Introduction

**GL [02:26]:** Dr. Rebecca Knackstedt is a plastic and reconstructive microsurgeon who occupies an unusual position in academic medicine. She is simultaneously a Duke faculty surgeon operating on breast cancer patients, an MD-PhD researcher, and a functional medicine provider, which we’re going to talk about. Her primary research interest is, get this, surgical prehabilitation with nutrition, supplementation, and exercise. This combination, as you know, is rare. She’s built her research career on the argument that the weeks before surgery, and probably after, are really the window for intervention, and that patients have far more influence over their surgical outcomes than they’ve been told. She trained at the Medical University of South Carolina, earning both her MD and PhD after a bachelor’s in science. She joined Duke as an assistant professor of surgery in 2022 and is a member of the Duke Cancer Institute. Welcome to the show.

**RK [04:38]:** Thank you so much for having me.

Why prehabilitation

**GL [04:40]:** We typically think of surgery as very invasive and a heavy burden to the patient. We don’t really think about before surgery. But you’ve spent your career with a different frame of reference: pre-surgical intervention. Meaning what patients do before surgery influences outcomes after.

**RK [05:04]:** Yeah, it’s such an important topic, and it’s something that patients aren’t aware of, and surgeons aren’t aware of. It’s a conversation that all patients should be having with their surgeons, and it’s a conversation that isn’t happening.

**GL [05:16]:** It’s also not really taught. Tell us a little bit about your training.

**RK [05:21]:** I did my plastic surgery residency at Cleveland Clinic, and I did a microsurgery fellowship as well. While I was there, I was doing research with the functional medicine department on a study in prehabilitation, and along the way I decided to become certified. So I took the classes and did the exam, and that process really solidified my goal to view patients holistically. As a surgeon, I think about all of the aspects of my patients that are going to impact their surgical outcomes, apart from just what I do in the operating room.

What functional medicine is

**GL [05:53]:** The really unique component here is this. When the audience hears “functional medicine” and Googles it, they see people who aren’t qualified putting “functional medicine practitioner” on their websites and social media.

**RK [06:15]:** Right.

**GL [06:15]:** We have lots of academics who listen to the show. I’d love for you to explain what functional medicine is and how it plays into your thinking. It’s wonderful when someone from a traditional academic institution like Duke or Cleveland Clinic, both top tier, is interfacing with this idea of functional medicine.

**RK [06:39]:** Functional medicine is really just the belief that all aspects of health and wellness are interconnected. You can’t just treat someone’s blood pressure with a medication. You should think about their diet, their exercise, their sleep, and their stress, because those things impact their blood pressure. So it’s a more holistic look at patients. The challenge, and what you were alluding to, is that a lot of different providers can become certified in functional medicine. You don’t have to be an MD, a PhD, or a DO, so people’s training backgrounds are very different. When I did my functional medicine training, I had already completed my MD and PhD and was almost done with residency. That’s a very different background from someone who comes in without as rigorous a medical training —

**GL [07:26]:** — or any medical training.

**RK [07:28]:** Very true.

The patient who changed everything

**GL [07:29]:** It really does a disservice, because there’s traditional medical care, which thank goodness we have. For example, you do breast reconstruction after mastectomy, which you’ll tell us more about. But the people who listen to this podcast also want health and wellness. They want to know what they can do and where the evidence is, rather than spending time on things that may not change any outcome. Was there a moment in your traditional training when you thought, “We are doing this totally wrong”? You were training at a time when patients were still put on bed rest.

**RK [08:11]:** There was a patient in my own practice who really changed everything for me. When I started at Duke doing breast reconstruction, I truly thought that if I did good surgery and talked to the patient about upping their protein and taking some supplements, that was all they needed to heal. Then I started to get to know my patients, because I take care of breast cancer patients who are being hit with all of these stressors. There was one patient in particular, a young woman who had just been diagnosed with breast cancer. I met her during chemotherapy. She was upbeat, which is fantastic. She was doing well. We talked about her reconstructive options and made our plan. Then, between that visit and surgery, she developed metabolic syndrome, lost her hair, got divorced, her mom died of breast cancer, she lost her job, and she became homeless. She was missing appointments.

**GL:** Wow.

**RK:** And somehow I still thought, “I’m a surgeon. I’m going to do good surgery. She’s going to heal.” Of course, she didn’t. How can you heal from surgery with all of that going into it? That was a really humbling experience, because it forced me to recognize that I wasn’t doing the best I could for my patients. So I went into the literature and read beyond nutrition, which was my passion and expertise. I looked at sleep, stress, and social support. What I found was that not only do those things negatively impact surgical outcomes, but there are evidence-based things we can do to help patients heal. That was game-changing for me. It changed the way I practice medicine.

Protein for surgical patients

**GL [09:41]:** What is the current recommendation for protein intake in surgical patients?

**RK [09:49]:** There’s no standard recommendation, and that’s mind-blowing. I get so many messages on Instagram from patients saying, “I asked my surgeon how much protein I should be eating before surgery, and the answer was, ‘I don’t know, just eat your usual healthy diet.'” So there’s no standard answer, but the evidence clearly demonstrates that you need protein.

## Why breast reconstruction

**GL [10:12]:** Why breast reconstruction?

**RK [10:15]:** When I was a medical student, I happened upon plastic surgery as an elective. I didn’t think I was going to be a surgeon. I was actually a little squeamish around blood. I distinctly remember the first case on that rotation. It was a bilateral mastectomy with immediate reconstruction, where we placed what are called tissue expanders, and it was so eye-opening. I thought, this surgery is going to restore form and function. It’s going to restore so much of what this woman just had taken away. That’s when I decided to become a surgeon and focus on breast reconstruction.

**GL:** Have you been happy with that choice?

**RK:** Absolutely. It’s such an honor and a privilege to take care of these women. What I really love about plastic surgery is that I follow women for their whole lives. I get to know them and their families and what they’re struggling with emotionally, beyond just body confidence. It’s an honor to be part of their care.

What prehab looks like

**GL [11:16]:** And now you’re implementing prehab, pre-surgical interventions. What does that look like for someone listening who is going to have surgery? Is it specific to breast surgery, or is it any kind of surgery?

**RK [11:32]:** It’s any kind of surgery. I’m sure most of your listeners have heard of rehab, or even done it. Rehab comes after an event: you have surgery, then you start physical therapy. Prehab just backs that up and uses a lot of the same tools before the trauma that is surgery.

