful practice

Transcript

Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I'm your host, Dr. Jason Hall.

Dr. Hall: So, in this show, I sit down with Dr. Mike Nayak. Dr. Nayak is an internationally known facial plastic surgeon based out of St. Louis, Missouri. He got his undergraduate degree at Yale, followed by his medical degree at the Washington University of St. Louis. He then did an ear nose and throat residency training at the Massachusetts Eye and Ear Hospital, which is part of Harvard. Maybe you've heard of that school up there. After that, he did a one-year facial plastic surgery fellowship in New Jersey before relocating back to St. Louis, and opening up his own solo practice with his wife. Please enjoy this wide-ranging conversation about cosmetic surgery business and life with Dr. Mike Nayak.

So, Dr. Nayak, welcome to the show.

Dr. Nayak: Well, thank you.

Dr. Hall: How did you kind of get to where your—give me a little background about where you're coming from, how you got started in St. Louis, and how you got started solo?

Dr. Nayak: That's so funny. The first question I got asked in the last podcast I was on was, "So, why St. Louis?" [laugh]. The exact same question. I grew up about 100 miles east of here, and my wife grew up in Southwest Missouri. And then her parents moved to pretty close to here as well, and so we wanted our kids to be close to their grandparents. Neither one of us got to see our grandparents much growing up. They got to see their grandparents all the time by virtue being located here. Also went to medical school here and my wife and I met here, so we had a lot of connections here. So yeah, so that's why we landed here. That's how it happened.

Dr. Hall: I'm in solo practice here in Knoxville; we're here for almost the exact same reasons. I grew up here, this is where my folks are living currently; we wanted our kids to be close to the grandparents, especially as they were getting older. And I started a practice about five years ago with my wife very similar to how you did things. How has that been working for you? And talk a little bit about what it's like going to work with your wife because I think a lot of people who work with their spouses wouldn't have it any other way, and a lot of people who don't work with their spouses can't see how you'd make work and marriage work.

Dr. Nayak: Yeah, that's a good question. So, when we started, it was she and I and, like, two or three other employees. And so we had a receptionist, a, kind of, medical assistant, and someone that was kind of scrub tech-y medical assistant-y. And that was it.

And so, Avani is my wife's name—if you look at our website or anything a lot of it says Avani Derm Spa. So, I branded the non-surgical part with her first name on it. So, she wore a lot of hats. She was accounts payable, she helped answer phones, she would help room patients, she would help do consent sessions here and there, almost anything that didn't require touching a person she would help with. As we have evolved, as you can imagine, each of those jobs has developed into its own unique job, usually in multiples, you know, 10 or 12, receptionist, or 10 or 12 medical assistants or whatever, so as each job peeled away from her, she got to relinquish each of those.

And so now she is mostly,

kind of, business development. She is no longer day-to-day in the office because we got to a certain point where we had enough other helpers, that we could do it well, and she was kind enough to help do what I wasn't able to do as well, just be home with the kids and raise them. So, she went from more than 40 hours a week, to 20-something hours a week, to now it's kind of more as needed stewardship, steering, directing ideas, outside eyes. Which is, interestingly, almost as helpful as when they're actually in the building. Because they can see it with fresh eyes.

As far as working with your spouse, it worked well for us. You know, I come home, I can't help but talk about work, and if she was not a part of it, I think it would have almost been harder because I'd come home be talking about something that is not as relevant to her. Whereas when she was a big part of it—and she's still a big part of it—you know, I come home and talk about work, and it's relevant to her. So, in a weird way, it's actually been easier, I think, than if she was in a completely different field.

Dr. Hall: Yeah, I couldn't agree with that more. I think my wife and I come home from the office every day and are making dinner and hanging out with the kids, and the back and forth the conversation, it never really steers away from work because that's kind of what we do all day, every day. And when we're both together, it really… it's a sense of understanding that kind of goes both ways. My wife, Amanda, understands the stresses of being a surgeon and seeing patients and operating, and I understand the business side of it that she's taken care of with, you know, business and employees and marketing and all of that. So, I think it really works well, at least it does for us.

You know, you mentioned something a minute ago, about jobs peeling away from her over time, peeling away from you over time, and that has been something that we have had a very difficult time doing is delegating. Once you start something from nothing then backing off and letting go of the reins, how did you—the two of you—go about that?

Dr. Nayak: Ah, it's a growing-up process, it's the hardest thing to do. So, she never really managed the staff. When we started out really small, we didn't have that many staff to manage, and that was one thing that she made very clear, she was never interested in being the office manager. That was not at all—so as soon as we got to a point where we kind of needed a true manager—or like, I want to say we had the two of us, three employees, and maybe the fourth hire was an office manager, the fourth hire, sixth employee.

I started off doing a lot of things myself, like all the pre-op visits, I'd do myself, the suture removal visits, the injectables, numbing patients, everything, I would do it all myself. And when you're starting, you have time to do that. And then as you start hiring people—and I still have this bend—you want to lead from the front, you want to lead by pulling, not by pushing, you want to set examples, you don't want to be… prima donna-y, you know, and say, "I'm not going to do this anymore; it's time for you to do it." And then you kind of have to grow up a little bit and go, "Well, if I'm doing that, then—that's actually not my job." You know, that is actually a job for someone and they're happy to do it. That's what they're getting paid to do, and it's keeping you from doing things only you can do.

That's one thing you can add to get over. And I still have a hard time entirely getting over that. Like, the other day, I emailed something to our web developer instead of emailing it to my COO, and she was like, "I really wish you would have emailed it to me because there's something else I wanted to add into that." You know? And meanwhile, I'm feeling guilty because I'm like, I don't want to email her something, say, "Hey, tell our web developer this exact sentence," when I could just as well address him and CC her. You know what I mean?