Training for your recovery

**GL [11:50]:** So what should someone do? Are there specific exercise recommendations?

**RK [11:58]:** Yes, and that’s something that has changed based on feedback from my patients. My initial recommendation was just to increase lean muscle mass. I didn’t care what they did. Get in the gym, lift heavy weights. But patients told me it was most helpful to work the muscles they’d be relying on after surgery. For breast reconstruction, I tell them they can’t use their arms for six weeks. And if they have a body-based belly reconstruction, their core is taken out.

**GL [12:24]:** What does that mean? What’s a body-based belly reconstruction?

**RK [12:28]:** It’s called a flap. It’s microsurgery, where we literally remove the fat and skin of a woman’s belly and transplant it to make a breast. It’s a big surgery with a long recovery, and it weakens your core. So what should you do before surgery? Squats. Strengthen your legs. Those targeted exercises are really going to help with post-surgical recovery.

**GL [12:52]:** Have you found a correlation between how much strength or mass someone puts on and — let me ask this a different way. Someone is scheduled for breast surgery, and friends, we’re not talking about elective surgery here. This is someone who has a breast cancer diagnosis or a significant family history, and they’re going in for an aggressive surgery. Is that correct?

**RK [13:20]:** Yes. It’s very different from a “boob job.”

**GL:** Which she said in air quotes, if you’re just listening.

**RK:** It’s a huge misconception.

**GL [13:28]:** It’s a huge misconception. When someone is scheduled for surgery, do they typically have lead time? For example, if someone knows they have a family history and needs to schedule a mastectomy, could they say, “Becky, I’m going to come to you in eight months. I’m going to spend eight months training and getting my nutrition right, because I know what’s coming”?

**RK [13:53]:** Absolutely. That’s very different from a woman who’s just been handed a breast cancer diagnosis, where we need to get her to surgery more urgently. But if you’re having a prophylactic mastectomy, meaning you don’t have cancer and you’re doing it to reduce your risk, then yes. I’ll have patients come in, we’ll talk about reconstruction, and I’ll say, “I don’t think we’re in a great state of health and wellness right now. We can safely delay this. Let’s work on these things and regroup, to set you up for the best success possible.”

## Muscle mass, strength, and function

**GL [14:24]:** Is there a baseline muscle mass? This is a challenging question because we don’t have standards. We know that someone with 30% body fat or more falls into one body composition category. But have you seen a percentage of muscle mass that correlates with better outcomes?

**RK [14:46]:** We don’t typically measure muscle mass, so I go on the subjective things. I ask, “What are you doing for exercise? Do you struggle walking up the stairs?” Getting a gestalt of where they are really helps me predict who’s going to struggle after surgery and who needs help preparing.

**GL [15:05]:** There’s the mass part, and then there’s the strength part. Anecdotally, do you think one or the other leads to better outcomes?

**RK [15:18]:** What I’ve found is that people with better functional muscle mass do better after surgery, because they’re better able to get out of bed when they can’t use their arms, and they can get off the toilet without assistance. When you start asking about activities of daily living, the people who can do those more easily recover better.

## Hormones and breast cancer

**GL [15:39]:** Hormones. That’s a question you get asked a lot.

**RK [15:44]:** Absolutely.

**GL [15:45]:** How do hormones play a role, not in diagnosis, but in treatment outcomes? I’m asking broadly so you can choose whether we talk about estrogen, testosterone, or progesterone.

**RK [16:00]:** With the recent removal of the black box warning, it’s becoming a huge area of conversation and research, as it deserves to be. Right now, the standard of care is that if you have a hormone receptor-positive breast cancer, you can’t be on systemic hormone therapy. Some women, after a risk-benefit discussion with their oncologist, still choose to be. But importantly, vaginal estrogen is safe, and that’s a conversation I routinely have with my patients. Thinking about holistic care: is it going to change her surgical outcome? No. But is it going to make her feel better if she can stay on vaginal estrogen? Absolutely.

**GL [16:38]:** That’s a really good point, and I want to add one more. For those listening or watching, vaginal tissue is very sensitive to a drop in estrogen, including in someone with a receptor-positive breast cancer. A lot of postmenopausal women go through that. But what about UTIs and sepsis?

**RK [17:06]:** Yes. What I also see a lot in my practice is young women put into medical menopause to reduce their chance of a breast cancer recurrence. I have patients who are 30 years old and in menopause. So to your point, vaginal estrogen keeps that mucosal tissue healthy and helps prevent UTIs and sepsis. It’s quality of life, but it’s also preventing sepsis.

**GL [17:31]:** Do you get pushback from other physicians? You probably get out-of-state referrals, because Duke is such a major academic institution. You’re primarily at Duke now, not Cleveland Clinic?

**RK:** Correct.

**GL:** People come from all over, and this is what happens in our practice too. They say, “Well, I can’t be on any hormones.” Do you see that?

**RK [17:59]:** Absolutely. I’m lucky to be at Duke, where we have providers and surgeons at the forefront of education and research. In those cases, I usually try to get them in to see a Duke provider so they can have an evidence-based discussion and decide what’s best for them.

**GL [18:17]:** So vaginal estrogen is really important for women. And what we were alluding to, which I realize we didn’t fully explain, is that when a woman’s estrogen is lower and her vaginal pH is off, she can get a urinary tract infection. Many people don’t think that’s a big deal, but UTIs are one of the primary causes of sepsis. There are many stories of people becoming septic, going to the ICU, and not surviving because it was caught too late.

**RK [18:54]:** Absolutely.

## Rising breast cancer rates

**GL [18:56]:** Say someone has a full mastectomy and the cancer is estrogen-positive. Do we know what percentage of breast cancers are hormone receptor-positive?

**RK [19:14]:** I don’t know that off the top of my head. The challenge is that there are so many subtypes of breast cancer.

**GL [19:20]:** Talk to me about that. It’s increasing, isn’t it?

**RK [19:23]:** It’s increasing across all age groups. What’s terrifying is that I’m seeing more and more young, premenopausal women in my clinic with a breast cancer diagnosis. When I’m talking to them about reconstruction, I’m talking about something I want to last, and that they’re happy with, for six or seven decades. That’s a very different conversation than with someone later in life, after menopause. But yes, breast cancer rates are rising.

**GL [19:49]:** Is there a primary driver we know of? Or a handful of drivers associated with breast cancer?

**RK [19:57]:** There are certainly things we know increase your risk: BMI, family history, genetic predispositions. But one of the biggest things I talk to patients about is that even if you do all the right things, you exercise, your BMI is in check, you’ve never touched a drop of alcohol in your life, you can still get breast cancer. What I see a lot on social media, usually from someone selling something, is people telling women how to prevent breast cancer: take these supplements, do this exercise routine. That leads to guilt and anxiety in women who were diagnosed after thinking they were doing everything right. It’s important to know you can still get it even in an optimal state of health, and it’s a conversation we need to keep having so women know their risk and listen to their bodies.

**GL [20:47]:** Do you have your own perspective on why there seems to be an increase in the diversity of breast cancers?

**RK [20:55]:** There’s been a lot of research into this. Is it estrogens in our water? Is it changes in environmental exposures? We just don’t know. That can be overwhelming, because what can you do in your life that will move the needle in a meaningful way? We don’t really know the answers yet.

**GL [21:14]:** I just want to point out for the listener or viewer that she hedged that question, because the evidence probably doesn’t support any one thing. Is that correct?

**RK [21:24]:** Correct. It’s something we’re still starting to understand.

**GL [21:26]:** I appreciate that. When it comes to treating non-hormonal breast cancer, do you think hormones seem to improve outcomes?

**RK [21:43]:** Great question. We don’t have the answers yet, and the reason is that for so many years women weren’t even offered hormone therapy, so we don’t have the short- or long-term oncologic outcomes. But there are studies underway, and I hope that as we learn more, we’ll know which patients can safely use different types of hormone therapy.

**GL [22:05]:** That goes back to this idea of precision medicine.

**RK:** Absolutely.

## Chemotherapy, surgery, and radiation

**GL:** Something I’d been reading about, and correct me here: chemotherapy typically comes before surgery, and then there are adjuncts to treatment. There’s radiation, and there’s chemotherapy. Do I have that right?

**RK [22:31]:** There are basically three ways to treat breast cancer: chemotherapy or medical therapy, surgery, and radiation. Every woman’s combination of treatments for her individual cancer will be different, both in what’s recommended and in the timing.

**GL [22:49]:** Meaning the timing before surgery, for example, if someone needs to shrink a tumor?

**RK [22:57]:** Correct. Sometimes it’s before surgery to shrink the tumor, and sometimes it’s after to decrease the chance of recurrence.

**GL [23:04]:** Do you find that body composition, muscle mass versus fat mass, plays a role in the dosing or effectiveness of chemotherapy?

**RK [23:16]:** Women are always told before they start chemo, “Don’t lose weight. Keep your appetite up.” But the studies show that 60% of women will gain weight or develop metabolic syndrome during neoadjuvant chemo, without changing their diet or exercise. It’s just the effect of the chemo. So now your body is in a state of metabolic uproar, and we expect you to somehow heal from surgery.

**GL [23:43]:** I’ve read that too. It seems that depending on the type of chemotherapy, and this is a very complicated topic, body composition does seem to play a role. For some treatments, people with more muscle mass and a lower body fat percentage seem to respond better, or can use less. So I was wondering.

**RK [24:10]:** It’s also tolerability. Can you safely get all of your chemotherapy treatments? If you get so sick that you can’t tolerate the chemotherapy, you have to stop the regimen. Being in a good state of health before chemotherapy helps with that.

## Social support

**GL [24:27]:** Has anything really surprised you about your patients? When I first started practice, I moved to New York City, and in the winter it’s miserable. It’s cold, everyone’s rude, and it’s dirty. But I noticed that patients who got outside early and walked to work seemed to have better moods over the years. Again, just an association. Have you ever noticed something like, “Gosh, the patients who have puppies seem to do better”?

**RK [25:11]:** Patients who have social support do better, and that’s been shown in the literature too. When patients come in with a loved one who takes notes and reminds them of the questions they wanted to ask, those are the patients who do better.

**GL [25:25]:** Okay. So have friends and loved ones.

**RK:** Absolutely.

## Movements that matter, and the end of bed rest

**GL [25:29]:** Circling back to prehabilitation, because people are really interested in optimizing muscle mass. Are there movements you think are really important, like the overhead press? Just their ability to move through life?

**RK [25:53]:** Absolutely. Once again, it was my shift from just “increase your lean muscle mass” —

**GL [25:57]:** Did they think you were crazy?

**RK [25:58]:** No, patients loved it.

**GL:** Your colleagues didn’t give you pushback? “Here she comes again with the weights”?

**RK [26:04]:** They might have said that, but hopefully behind my back. The real shift was toward doing the exercises that will help you move after surgery, because, as we talked about a little, patients used to be told to be on bed rest after surgery.

**GL [26:18]:** Will you explain that? Because we used to write those orders.

**RK [26:20]:** For some surgeries, we still do suggest bed rest, but certainly not in breast reconstruction. The idea was that you let your body heal and don’t stress it by moving. Now we know that early ambulation decreases your risk of blood clots and gets you out of the hospital faster. Importantly, it also reduces the loss of lean muscle mass you’d see with prolonged bed rest.

**GL [26:46]:** People would come to the ER, or get admitted, or be post-op, and one of the orders we’d write was bed rest. There’s ambulation, which just means getting up and walking. We’d write “bed rest” or “ambulate with assistance,” and it was routine for every single surgery. Even if someone broke their arm.

**RK [27:15]:** Right.

**GL [27:15]:** It’s so counterintuitive. Maybe I’m being a little dramatic, but most of the time patients were put on bed rest, and you can imagine the acceleration. If someone is on a GLP-1, isn’t training, has lost a lot of weight, and then you put them on bed rest, there’s an accelerated loss of lean, quality tissue, especially in older adults.

**RK [27:42]:** Absolutely. Even in young patients, studies show that immobilizing young men leads to a loss of muscle mass. So think about a post-surgical patient who is inflamed and potentially cachectic. Yes, they’re going to lose significant lean muscle mass.

## Pre-surgical labs

**GL [27:58]:** Do you optimize certain blood markers before surgery, like vitamin D? Do you have five or so markers where you say, “I want their estrogen status at a certain level”? Is there a series you think is critical?

**RK [28:20]:** I have some that I think are critical, but that’s definitely a limitation in surgery. We don’t have good lab values or markers to predict who’s going to have complications. The ones I look at are albumin, which is a measure of protein stores, and pre-albumin. I also look at vitamin D. A study just came out showing that women having breast reconstruction whose vitamin D is low, low by normal standards, which is abysmally low by my standards, have an increased risk of complications. So those are the lab values I really look at.

**GL [33:04]:** One of the markers you mentioned that I think is more unique is vitamin D. What does the literature say would be more optimal?

**RK [33:51]:** The challenge is that there isn’t good literature in surgery to guide those lab values. And if we think about vitamin D, “normal,” in air quotes, is a level that prevents things like rickets and supports good bone health. It isn’t the level that’s going to encourage healing, or, as some studies show, even help prevent cancer. That level is much higher than what traditional medicine views as normal, but we don’t have the literature yet to really guide those numbers.

**GL [34:24]:** Do you have a perspective? I’ve worked with Mark Hyman for many years, and I’m friends with a lot of the doctors at Cleveland Clinic. One of their targets is vitamin D between 60 and 80.