But I needed to not. I needed to say to her, "Tell him this," because she had something to piggyback onto it. You know, so you kind of go okay, well, there's reasons for that. And then the second part that's hard to let go of is perfection, you know, so—or what you think is perfection. So, when I did Ed Williams' podcast, we spent a lot of time on this topic, and it is, you know, if you have an employee that can do something—this is not medical, this is not people's lives, this is your processes—that can take something away from you and do it 80% as well as you can, you should be giving it to them. You know, because eventually, they'll do it 90% as well as you can, and eventually they'll do it better than you can.

But you have to be able to live with that uncomfortable period of time when they're only doing it 80% as well as you can. And you have to be able to live with those decisions that they make that are not the direction you would have turned in that little circumstance. But again, if you're holding everything, you don't have any room left in your hands to do other work. You know, so you just kind of have to get over it.

Dr. Hall: Yeah. And that is so true. And what you just said about being able to turn things over to people who can do it 80% as well as you can, that, at least personally, has been the difficult part is deciding what those little things are.

Dr. Nayak: Yep.

Dr. Hall: Is, you know, within the office is, what is something that somebody can do 80% is as well as I could do it, having done every job in the office except for answer the telephones, to turn over to them?

Dr. Nayak: Can I tell you the second part of that?

Dr. Hall: Sure.

Dr. Nayak: Layer two of this—

Dr. Hall: Yeah.

Dr. Nayak: —is that needs to happen with your staff, too. So, you know, we have somewhere between 55 and 60 employees right now. I could not personally manage 55 to 60 people, and so it's also not reasonable to expect my one HR manager to directly manage 55 to 60 people. And so number one, you need to build a branching leadership structure.

And number two, you need to make sure that your managers are doing the same thing that I just described to you, identifying things that they can give down, give away, peel off, supervise, accept that it's not going to be exactly what they wanted. Because otherwise, your managers are going to get bogged down. It's actually, you know, one of the things that we're always talking about. I do a meeting every day with my managers of the things we just talked about today, what could you have not done yourself?

You know, and so I help them, like you're saying, it's hard for you to see what you can give away; it's hard for them to identify what they can give away, so we try to make a minute almost every day to say, "Okay, all these things that you just told me about and we just did, what parts of this could you have delegated to the next tier and it's off your plate?" And so I tried to help them see those opportunities as well.

Dr. Hall: And you have that meeting every day? That's impressive.

Dr. Nayak: Every day. Yeah.

Dr. Hall: Yeah.

Dr. Nayak: In software development especially, they call it up morning standup or morning Scrum. So, what happens is, I operate every day. When the patient is going—after I finished marking on the patient and they go to the operating room to get sedated and prepped and draped and injected, I usually have anywhere between 20 minutes and an hour of time where I've finished marking but it's not time to cut yet. And so, that is just—it's reserved, that period of time—we call it morning meeting in our realm—my managers and I sit down together and we have active lists of topics that we keep up to date, and we run our lists.

And we run them until we run out of topics or until it's time to cut, whatever comes first. And so every day, we meet between 20 and 60 minutes in the morning, and they debrief me on what happened since our last meeting, they seek input for what they're having decision issues or want my opinion on something, and if I have new things to bring up, I don't even—I just add them to the list, actually, all day long. I stick them on that list and we talk about it the next morning. So, it keeps us efficient. So, every day, once a day, we are realigning. And I'm getting informed and I'm giving my input and opinion and then I go off and be a doctor for the rest of the day. And those managers keep the place running until we meet again.

Dr. Hall: That's fantastic. It sounds like the system that you have built there is really streamlined and efficient to maximize your time in the operating room and your time with patients, which I think a lot of solo practice surgeons, a lot of group practices could learn from because that is a very difficult thing to get right.

Dr. Nayak: So, I got that system from a book that I would strongly recommend. It's called The Art of Scrum, S-C-R-U-M, The Art of Scrum. And the Scrum is, again, from the software development world. It is a way of organizing your to-do lists to be maximally effective and it's a way of executing projects to be maximally effective.

And it's a short book, but I would recommend reading it because it helps you maintain focus where it's important and not get bogged down in details are not quite as important. And one of the things in this book is what they call the Morning Scrum or the Daily Scrum [or whatever 00:11:43], which is this meeting. And then other aspects of the business world, they call it a morning stand-up. And the reason they call it—we don't stand, we sit, but the reason you call it a morning standup is it is intended to be a meeting that is so short, you should be able to carry it on standing up. Like, it's not a four-hour meeting. Honestly, morning standups should probably be a 15, 20-minute meeting, you know? But it's constant, short touch base, touch base, touch base on a daily basis. And then we have other you know, once a month, we have an office meeting or whatever. But this is just management team.

Dr. Hall: That's interesting. I wrote that down; I'll have to take a look at that. You know, you have a huge team, and I was looking through your website, which is beautifully designed by the same folks that designed ours, just out of—

Dr. Nayak: Nice.

Dr. Hall: —interest. They do a fantastic job, these guys out in LA do a fantastic job with that. But one of the things that I noticed, you've got a lot of injectors, and you take great pride in the fact that your injectors are personally trained by you to inject and see people the way that you see them. How do you go about training each one of those injectors who brings with them, maybe a preconceived notion of what good injectable treatments are, or help them develop their aesthetic eye so that their treatment plans are in line with what you would do if you were in the room with a patient?

Dr. Nayak: I make them tag along for a while with me and then with our senior injectors. So, we just write off their first two months or so in the training. So, the first two months or so that they're with us, they're going to follow. So, on my end, they—I don't do as many injections anymore, but they follow me into injecting and they follow me into consultations, they follow me into the operating room.