**RK [34:41]:** I’d agree with that. I’d love to see 70 for all patients before and after surgery.

**GL [34:47]:** That makes sense from a muscle standpoint. There are vitamin D receptors in muscle. There are vitamin D receptors everywhere. Are there other lab values that are a bit more specific? This could be functional medicine or surgical outcomes, and I say that carefully, because a lab might not predict the outcome but could help facilitate a better one.

**RK [35:11]:** Once again, pre-albumin and albumin, looking at protein stores.

**GL [35:14]:** Why pre-albumin?

**RK [35:16]:** It’s not the greatest indicator of protein stores, but it gives a hint. It’s also an acute phase reactant, so it shifts when a person is inflamed, which makes it less helpful. I usually rely on albumin. For women finishing chemo, I also look at their absolute neutrophil count. Neutrophils are the white blood cells that prevent infection. They plummet during chemotherapy, and then you have surgery, where we want to prevent infection. So that’s something I look at as well.

**GL [35:43]:** Are there any ways to improve neutrophil count?

**RK [35:48]:** There are medications we can give, but they really just artificially inflate the number. There aren’t studies showing they actually decrease infection. It kind of just makes us feel a little better.

## Screening: mammograms and thermography

**GL [36:00]:** What about screening? We get a lot of questions. Should someone get a mammogram? What about thermography, which I hear a lot about? People are very concerned that breast imaging can cause breast cancer.

**RK [36:21]:** What a great question. This is all over social media, at least on my algorithm, and probably yours too. The current recommendation is that mammograms start at age 40, and mammograms have been shown to prevent breast cancer deaths. That gets twisted a lot on social media. Are there other options? Yes. Sometimes we use ultrasound or MRI, especially for high-risk people, and we might start MRIs earlier for them. But the gold standard right now is mammography.

**GL [36:54]:** And thermography is heat patterns?

**RK [37:00]:** Yes, and it doesn’t yet have the data that mammograms have. Will it eventually, someday? Potentially. But right now your best option is still a mammogram, and sometimes an ultrasound.

**GL [37:13]:** Do patients ask you about that because they’re concerned about mammograms?

**RK [37:17]:** Usually they don’t ask me, because I’m so far down the line. They’ve either been identified as high risk and are probably getting MRIs and mammograms, or they’ve been diagnosed with breast cancer and already have a tissue diagnosis. But I know for a fact that our radiation oncologists, medical oncologists, and primary care doctors get that question. It’s a tricky one because, for whatever reason, it carries a lot of emotion for some people.

**GL [37:44]:** Is it fair to say that thermography, as it stands, is not an appropriate screening tool for early detection of breast cancer?

**RK [37:53]:** Correct. Mammography is still the gold standard. It still has the evidence to show it prevents breast cancer deaths.

**GL [37:58]:** And there was no hesitation in your answer. I feel the same way. In terms of the risk of getting a mammogram, is there a risk from radiation exposure?

**RK [38:14]:** Mammograms objectively involve radiation, the same way riding on a plane does. There have been really great studies looking at the number of cancers caused versus breast cancer deaths prevented, and the numbers are staggeringly different. A mammogram has a much greater chance of preventing a breast cancer death than causing a breast cancer.

## Combining evidence-based medicine and lifestyle

**GL [38:42]:** When I was in medical training, there was a psychiatrist who didn’t want to get mammograms. She was very against them. When she eventually got a breast cancer diagnosis, she was in Arizona at the time, and she decided to take treatment into her own hands. Instead of chemotherapy, radiation, or surgical removal, she went on a very aggressive nutrition plan: all raw foods, no protein. It was very extreme. Unfortunately, by the time she wanted an intervention, she’d missed that window, and she died.

**RK [39:37]:** I think that’s one of the failings of our healthcare system. There’s such a separation between Western medicine and complementary medicine that people feel they have to choose. Prehabilitation says you’ll get the best outcomes by combining them. Take your muscle-centric view, your targeted nutrition, your sleep, and some of the “fluffy” things like stress and anxiety, and combine them with evidence-based treatment. But at the end of the day, every patient has to choose what they’re most comfortable with. Even people who follow the recommendations exactly can have a recurrence. So you have to choose the treatment plan you’ll be okay with, regardless of the outcome.

## Making big decisions

**GL [40:21]:** If someone is listening, how do you suggest they make decisions? I know that’s a broad question. Say someone comes to you as a surgical candidate and says, “But I really want to do things naturally.” I’d love to hear the questions they ask you. If someone can’t see you at Duke, how can they have agency and think it through?

**RK [40:50]:** I get a lot of this in clinic. Patients come to me and say, “I have a hormone receptor-positive breast cancer. I really want to stay on my hormone replacement therapy. My doctors won’t prescribe it. What should I do?” The conversation I have with them is: I don’t have a crystal ball. Even if you take the standard Western medicine approach, you could be a patient who has a recurrence. And then you might think, “Gosh, I really wish I’d stayed on my hormone replacement therapy. I would have felt better.” It’s asking someone to predict the future, which is impossible. But it’s about figuring out what you’ll be most at peace with if the different outcomes happen. Then find out as much as you can about actual statistics and actual numbers. I always tell patients to ask their medical oncologist, “What’s my absolute risk reduction, and what’s my relative risk reduction?”

**GL [41:46]:** We’ll put that on the screen. What’s the difference between absolute risk reduction and relative risk reduction?

**RK [41:53]:** This is all over social media too. They’ll say that a certain treatment or exercise reduces your risk of breast cancer recurrence by 50%. That sounds amazing, right? Fifty percent. But if it’s really taking you from 2% to 1%, that doesn’t seem like it moves the needle much. It’s about understanding those numbers and what they actually mean for you.

**GL [42:19]:** That’s a really good point. If someone is making a decision this big, they should know their prognosis and survival rates. Have survival rates improved for people diagnosed with breast cancer?

**RK [42:37]:** We’ve improved, and we continue to improve, and we need to keep doing good research and randomized controlled trials. A super exciting area right now is de-escalation therapy. If someone has certain types of cancers or precancers, could we safely watch for a while, maybe delay surgery, or never need surgery at all?

**GL [43:03]:** Wow, that’s interesting. What kinds? Which subtypes?

**RK [43:06]:** DCIS. There are studies looking at whether you can do medical therapy and monitor, and maybe not need surgery, versus jumping to a mastectomy or lumpectomy. There are a lot of exciting things in research right now.

## Nutrition before and after surgery

**GL [43:20]:** Most people have never heard the word “prehabilitation.” You have patients lifting before surgery, I’m assuming two to three days a week, as much as they can. And I’m sure you address their nutrition.