I show them the relevant anatomy, and my injectors have all seen orbicularis oculi, they've all seen zygomaticus major, they've all seen the platysma, they know it deep under the skin it is, they know what it looks like. They've all seen roughly where the supraorbital bundle is, you know they've all—all these infraorbital bundle, they've all seen these things in with their own eyes and real heads. So, I think that gives them a step up because not only they watched me inject and then got a flavor of aesthetic from being in with me through surgeries and injections and consults, they've also seen real-life anatomy. Then they go off and they spend time with the nurse injectors the senior team, basically being their assistant, drawing up their drugs, getting their stuff ready, documenting. Because later on when—none of my nurses inject without an assistant; they all have medical assistants with them always because it's just silly to have a nurse not treat someone because, you know, in a certain hour if you're across all the different [unintelligible 00:14:11] spending ten minutes drawing up botox, that could have been a whole ‘nother Botox visit which more than pays for a different medical assistant, you know?

So, if you're the nurse and you being assisted by a medical assistant, you need to know what they're doing; you need to make sure that they're doing it correctly because in the end the documentation is your responsibility that—making sure they got the right dose and drug and whatever is your responsibility. So, we have them actually shadow and pretty much assist our more established injectors for the rest of that. So, in those two months, it's a little time with me, a little time with them, and by that time they have been thoroughly brainwashed because they've seen the same pattern, or they've heard the same pattern, they also know what a proper note looks like, they know where we keep all our stuff because they've had to go get it, they know how to reconstitute a bottle to—because they'll come here—some people come with on-label 2.5 for a hundred units. Some people come with one. Some people come with four, you know? So, their math has been reprogrammed.

We do take it though as an opportunity. You know, we have, kind of, onboarding and offboarding interviews, so when we bring someone on, one of the things that I make sure to tell them, especially if they're from another practice is, we're kind of stuck in our ways to a degree, and you're going to walk in here and some of the stuff you see, you're going to think in the back of your head, "That's stupid. I don't know why they're doing that." You need to say that out loud to us. And we may say, "Oh because, you know, we used to do it this other way." Or, "Oh, my God, you're right. There's a better way."

So, you know, I always tell them as a very fresh person, whether it's injecting technique or anything else, you are actually a valuable asset to us if you show us different ways. And then we have an onboarding interview which we can talk about later. But that's kind of the answer is, that's how we train them all, is they just—we just write off a couple of months at the beginning.

Dr. Hall: Yeah. And that is a great way to go about training people because that, you know, one of the hardest things from our standpoint, as you are well aware of, is bringing people on from other practices or starting somebody from scratch and making sure, A, that they're safe, but then that they're good; that they get the kind of results that you would expect that you and I would want our own patients to have. So, that's an awesome, awesome way to go about it. So, let's switch gears to talk about some surgery.

Dr. Nayak: Sure.

Dr. Hall: So, right now, you're kind of the neck lift guy on Instagram, that seems to be what a lot of your posts are about, and a procedure that you really enjoy. How did you develop that focus and where did that come from?

Dr. Nayak: That's a good question. So, I am ENT background originally, and then did a facial plastic fellowship, and I was in university practice for two years and then in 2006, entered private practice. And I do all full-spectrum—I almost never inject anymore, to be honest with you. It's only in the training sessions anymore, but I do everything else with really to facial cosmetic surgery.

So, I do almost no reconstruction anymore unless it's a friend of the family. So, I do all day, every day, aging face, and rhinoplasty. Those are the two things that I do. And as far as how did the neck become a focus, you know, people talk about the nose as being the most challenging cosmetic procedure, and it probably still is, but number two is the neck. But unlike the nose—the nose is probably the most challenging and everybody knows it—the neck is right up there, just barely less challenging, and nobody respects it. Everyone thinks it's an easy operation, or it's—you know, that it—no one really understands what a true neck rejuvenation entails if you can do it right.

And I just love it, you know, so it's one of the things that has been a passion of mine. I had great mentors; Tim Martin taught me 99% of what I know about the neck. You know, I used to say one hundred percent, but I've learned a little bit, but it's still 99% of what I know about the neck I learned from Tim Martin. And I make sure to say it as often as I can because you know he deserved it; he was nice enough to share all that with me. And so that has just become, I think because almost anyone can do a pretty nice facelift and almost anyone can—almost anyone can do a pretty nice upper blepharoplasty, and lots of people doing nice lower blepharoplasties, doing a truly beautiful neck lift is still less common, I think. And so, for me, it's something I like, it's something where I kind of have a competitive edge, and it has just become self-sustaining in some ways; you know, you kind of get known for it.

Dr. Hall: Yeah. So, whether a patients or—potential patients or surgeons out there that are going to be listening to this, tell our listeners what it is about the neck that makes it such a challenging operation.

Dr. Nayak: Well, I like to talk about the neck or the evolution of neck lifting is kind of generation one, generation two, generation three. So, the neck lifting 1.0 was suction the skin and suction the fat immediately under the skin and then tighten the skin. And that was, kind of, neck lifting—or not maybe not tighten the skin—neck lifting 1.0.

And so by analogy in your belly, that would be, you know, liposuction outside of your abs, plus or minus cut some extra skin away. That was 1.0. But that is the least important layer of the neck, especially in older necks. In older necks, there's almost never significant, meaningful excess fat in that layer.

The layer behind that, the platysma, it's analogous to your abs and your belly. So, neck lifting 2.0 was like what abdominoplasty is: You know, you get rid of the extra skin, if there is excess fat, you get rid of it and you tighten the muscles that create the waistline of the abdomen or of the neck. So, that was neck lifting 2.0 point.

And it was better, but I want you to imagine you know, a woman that's pregnant and you come in with an abdominoplasty and say you're going to give her the scaphoid belly of a 18-year-old. You know, not without delivering that baby you're not going to get that to happen. And so, neck lifting 3.0 is, we're going to set the foundation of the neck to be the shape we want it to be instead of taking the precious subcutaneous fat that's left when you're 50 and throwing it away and then taking the platysma, which is by nature a weak prone to failure muscle and somehow trying to tighten it so much that you pack all the non-compressible deep neck structures into the mandible and hope they stay there. Why don't we sculpt the deep neck so it is sitting at the shape you want it to and let the platysma and skin passively follow that shape?

And so that's kind of 3.0. So, one 1.0 is suction the fat, ignore everything else, maybe take some skin; 2.0 is take the platysma and try to push everything up into the jaw and hide it, and 3.0 is just move the skin and platysma out of the way, sculpt the neck the way it's meant to look and just put the skin and platysma back.

And so we are so programmed to think of looseness and excess fat as the enemies of youth, that treatments that start with tightening and defatting are doomed to failure. And that's why neck lifts are hard.

Dr. Hall: Yeah, what would you say is, when you're assessing a patient? Because I'm sure in your practice, very much the same as mine, probably a lot of the surgeons listening, people come in and say, "Oh, I just want you to liposuction right here. I don't like the way my neckline looks; I need some liposuction." How do you go about, A, assessing that, whether or not that's a valid treatment option, and then explaining that to the patient so that, you know, what is a much more aggressive operation in their minds, is something that they say, "Okay, I see where you're coming from. That makes sense. Let's proceed."

Dr. Nayak: So, you know, if it's soft, pudgy, round, baby fat kind of neck, then liposuction can often be a good choice. [pause]. It's still usually not the best choice to be a hundred percent honest, but I mean, it can be an okay choice. If it's soft, pudgy round, baby fat back, springy skin, and the floor of the neck feels like it's in good condition, good shape, then, you know, you could debulk the subcutaneous layer and get a nice change.

In my opinion, that is actually pretty rare. And you can start fights with that statement I just made, but it all depends on who's examining and what their standards are, you know? So, I like a lot more subcutaneous fat left in the neck at the end, in general, because I want the de—it's like a rhinoplasty and you want to sculpt all the deep stuff, you're not making those smaller by thinning the skin and using camouflaged [crushed 00:22:16] grafts and leaving the framework intact. You want to do all the work on the framework level and then at the very end, maybe some camouflage grafts, maybe some skin thinning, that kind of stuff. So, it's kind of like saying, "All right, so you got a person with a big nose. In which cases would you mostly just thin the skin on that nose and not work on the framework?"

And the answer is almost never, you know? And that's the same with the neck; in which cases do you omit the framework and mostly in the hypodermis, the fat? And it's rare, to be honest with you. Again, 20s, baby fat, maybe. The other ones I'll do it with is if it's just, like, it's the finishing touch; it's not what they're judging me by.

They're getting a rhinoplasty and a chin implant and we're, you know, need to take a three cc's of fat of there, so [unintelligible 00:22:58] out; it's not the only thing they're hanging their happiness on. That's a pretty good candidate, too.

Dr. Hall: Yeah I'm going to ask the question, I think I already know the answer. Kybella: Thumbs up or thumbs down?

Dr. Nayak: I'm not a fan. I'm not a fan. So, if Kybella worked amazingly and predictably, it would be equally dissatisfactory to liposuction, but it doesn't work amazingly and predictably, so it's a poor approximation of an already poor solution for a problem.

Dr. Hall: Yeah. I totally agree with you there. Good for maybe tiny liposuction touchups on the body—

Dr. Nayak: [crosstalk 00:23:40], yeah.

Dr. Hall: —but—yeah, but it's just too unpredictable. In that area, you see too many central neck complications from aggressive defatting for Kybella to really be worthwhile. Speaking of aggressive defatting, you know, most of us who make a name for ourselves doing one particular procedure end up being the revision specialist for that procedure. Have you started seeing a lot of neck revisions?

Dr. Nayak: Yeah, absolutely. I mean, I see my ow—you know, I have gone through an evolution in my own practice and, you know, 10, 15 years ago, I was doing exactly what I just described to you is not my favorite thing. You know, I doing more liposuction. I used to start every necklift by liposuctioning the subcutaneous fat. That was the first thing I did.

Now, it's never, you know? Or at the very end of surgery, I'll directly, meticulously sculpt it with scissors, but I used to start every procedure by liposuctioning subcutaneous fat. So, I'm seeing my own people come back. And they got good results. The standards have changed just in the last five years as far as what a good result is, you know, so I don't want to give you the wrong impression that the people I treated 15 years ago, I'm not proud of.

They were great for that era. You know, they looked really good 15 years ago, but as time goes on and they age and they come back then I see patients of my own—and others—where they've had subcutaneous defatting, and now we have to do a neck lift in an older patient with less than optimal subcutaneous fat. I don't have a great way to completely put it all back, you know? It's not—I know there are people that do fat transfer to the neck and then stage it and then do a neck lift; I haven't done that. Maybe I'll try it one day, more than anything, I just do my best with what I've got and I set expectations.

And the wonderful thing about neck lifting is the relatively unforgiving 16-year-old doesn't need a neck lift, like, a rhinoplasty might have happen, you know? Most neck lift patients are older, 40s at least, they have a little bit of humility, they've kind of seen things happen in life, they have some understanding, they have some empathy, and so the patient you and I are just describing is, like, 60, and she's had a previous neck lift and it defatted or whatever. And so you approach her and say, "Okay, listen. I can make an improvement. It's not going to be my best one. Here's why." And for the most part, you know, she looks at [it and 00:25:57], she goes, "Doc, I get it." You know. So.