**RK [43:42]:** Absolutely.

**GL [43:43]:** How do you address it? I keep thinking back to your patient for whom everything seemed to go wrong.

**RK [43:55]:** I ask what their baseline nutrition looks like. What do you eat in a day? What are your protein sources? Are you open to eating animal products? Then we go from there. I’d love for all patients to get 2 grams per kilogram per day of protein as they prepare for and recover from surgery.

**GL [44:11]:** That’s close to one gram per pound, correct?

**RK [44:13]:** Correct. The challenge is that I’m asking them to make all these healthy protein choices at a time when they’re stressed out and not sleeping. They want a donut. They want comfort food. Then after surgery, they’re in pain and maybe nauseous. It’s a time when protein matters so much, but it’s hard.

**GL [44:30]:** I know. Do you tell them to take essential amino acids or shakes? Do you have a game plan, like, “Okay, you’re not going to eat all this protein, so here’s your beef jerky plan”? I kid you not, we use canned chicken, because a lot of people don’t like the texture of other things but are willing to do that.

**RK [44:56]:** I tell patients, and I tell surgeons this too when I give this lecture: track your food for three days. Don’t change your diet. Just track it in an app and see where you’re at. I almost guarantee you’ll be surprised by how little protein you’re eating. Then figure out, “Here’s where I’m at, and I need to get to 100 or 120 grams.” Maybe you have a quick shake in the morning while you drive to work, or a protein bar, something easy. I’d love for protein to come from whole foods, but during this period, we just have to get you to that number.

**GL [45:30]:** According to NHANES data, the average woman gets 60 to 70 grams of protein a day.

**RK [45:38]:** Right. That’s not enough.

**GL [45:39]:** That’s enough for maybe a meal and a half. Especially under stress, no less than 100 grams a day. If you’re listening and you’re having surgery, whether it’s cosmetic or medically necessary, no less than 100 grams a day. And if you’re not going to get it from whole foods, which we love, or your appetite drops after surgery or you’re on pain meds, essential amino acids are critical. I always recommend, as I’m sure you’ve heard me say, BodyHealth. We saw this in the older population. I did my training in geriatrics, and those patients had no appetite. It was so difficult to get them to take a shake. I even tried milkshakes — please cover your ears — that looked like an old-school milkshake with caramel on top, like a Frappuccino, and they still wouldn’t drink it. But clear essential amino acids, with maybe a little flavor — and I’ll give you some to try — from a recovery standpoint, they’re so much better. Beyond that, are there supplements, or maybe “nutrients” is the better word, that you think are important?

## Supplements: what helps and what to stop

**RK [47:13]:** When I think about which nutrients or supplements I want a patient to prioritize before and after surgery, especially as a supplement rather than from food, I want to make sure it will move the needle in a meaningful way. It has to be at a dose that matters, so not your standard multivitamin dose. And importantly, it has to be safe to take before or after surgery. We may get into this, but some supplements are definitely not safe around the time of surgery. So it needs to be safe, effective, and actually help your body heal. Those include protein, like we talked about, probiotics, vitamins A, B, C, and D, zinc, arginine, and glutamine. All of those have evidence behind them as critical for healing and surgical recovery.

**GL [48:02]:** What should someone not take near surgery? And for how long? Four weeks? Does it depend on the half-life of the supplement?

**RK [48:14]:** The standard answer most patients get is to stop all supplements for two weeks before surgery and usually two to four weeks after. The reason is that some supplements, like vitamin E and ginkgo, increase your risk of bleeding.

**GL:** What about omegas?

**RK:** I love that question. It’s funny, because when you see those “stop all supplements before surgery” instructions, they’ll say, “Stop all supplements, especially omega-3s.” But meta-analyses have shown that omega-3s don’t increase your risk of bleeding before or after surgery, or your risk of transfusion. And they’re super anti-inflammatory. Surgery is uncontrolled inflammation, and omega-3s, with the cool little resolvins they bring along, can help resolve that inflammation and make it work for you after surgery.

**GL [49:07]:** So do you tell your patients to continue their omega-3s? This is the moment where pushback can happen within an institution.

**RK [49:18]:** Absolutely, and that’s one of the challenges of working at an institution with anesthesiologists who give those blanket statements. I tell my patients, “Here are the supplements I recommend before and after surgery. You’ll get a blanket statement to stop all supplements. I’m fine with you continuing these, but do whatever you feel best about. If you want to stop them, just restart the morning after surgery.”

**GL [49:40]:** In your practice, do you check omega-3 levels?

**RK [49:45]:** I don’t, but I’d love to.

**GL [49:47]:** I’m sure you could order it through a lab.

**RK [49:52]:** That would be great information.

**GL [49:53]:** What about iron stores for recovery? Ferritin, total iron. Is that important?

**RK [50:02]:** It’s important because it helps your red blood cells carry oxygen, so it’s critically important. But there really haven’t been studies on supplementing it, and the challenge is that too much can actually increase your risk of infection. So you don’t want to supplement with supratherapeutic doses. But it’s definitely a critical micronutrient for healing.

## Post-surgical eating and cravings

**GL [50:24]:** When you give patients a nutrition plan for after surgery, what are you telling them to have? For example, after surgery, we’ve been making protein ice cream.

**RK [50:41]:** I love that.

**GL [50:42]:** Although I made it with a vegan protein powder because I was just messing around, and it was green. Needless to say, it wasn’t a fan favorite. It was kind of a green frozen thing. We’ll make the team try it and see how they do.

**RK [50:58]:** I love easy protein options. One of the resources I give my patients is a list of animal-based, vegetarian, and vegan protein options that are easy to whip together after surgery or easy to prepare before. Once again, prehabilitation is preparing your mind, your body, your spirit, and your home. Part of that is getting healthy groceries and preparing meals, so that after surgery, when your carb cravings are high —

**GL:** Do you know why that is?

**RK:** Yeah.

**GL:** Tell me.

**RK:** It’s largely related to sleep deprivation. And what’s more sleep-depriving than surgery? Or perhaps being a surgeon.

**GL:** Or being a mom.

**RK:** Being a mom, yes. Those are the top three. Even one night of sleep deprivation makes you crave simple carbohydrates. So at a time when your body needs protein and complex carbohydrates, you’re craving simple carbs. That leads to a blood sugar spike, then a crash, and then you crave more simple carbohydrates. It’s important to recognize that and talk about it with patients, and then have easy protein snacks ready to go.

**GL [52:04]:** What are your go-tos?

**RK [52:07]:** I’m a huge fan of beef jerky. I rarely eat during the day because I’m in surgery, so I carry a lot of different protein bars and beef jerky. Again, I’d love for all my protein to come from food, but it’s hard to carry around a chicken breast when you’re getting ready to do surgery.