Dr. Hall: Yeah, and I think that honest discussion is really important. Acknowledging our own limitations with the patients when we're talking to him in the concert room, instead of just trying to get them to sign on that line for surgery is very important. What of the various techniques, deep neck techniques—describe those for the listeners as to what those different techniques are that are not just removing fat and tightening the muscle.

Dr. Nayak: Yeah, so this is not what it really is, but it'll be a good analogy. So, if you think of, you know, peas in a pod, and you can see the contour of the peas through the pod, you know, we're literally going in the pod, taking the peas out, and now the pod looks—in collapses into that dead space. So, I'll describe it in true anatomical conditions. We're lifting up the skin and soft tissue, lifting up the platysma, which is, like, a little curtain of muscle, those two layers together are not even a third of an inch thick.

So, when you start from the surface and go into your neck, not even a third of an inch you're past all that. And we talked about ‘deep neck,' well starting about a third of an inch under the skin, you're in the deep neck. So, it's deep anatomically, it's not deep, meaning six inches deep into your neck, right? So, once you get into that layer, there are other structures. There's other kinds of fat, and it's typically fibrous fat that is not dietarily responsive.

So, they're built with it, they either have it or they don't; it can grow with age, there are muscles of different shapes and configurations that we can change or sculpt or reorient which can make the foundation of the neck look better. There are overgrown lymphatic tissues, overgrown salivary glands, under-supported bony structures, you know, like, a soft chin, that kind of thing. All of those things can be readjusted to create the ideal kind of flat area under the chin and a vertical segment of the neck and a nice transition as sharp as you want or don't want between the under-chin and the front of the neck. And then again, the superficial areas, which we used to be totally focused on, we just put them back down. So, we're rolling the grass up, doing all the landscaping on the bedrock and the soil, and then unrolling the sod again. That's probably the best analogy for it.

Dr. Hall: Of those techniques, or those myriad little maneuvers in the deep neck, is there one that you find gives a more reliable, good outcome, whether it's submandibular gland contouring, digastric muscle contouring, removal of that central deep fat, chin augmentation that really is the, kind of, workhorse of your operations?

Dr. Nayak: No, they're all equally important. So, if the problem is under-projected chin, then there's only one answer to that and that's make the chin more projective. Now, how you chose to do that, sliding genioplasty, or chin implant, or whatever, but the idea is you have to build that spot, if that's a weak spot. If the fullness in the deep neck is paracentral, you know, just outside the midline, that's digastric. If it's a little further out and it's submandibular, that's submandibular gland.

So, it's not so much that one has a better, more reliable treatment than the other. It's, anatomically is the fullness here, or is it here, or is it here? Or, is the weakness here, or is it here, or is it here? And depending on where the fullness or weakness is, different structures account for those different contours.

Dr. Hall: Mm-hm.

Dr. Nayak: So, it's all the above, like, basically. So, some people don't need any gland work they need only digastric and deep fat. Some people's chins are perfect, some people need a chin implant. So, basically just—fit the key to the lock.

Dr. Hall: And this is a theme that tends to come up in this show. Certainly, I've said it multiple times; say multiple times a day during consultations, it's important to diagnose before treating. You've got to get an accurate diagnosis to have a good treatment plan that's going to be effective in this, just like in any other area of medicine.

Dr. Nayak: I think Osler said that. I think, "First diagnose, then treat."

Dr. Hall: Mm-hm. Exactly right.

Dr. Nayak: I say it all the time. I say it all the time in office hours. First diagnose, then treat.

Dr. Hall: Yeah. I'm right there with you. So, deep neck surgery, at least in some of the meetings you hear some surgeons talk about how deep neck surgery is dangerous. Lots of complications; don't want to get into any of that. Talk to me about what some of those complications are, and how common they are.

Dr. Nayak: It is absolutely more dangerous than other neck lifting. I'd be a liar to say it's not. But neck lifting is more dangerous than liposuction, and liposuction is more dangerous than no surgery. So, where you draw the danger line is up to you.

And you can modify, you know? Liposuction with one doctor is more dangerous than liposuction with another doctor, you know? And regular platysmaplasty with one doctor is more dangerous than—I would argue that deep neck surgery with a skilled deep neck surgeon is safer than regular face lifting with someone that's an average facelift surgeon, you know? So, which one are we going to outlaw? Are we going to outlaw facelifting with an average surgeon? Or—

Dr. Hall: [laugh].

Dr. Nayak: You know what I mean? Like—

Dr. Hall: Yeah. Oh, yeah.

Dr. Nayak: Where do you—you know? So, yeah, sure, within any one given person's skill set, the things that are more complicated are by nature more complicated. But if it's done correctly, that can still be a completely acceptable and manageable risk. So, the things that people really talk about deep neck-wise, risk-wise, one is nerve injury. So, the most commonly injured branch of the motion nerves of the face, the motor nerves of the face, depending on who you read and who you believe, [unintelligible 00:31:28], it's the marginal mandibular nerve, the nerve that moves the bottom lip. That nerve is at risk just with liposuction. That nerve is at risk with Kybella. It's at risk with heat-based, non-ablative—you know, with things that don't even truly penetrate the skin. So, you know, if you're saying, well, the risk to that nerve makes the deep neck surgery unacceptable, well, then you can't do anything to the lower face because it's at risk with that—you know what I mean? So—

Dr. Hall: Yeah.

Dr. Nayak: —done well, I do not believe that risk to that nerve is any higher than just a regular facelift. So, that's one thing. Lingual and hypoglossal nerves, the nerve that helps move your tongue and gives your tongue sensation, and helps create taste in your tongue, those nerves are kind of near the field when you're working deep in the neck, but you'd have to be really way out of line to actually encounter them. But I mean, they're—technically you're near them.

But when you're a layperson, and I say to a layperson that those nerves are within millimeters of where I'm working, it sounds terrifying. But when you're a surgeon, you say those nerves are well protected by an obvious plane, you know that's a totally separate layer of onion. You know, we're working on onion, as long as I don't go past that next layer of the onion, I'm safe, and it's an obvious layer. Then it's actually very reassuring for me to know exactly—I know exactly where not to be.

The next one is, since we are working on salivary tissue, a salivary leak, where you know, saliva collects in the neck, maybe. That risk is very easily controlled by the use of drains and just basic surgical principles. You know, we work on secretory tissues all over the body all the time, and there are principles that are hundreds of years old that we use to manage that and keep the risk as close to zero as possible. So, that's a risk that I manage extremely well, do it the exact way Tim Martin taught me with deep drains. I do Botox the gland, which he is not a fan of, but I do that so that if the drain falls out earlier, if the patient doesn't follow their diet or whatever, I have a safety net in there, and I know that salivary secretion is going to shut down for a couple of months afterwards, and I'm safe.

The last one that is unique to the deep neck surgery is bleeding in deeper structures. And so, if you're not working in there and cutting in there, well then you can't have bleeding from there. If you work—anywhere you work in the body, there's a chance in the next week or two, it could bleed. And so that, in my opinion, is the biggest one. So nerves, saliva, all that stuff, that's fine.

True bleeding, that's a real risk. And with the deeper neck surgery, there is risk of delayed bleeding, so you have to be an especially meticulous surgeon. So, most facelift hematomas, bleeding is going to happen in the first 24 or 48 hours. With deep neck surgery, it's been seen as late as a week or two later, seven or eight days later. And so you have to be a super meticulous surgeon, find vessels, control them, you know, oversew things.

It requires attention to detail. And that doesn't make the risk zero, but again, I think it's very controllable. And I'll say for the surgeons out there if this doesn't sound like fun to you, don't do these procedures because you can't do them if you're not willing to take all this extra step to do them safely and correctly.

Dr. Hall: I agree with that statement a hundred percent. In terms of hematomas, another one of the things that those of us who do cosmetic facial surgery all the time talk about back and forth is general anesthesia versus IV sedation and local. What's your preference there?

Dr. Nayak: I do everything under IV sedation and local. It's deep IV seda—it is not conscious sedation, it's deep sedation. They are not aware, they don't feel anything. They don't remember anything. It's true deep sedation, it's not conscious sedation, or [unintelligible 00:34:47] or any of this stuff. It's true deep sedation.

Dr. Hall: Mm-hm. And for the non-surgeons out there, the reason that that is important is because you can have some high blood pressure issues coming out of anesthesia—out of a general anesthesia—and that has to be if you're using a general anesthetic, which I personally use a general anesthetic endotracheal tube for every facelift necklift. You have to really—between you and your anesthesia provider—have to be really careful to avoid that spike in blood pressure, which can cause a hematoma.

Dr. Nayak: And that can happen with [unintelligible 00:35:25] sedation. It happens just—

Dr. Hall: Yeah.

Dr. Nayak: Yeah. That's another one of the things that I think is super important: The surgeon is important, the facility is important, the care team is important. My team does nothing but [unintelligible 00:35:34] me, and all we do is this advanced facial surgery. So, when I go to a hospital, I'm always worried that the nurse in the recovery area, you know, she's also being called away for the person that's having pain after their knee replacement, whatever.

You know, my patient has to pee real bad in the recovery areas; she doesn't realize that's an emergency. Getting my patients bladder empty so that they don't have high blood pressure from a high bladder, so they don't develop a hematoma in [unintelligible 00:35:57] PACU. A full bladder is an emergency. They might not consider it an emergency, but it's an emergency, you know, and my team knows that. My team will identify the beginning of a hematoma and firewall it off so it can't occupy the whole neck, and they'll have that thing controlled—meaning it can't expand—and someone's getting me, and it's a little exploration.

You know, if you don't have the right PACU team, that hematoma has occupied the whole face and neck, you have no idea where it started, and it's a much bigger production. When we have them, I know exactly where it is because they've trapped it off and it hasn't had an opportunity to propagate, you know? And it's a little deal at that point. So, we talked about it's got to be important for the surgeon to have skill, and the surgeon to be meticulous, and surgeon, surgeon, surgeon; all that's worthless if the anesthesia team as you were talking about, and even the post-operative care team isn't tuned to that same level.

Dr. Hall: Now, your operating room is in your building, is it not? Yeah. And I think that's something we're fortunate enough to have the same setup here, and I think that is—being able to control that patients experience from the time they walk in your front door, never having met anybody in the office, except for maybe a phone call and browsing social media, all the way through the recovery process, I think is crucially important for good outcomes.

Dr. Nayak: Yeah. It makes all the difference. Again, you can do your absolute best, and then when you give it up, you lose control over it, you know? And I don't go to the hospital anymore, you know?

And a part of it is the convenience and the efficiency, and part of is this, you know? I have, again, the same anesthesia providers, the same equipment, the same first assistant, the same scrub tech, the same PACU team. When the patient's in the recovery room, I'm just—I'm in office hours seeing people you know? And again, that same issue—say hematoma starts behind the ear—when it happens in my office, it's trapped off, they call me, they have the OR ready and I go fix it, and 15, 20 minutes happens in the hospital, it doesn't get caught until it's the entire neck; I'm across town, there's no room available. It's a completely different world.

Dr. Hall: Yeah. And a completely different world does not benefit the patient at all.

Dr. Nayak: No. So, that brings up the question, so what patients that need to be in a hospital environment? The answer is I don't do them. If you really need to go to a hospital, I'm not your surgeon.

Dr. Hall: Yeah. And we're very open about that same thing is that I don't go to the hospital anymore because it's—what we do is a want not a need—

Dr. Nayak: Yeah.