**GL [52:24]:** You could totally put it in your purse. But after surgery, do you give them something easy to digest, maybe dairy? Do you find they get constipated, or that they don’t want a heavy meal?

**RK [52:41]:** I usually tell patients to find something that’s appetizing. Experiment, see what sits well with your stomach, and prioritize protein. That’s why protein shakes are so easy. Even if you feel nauseous after surgery, you can make a little whey protein shake with six ounces of milk or water and get 20 to 30 grams. So experiment, see what works for you, and have lots of options available.

**GL [53:06]:** Do you care about carbohydrates and fats after surgery?

**RK [53:12]:** There’s not great science on this. I haven’t seen much. But we know carbohydrates and fats are important for healing, so I encourage patients to choose whole foods. I have them start with protein and fill in after that. That’s also where targeted supplements can help meet micronutrient needs after surgery, when it might be hard to eat your usual healthy diet.

## Preparing the mind

**GL [53:38]:** You said something interesting: preparing the mind for surgery. How do you take your patients through that from a mental perspective during prehabilitation?

**RK [53:50]:** This goes back to that game-changing patient. She might have been in an okay physical state, because she was eating protein and taking my supplements, but she was stressed out, anxious, and not sleeping. So first, I normalize it with my patients. It’s okay to be stressed. It’s okay to be anxious. But let’s figure out whether you have the tools in your toolbox to manage it. Whether that’s a meditation practice, quiet time, a calming bedtime routine, optimizing your sleep, or talking to somebody, which there’s no shame in. In my opinion, every surgical patient should talk to a counselor. We need those tools in place, ideally before surgery, so that when you’re in pain, stressed, anxious, and dealing with anesthesia-associated depression, you’re not taken aback and you know what to do.

**GL [54:45]:** What is anesthesia-associated depression?

**RK [54:48]:** A lot of patients, after anesthesia, can feel the blues. I don’t understand the actual science, and I don’t know that we fully do yet, but it’s normal, and it’s something I talk to patients about. Your body has been through tremendous stress. You’re probably in pain and probably not sleeping well, and it’s okay to feel those feelings. But if they’re feelings you don’t think you can handle on your own, talk to your team so we can get you to someone who can help you with them.

**GL [55:18]:** Do you think there’s one linchpin for patients? I’ve heard you use words like strength, resilience, and even confidence before surgery. That’s unusual for a surgeon to think about, or to have in their repertoire.

**RK [55:35]:** I think we view surgery as something that happens to us. We need surgery, or we choose an elective cosmetic surgery, and we trust our surgeon to do a good job. But patients often don’t fully understand the surgery. They don’t know what’s going to happen or what to expect afterward. And they’re not doing anything to prepare their mind, body, or spirit. You have to be in control. You have to advocate. You deserve to know that information about your own body. And like you said, it builds confidence. You go into surgery feeling emotionally strong and ready for this emotional and physical stress.

## Setting expectations

**GL [56:17]:** Do you find it’s best to say, “Okay, you’re going to have breast reconstruction” — I’m just picking that one — “let’s watch it together”? Because it can be very graphic. I think a good doctor is good at diagnosing patterns, but a great doctor is really good at looking at people and seeing their patterns. You’ve probably seen this: for some patients, showing them what it looks like reduces the burden and the stress. Others say, “I don’t want to see anything.” My videographer, Matt, is so squeamish. He’d be the one saying, “I don’t want to see any of that. Just tell me the outcome. What’s the bandage going to look like? What can I expect?” Do you find there are certain archetypes of people? Archetype might not be the right word.

**RK [57:20]:** Oh, absolutely. I have patients who ask if I’ll film their surgery because they want to see it. I think that’s a bit aggressive, and the answer is always no. But I do show my patients pre- and post-op photos. I ask them, “Would this help you?” I’ve only had one patient say, “I can’t look at this right now,” and that’s okay. I like to show them where the scars will be, what they’ll look like, and what they can expect. Then I have them look at their breasts once a day after surgery, to watch for complications. I also tell them that if they’re not ready to look, that’s okay, but someone needs to. The reason I want to give them that information is that if I don’t, someone else will. They’ll go on social media, see a photo of a woman who had a breast augmentation, bring it in, and say, “This is what I’m going to look like after surgery.” I can’t tell you how many times that’s happened. One of the biggest things I can do as a surgeon is talk about expectations and what a realistic outcome is. I never want a patient to wake up and think, “This isn’t what we talked about. This isn’t what I expected.”

## Getting moving after surgery

**GL [58:30]:** When it comes to recovery, how soon can they start moving or training?

**RK [58:37]:** It depends on the surgery. Most of my patients are walking the day after surgery, if not the same day. For breast reconstruction, which again is different from a minimally invasive breast augmentation where you’re back in the gym in a week, I usually have activity restrictions for six weeks. That’s to prevent things like wounds opening and fluid collections. But especially in my older patients, not moving your shoulders much for six weeks can cause issues. So I really love early physical therapy, getting them back to movement as fast as possible.

**GL [59:11]:** Is being up and walking right away now the standard? I’m not in the surgical field, but that seems so different from what the recommendations used to be. I love that idea.

**RK [59:27]:** It is for most surgeries. It’s been shown in the literature to decrease blood clots, so we don’t have to send patients home on blood thinners anymore, and it decreases the loss of lean muscle mass. At least we’re recognizing that as a surgical specialty, and it’s a huge change for patients and outcomes.

## Red light, sauna, and peptides

**GL [59:45]:** In functional medicine, it’s interesting. Many times they’re ahead of the curve, before the clinical data has caught up. For example, Dale Bredesen, who’s a big Alzheimer’s researcher, was talking about zinc-copper ratios, DHEA, and hormone status years before it showed up in the literature. Is there something in the functional medicine space, like red light therapy, sauna, or cold exposure, that traditional medicine hasn’t adopted yet but you suspect it will?

**RK [1:00:35]:** When I think about those interventions, I’m always thinking about the risks and potential benefits. I love red light therapy. I do it myself, and I recommend it to my patients, unless they’re on a medication that increases their risk of hyperpigmentation. It’s generally regarded as safe. So there are potential benefits and really no risk.

**GL [1:00:55]:** So you like it?

**RK [1:00:56]:** I love red light therapy. Absolutely. Saunas, I love saunas. They’re not going to melt your breast implants. That’s another one.