Dr. Hall: And you may want it, but you don't need it, so just being able to control the experience. And we have so many of our patients—as I'm sure yours do—that comment on that, after the fact, how nice it was and how comfortable it was to come in, see the same people, know that you're getting taken care of, know who to call, as opposed to being kind of left in the wild in some hospital recovery room somewhere.

Dr. Nayak: Yeah.

Dr. Hall: Shifting gears a little bit to recovery after neck lift surgery. In we'll use your terminology—generation one and two, treatment of the neck, the healing can be pretty prolonged with, you know, prolonged edema of that skin swelling of that skin, stiffness. How have you seen the recovery change as you've transitioned your practice from that generation to neck lifting to, now, deep neck lifting?

Dr. Nayak: It's still pretty intense. Gosh, I wish I could say it's so much easier now that you—I think as a general rule, the more tissues we touch, the more disruptive you are, the more healing needs to occur. And it's a recovery. I tell my patients is two to three weeks… by the time they are presentable.

Which, if you turn that statement around, you are not presentable in less than two to three weeks, you know? And that's just—you have to accept that and if someone is not okay with that concept, it's just like, you know, if they have to go to a hospital, we're not doing the surgery. I don't have a way to make it any faster. If I did, I would do it and I would triple my prices and we'd do it in a week. But it's not doable. As far as know. Maybe someday, but as far as I know, it's not possible to speed it up meaningfully.

Dr. Hall: Mm-hm. How do you have that discussion with patients in a consultation? Because now with the Covid Zoom boom and all of that has made prolonged recovery from some of our procedures a little bit more tolerable because people can get back to work sooner, remotely. But I'm still seeing a lot of patients that want the kind of the holy grail of plastic surgery: A surgical result with no downtime, no pain. How do you handle that?

Dr. Nayak: I'm turning 50 in a couple of weeks; that's what I want. I want surgical result with low risk and no downtime, and that's—you know, I want the same thing; I don't blame them for it. This is a whole different discussion, but by the time the patient makes it to the consult, if they are in my consult room and I'm walking into talk to them, if they don't know that already, our process has broken down. They should not have made it to my room without knowing.

And this is, like, a plug and it's not a plug, there's a company called Yellow Telescope, from Miami, and it's a consulting company that is based—their focus is on the consult coordinator, sales coordinator kind of process. And one of the things that they taught me—I don't have any economic relationship with him, it's just that they've made my practice better, so I like to acknowledge that, just like I acknowledged Tim with his neck lift stuff—we used to when people would call in for a consultation, we told our reception team or, you know, whoever answered the phone, like, "Just get them on the books; your job is to get them booked, and our job is to wow them and [unintelligible 00:41:27] them and get them on the surgical schedule. Like, just get them on the books."

This model is completely different. It's whoever answers the phone, their job is to get them to one of our very few people who have the privilege of putting a consultation on my schedule. And that person's job is to educate so thoroughly that by the time the patient makes it in here, they know what the procedure is, what the cost is, what the recovery is, what the major risks are, we know what their health conditions are, we know what their status is so that there should be no major surprises, nothing left to learn, one direction or the other, before the patient enters the building. And so those patients that can't make the two to three week kind of thing work in their life actually don't make it to the consultation. And if they did, we've had a horrible breakdown or process.

Dr. Hall: Yeah, I'm seeing and hearing more and more surgeons going to that model, that really aggressive—we'll call it aggressive; sounds like a bad word, but the aggressive education on the front end, partly because our time in the office is limited because our time is spent in the operating room.

Dr. Nayak: Our time on this earth is limited. How much time do you want to spend doing consults that don't matter, you know?

Dr. Hall: Exactly.

Dr. Nayak: Yeah.

Dr. Hall: Gosh, that's a great, great point. I saw somewhere that you have hyperbaric oxygen, a hyperbaric chamber in your office. Is that right?

Dr. Nayak: I do.

Dr. Hall: Tell me about that.

Dr. Nayak: There—as you know, for wound healing, there's incontrovertible evidence that hyperbaric oxygen is actually beneficial to wound healing. For optimizing surgical recovery, I think they're softer evidence. And there's kind of a three variables situation: Pressure, oxygen concentration, and time, that together inform how much benefit there is the treatment, right? And so you know, if you're under one hundred percent oxygen, three atmospheres, a short period of time, there's good exposure.

For a consumer-level hyperbaric chamber, you know, 1.3 atmospheres is pretty much what you're going to get. And so that's what we have a 1.3-atmosphere chamber. And we have our patients in there for, like, 90 minutes, you know, and I feel like that's better than a 30-minute dive or a 60-minute dive.

You could even do oxygen and nasal cannula for two or three hours and it's actually somewhat helpful, believe it or not, even though they sat one hundred percent. Without it, there's a little bit extra that gets absorbed into the liquid phase of the blood, you know, the serum of blood. So, what we have is a 1.3-atmosphere chamber. We're not going to drop anyone's lungs, no one's going to have a seizure. If we had to absolutely emergently decompress them, it's not going to be a big deal.

So, to me, this is kind of the sweet spot, it's a consumer-grade kind of thing. When we hit two and three-atmosphere chambers, it's actually a whole ‘nother business, you know, hyperbaric medicine is a whole ‘nother science, and that is outside where I need to be living right now. So, we do 1.3 atmospheres, it's just a built-in part of the recovery offerings that we have. There's not a cost for it, it's packaged into the surgical plan, and as long as they're not claustrophobic or don't have problems equalizing their middle ear pressure, we just offer it to everybody postoperatively.

Dr. Hall: What percentage of patients choose to dive and how many dives does your average patient do?