**GL [1:01:03]:** Ooh, that’s a good one. I have heard that people were concerned about going in the sauna with implants because it would increase —

**RK [1:01:13]:** — the leaking of silicone. Yes.

**GL:** I’d never thought of that.

**RK:** That’s never been shown to be true. So I love those types of interventions. I hope there’s more research, and really good studies on peptides, because that’s one of the fields where certain functional medicine doctors are really getting into peptide therapy.

**GL:** Oh, I like to hear you say that. Interesting.

**RK:** I think it holds promise, but right now we don’t know the safety and we don’t know the efficacy. Again, I work with cancer patients. How is it going to impact cancer? I’d love for there to be well-done studies on that.

**GL [1:01:42]:** Are all your patients cancer patients, or do people come in for something else, like a burn or trauma?

**RK [1:01:53]:** My practice is about 70% breast and 30% gender affirmation. But either way, it’s chest or breast surgery.

## Hyperbaric oxygen and wound vacs

**GL [1:02:01]:** As we get more data, there may be modalities like red light therapy for healing. What about hyperbaric oxygen, or wound vacs?

**RK [1:02:18]:** Oh, yes.

**GL [1:02:19]:** Talk to me about those. These are modalities that may be used in different areas.

**RK [1:02:26]:** Hyperbaric oxygen is definitely evidence-based for helping healing after surgery. We typically use it when there’s pending or evident skin necrosis, which means skin death, usually from a lack of blood flow. We also use it to help with radiation changes. It can soften the tissue after radiation.

**GL [1:02:48]:** And what I’m hearing you say is that it’s not the soft chambers or smaller machines —

**RK [1:02:58]:** No. They’re doing a full dive, and that’s an important distinction. When I recommend hyperbaric for my patients, they go to the basement of Duke and have medical-grade hyperbaric therapy. That’s very different from the ones people have in their homes or at the corner clinic. So make sure you’re getting high-quality hyperbaric oxygen.

Wound vacs, I love wound vacs. I think of them as super fancy, expensive band-aids. They apply negative pressure over an incision or a wound, and they’ve been shown to help healing happen faster, potentially help clear infection, and decrease fluid collections. I use them very frequently.

**GL [1:03:41]:** We should link a picture of a wound vac so people can see how it’s used. Has that science advanced over the last 10 years in terms of utility and what it does?

**RK [1:03:57]:** Yes, it’s really expanded. I primarily use two types of wound vacs. One is called an incisional wound vac, where, as the name implies, you put it right on top of an incision, and it helps the incision heal faster.

**GL [1:04:09]:** How much faster?

**RK [1:04:11]:** I don’t think that’s been studied objectively, but I’ll tell you anecdotally: at one week after surgery, I can tell who had a wound vac and who didn’t.

**GL [1:04:19]:** Do you think it should be considered standard of care?

**RK [1:04:24]:** I consider it my standard of care for wounds I’m concerned about. I use it a lot on big belly incisions from my flap surgeries, because it’s made a distinct difference in healing.

**GL [1:04:36]:** In the speed of healing, or the quality of the scar?

**RK [1:04:40]:** Both, because it’s making those tissues come together better and increasing blood flow. It’s a great modality, and it’s very well tolerated by patients, which matters too. The other thing that’s new within the last 10 years, and I actually wrote papers on this as a resident, is an instillation wound vac. That’s a wound vac that lets fluid go in and out. Think of it as 24-hour-a-day cleaning. We use it to help salvage implants after an infection.

**GL [1:05:12]:** Okay. So implant salvage is when someone gets an infection. Is it typically post-operative, or are there other reasons?

**RK [1:05:18]:** One of the main complications after implant-based breast reconstruction is infection, and it’s really feared. The remaining skin and fat have decreased blood flow, you’ve put in a foreign body, and the patient has often just had neoadjuvant chemo, so she’s at high risk for infection. The standard of care used to be to simply remove the implant, which left the woman flat for at least three months. That’s emotionally devastating. What we showed is that placing this wound vac, which allows frequent cleaning for one to five days, can increase salvage rates, which is amazing for women. I use that in my practice as well.

**GL [1:05:55]:** Does insurance cover any of these, like hyperbaric oxygen or wound vacs?

**RK [1:06:02]:** Wound vacs, yes, because they’re considered part of your surgical care. Hyperbaric depends on the indication. I’ve seen a lot of women on social media lately paying for hyperbaric before or after surgery to augment healing, and that won’t be covered by insurance. But if we’re using it to treat something like skin necrosis or radiation changes, then yes, it’s covered.

**GL [1:06:24]:** And it needs to be a hard chamber?

**RK:** Correct. It has to be a hard chamber. At least, that’s what the data shows.

**GL [1:06:30]:** That’s what I’ve seen too. When you said it can soften tissue, can you explain a little more?

**RK [1:06:37]:** Sure. Radiation is great at preventing cancer from coming back, but it leads to fibrosis, or scar tissue, in the remaining tissue. It also decreases blood flow to the area, which can make it a poor home for an implant, or uncomfortable, or lead to open wounds. In those cases, hyperbaric oxygen, likely because of the increased oxygen delivery, seems to soften the tissue, decrease some of that scarring, and help wounds heal faster.

**GL [1:07:05]:** How often does someone go? When we put a soldier in a hyperbaric chamber, it might be 30 days, an hour and a half, five days a week. Is it the same?

**RK [1:07:23]:** Usually it’s one to two months of daily dives. Sometimes they’ll do two a day, one in the morning and one in the afternoon. That’s really hard for young women who have a job and a family. It’s a big investment, but it can make a big difference.

**GL [1:07:38]:** Are there any contraindications? I remember reading a while ago that you could dive too much and it would increase free radicals.

**RK [1:08:01]:** There are definitely contraindications, medical conditions where you don’t want to increase the atmospheric pressure you’re under, which is how hyperbaric works. But at least for breast reconstruction, since it’s only one to two months, I’m not aware of increased free radicals causing any noticeable clinical problems.

**GL [1:08:20]:** So that was a social media thing. You got me. Is there anything else for recovery in the functional medicine space that maybe isn’t thought of? Peptides are interesting. There’s been back and forth about whether they can be prescribed. Has that been part of, maybe not Duke, but the functional medicine space?

**RK [1:08:49]:** It’s something I see talked about a lot at functional medicine conferences. It’s not covered by insurance, and it’s not something I would prescribe right now, because I think the data is lacking. I think it holds promise, and there are a lot of interesting anecdotal experiences out there, but I need that safety and efficacy data.

## Scars and sun protection

**GL [1:09:06]:** What about skin texture and quality? I know you mentioned your husband is a dermatologist. Is there anything that can be done for skin laxity or texture changes?

**RK [1:09:17]:** The main thing I’m concerned about is scars, and there are evidence-based things you can do to improve them. The main one is to follow your activity restrictions and make sure you’re not putting early tension on those scars.