Dr. Nayak: I'd say 80% chooses to try, and I'd say 50 or 60% actually do a few dives. 80% choose to try, a third of those, like, "Nope. I'm out. I—claustrophobic, or my ears are just not equalizing."

So, only probably about half really go through with the program. And I can't tell you that it's just a dramatic difference between A and B, but it feels like we're doing something good, the patient understands and appreciates it, and I mean, there's no real risk to it. But I would be lying if I said ever since we turned that [unintelligible 00:45:07], wow, the recovery's dramatically better. And I don't like just making stuff up or, you know, so would I buy it again? Yeah, I probably would, you know, because I've seen some dusky flaps look way better, and for that, I'm actually very satisfied with it.

But for the average, uncomplicated recovery, is it dramatically smoother? I don't know. I don't know that it improves the average uncomplicated recovery. I do think it helped my borderline patients significantly. Maybe it's keeping some of the uncomplicated ones from becoming borderline ones and I don't see that [unintelligible 00:45:33].

Dr. Hall: Yeah. Now, do you operate on smokers?

Dr. Nayak: I don't.

Dr. Hall: Okay.

Dr. Nayak: I'm just lucky if we have enough of a pool that we just have a policy that we just don't do smokers.

Dr. Hall: Mm-hm. And in terms of other, kind of, pre-surgical things, BMI requirements, you have a cutoff of, what, 30? 31?

Dr. Nayak: I'll tell you, the truth is, it's 32. In our accreditation documents and policies and procedures and everything, I write 32. And that's where our accreditation was based around, we tell the patients 31 so that if they come in a pound or two over—because I mean, I'll cancel. I am not going to I'm not going to have a record where I operate in someone that's outside of my policies. It's not worth it to me.

So, we tell them 31. I prefer 30. And also, as you well know, overlaid on all of that is where are they carrying their 30, 31? Are they carrying it on their chest, or they can get in their bottom? You know, if they're carrying their hips and their butt 30, 31 is no problem. If they're carrying it on their barrel chest and on their gut, then—their breasts, then 29 can be tricky. So, there's absolute ceilings with people that will still fail under that ceiling if they're built wrong.

Dr. Hall: Yeah. We have the same very similar requirement here for the same reasons. And it does, fat distribution matters, for results, for anesthesia safety, it certainly matters. We've been talking to here for almost an hour; I want to respect your time, but I do want to ask you, you seem to have an unlimited amount of time; you are an incredibly busy surgeon, run a huge practice, are very active on social media. What daily routine or routines do you have in place that allow you to accomplish so much every day?

Dr. Nayak: Well, you know, I have Avani at home, which is tremendously helpful. My son is in college, so his time requirement for me is next to zero. My 16-year-old daughter lives at home, but has, you know, a very busy life, so her time requirement is shrinking. So, I have time that seems unlimited compared to when I had, you know, 6, 7, 8-year-olds running around. I think that's the single biggest thing that creates more time in my life.

Number two is, again, I have this, I have a huge team and I give away as much as I possibly can. And as you can tell, I'm very into systems; anytime I think I can streamline something, I'll write a new system, make it more streamlined. So, I'll give you an example. So, you know, virtual consultations now, my consult coordinators will put together a packet for me, and it shows up, every—it has to be in one email; I want the Zoom link, I want the new patient paperwork, I want the standardized views, I want whatever you were going to text me and tell me right before we got on the consult, or email me, or leave in their medical record note or whatever, I want it all in one packet. And if you need to update something, oh, there's a new piece of information, you're not going to send me an email with a stinger on it; you're going to send me a brand new email that has everything still in one place so that I'm just going to open the most recent email related to that topics, and I have everything in it. So, I'm not spending any time searching, you know what I mean? So, any little thing that I can give away gets given away.

And then the last thing is—this is going to be really silly, you're not going to believe this—I don't have an attention span to watch TV. I don't have an attention span to watch episodes, or movies, or any of that stuff. I can't do it, I get bored. I'm on my phone, I'm daydreaming or whatever. So, if it's sitting down and creating content, I have the same attention span I have when I'm in the operating [unintelligible 00:49:02] something, or I'm working on something.

If it's consuming content, I don't have a great attention span. So, think of the average, I don't know, hour-and-a-half to three hours that the average person might spend watching something, I'm doing something. It's not because I feel like it's better, I just don't have the ability to sit down and watch that kind of stuff. [unintelligible 00:49:23] crazy. I mean, I used to and I kind of miss it. Now, I can't talk to people about TV shows anymore but I can't do it.

Dr. Hall: Yeah. And I think that's a blessing and a curse.

Dr. Nayak: Yeah.

Dr. Hall: You know, because I'm very much the same way. It's hard to sit down for any length of time and not be engaged with something.

Dr. Nayak: Yeah. I mean, that's the real answer. Yeah, that's it. I have nothing else to add.

Dr. Hall: I very much appreciate you taking the time to talk to me today. Where can people learn more about you?

Dr. Nayak: Probably the best places would be my website, nayakplasticsurgery.com, brought to you by the fine folks that brought your website out, or I only have the time really to focus on one social platform. I do always social myself and so I only had the time to focus on one platform, and that platform is Instagram just because it does everything that the short-form video, it does long-form educational video, it does daily stories, it does posts, I can do it all-in-one place, so it's kind of nice. And so our Instagram is just @nayakplasticsurgery. And it's N-A-Y-A-K. So, @nayakplasticsurgery on Instagram or nayakplasticsurgery.com.

Dr. Hall: Very good. Well, Mike, thanks so much again. I appreciate your time today.

Dr. Nayak: My pleasure, Jason. Thanks for having me on.

Dr. Hall: Yeah, absolutely.

Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.

Dr. Mike Nayak - Necklifts, time management, and building a successful practice

The Trillium Show Podcast with Dr. Jason Hall

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