**GL [1:09:28]:** Why?

**RK [1:09:29]:** If you put early tension on a healing scar, you can get scar widening, or the scar can even open up. You want those scars to heal in nice, thin lines. Other things are silicone sheets or silicone gels. The number one thing I think is overlooked is sun protection. For at least the first year after surgery, that scar is susceptible to sun changes, and in lighter-skinned people it will actually darken. So I talk to my patients about SPF early and often, and about applying it. Those are the most evidence-based things for helping scars heal well.

## Fascia, pec tightness, and physical therapy

**GL [1:10:05]:** This is a little off the wall, but it’s on my mind, and you might say, “Please, no.” Fascia and stretching. I work with a physical therapist who talks to me a lot about how scars seem to change movement patterns, because the incision has cut through the fascia. This is a little esoteric.

**RK [1:10:39]:** Interestingly, for breast cancer treatment or a prophylactic mastectomy, we have to remove the fascia off the pectoralis muscle. That’s been shown to be part of standard cancer treatment. What I see a lot in women after surgery, even if they don’t have radiation, because radiation makes it worse, is tightness of the pectoralis muscle, probably from a contracture after the fascia is removed.

**GL [1:11:06]:** Oh, I see.

**RK:** That’s never been shown scientifically. It’s my hypothesis. But for those patients, again, early, aggressive physical therapy to work on the tightness. So many women have decreased range of motion after a mastectomy, whether from scar contracture, cording, or frozen shoulder from activity limitations. So I have a very low threshold for sending my patients to physical therapy.

**GL [1:11:28]:** That’s interesting, because I hear about it anecdotally, also through my physical therapist: someone’s pec muscles get so tight that it causes shoulder problems and then neck problems.

**RK [1:11:44]:** Yes.

## Pain control: acupuncture, Journavx, and long-acting anesthetic

**GL [1:11:45]:** Has acupuncture helped at all with pain control?

**RK [1:11:50]:** I’ve had some patients use acupuncture. Again, when I think about risks and benefits, if they’re going to a good provider, it’s low risk with potential benefit. Acupuncture studies are hard, because it’s difficult to design a placebo-controlled trial. Those sham sites are still largely acupuncture. So I tell my patients I’m fine with it, and anecdotally some patients have gotten relief, but there’s not high-quality evidence to support it yet.

**GL [1:12:18]:** Have you heard of Journavx?

**RK [1:12:20]:** Yes.

**GL [1:12:21]:** Journavx for pain.

**RK [1:12:23]:** Yes.

**GL [1:12:24]:** Do you use it? Can you speak to some of the options for pain control?

**RK [1:12:29]:** Not yet, and a lot of that is insurance coverage. It’s very expensive, but I’m very intrigued by the idea. Part of the reason we can move so many patients to outpatient surgery, and off bed rest the day after, is that we’ve gotten so good at post-surgical pain control. I use a long-acting local anesthetic. It’s like when the dentist numbs you, but it lasts two to three days.

**GL [1:12:54]:** I’ve never had that. I need to go to your dentist.

**RK [1:12:56]:** You know how when your dentist numbs you, it lasts about four hours? I do the same thing, but it lasts two to three days. Combined with multimodal therapy, my whole goal is to limit the amount of narcotics a woman needs, because we know addiction can occur, and narcotics have so many side effects we want to avoid.

**GL [1:13:16]:** I think that’s really smart. Journavx, I don’t know the exact mechanism of action. It’s a medication, and we’ll link to it. My friend Dr. Christy Hamilton is a plastic surgeon who does all cosmetics, and she uses Journavx. I’ve tried it. There’s almost zero pain and no downtime. You’re not groggy. There’s none of that anesthesia effect. It’s extraordinary.

**RK [1:14:00]:** That’s amazing. I hope more medications like that continue to become options for patients.

## Surgery and skeletal muscle

**GL [1:14:11]:** There were a lot of really good nuggets in there that no one has ever talked about. The removal of fascia and the secondary pec pain. Anesthesia-associated depression. Those aren’t things people talk about. One thing I want to double back on, which you mentioned before we started recording, is the impact of surgery on skeletal muscle.

**RK [1:16:21]:** When I think about surgery and muscle, I like to think about what about surgery hurts muscle, and then what muscle is specifically important for in healing. Surgery in and of itself is a catabolic experience. As soon as you have surgery, you start breaking down protein, and that’s good. We need to mobilize those amino acids to help with healing and prevent infection. But we’re dipping into our protein stores. You’ll probably have some activity restrictions, or you certainly won’t be back in the gym the next day. So you have your protein stores being drawn down, a state of inflammation, and decreased protein intake. All of these, before and after surgery, dip into your protein reserve.

So what is muscle important for? Obviously for engaging with the world and doing the things you want to do: getting out of bed, getting dressed, your activities of daily living. But something often overlooked is muscle’s role in regulating glucose. Your muscle is your glucose sink. If your muscle mass decreases, you’ll have higher blood sugar, which is negatively associated with surgical healing. It also makes you crave simple carbohydrates, which leads to another blood sugar spike. So muscle is so important. What I tell patients is that we have to increase your reserve. We have to fill up that gas tank. I know this surgery is going to take a hit on your muscles, but let’s start high so the dip doesn’t go as low as it would have. And it’s even worse if you’re coming off neoadjuvant chemo, already in metabolic syndrome, and have already lost lean muscle mass.

## Carbohydrate loading

**GL [1:17:59]:** That’s really important and really well thought out. It’s established in the biochemistry and nutrition world, but it hasn’t made its way into medicine yet. What I’m hearing you say is that surgery is a catabolic condition, which it absolutely is. It decreases skeletal muscle, especially if someone is immobile. It’s a major stressor, especially with an infection. And skeletal muscle is the sink for glucose. So in your surgical practice, do you think about carbohydrate intake? Do you reduce carbs, or balance them with protein? How do you coach patients through that?

**RK:** I tell them to start with protein. Your appetite is going to be limited, so fill up on protein and try to meet your goals. After that, sprinkle in healthy fats and complex carbohydrates. The one exception is right before surgery. That’s the only time I actually recommend a simple carbohydrate, and it’s called carbohydrate loading. You don’t want to do this if you’re diabetic or have poorly regulated blood sugar. But studies have shown that 50 grams of simple carbohydrates, taken right before you’re no longer allowed to eat or drink, can, ironically, help with blood sugar regulation around the time of surgery, get you out of the hospital faster, and even decrease the pain you feel afterward. It’s an easy thing you can do before surgery, and most patients aren’t told about it.

## “I only have five days. Does it matter?”

**GL [1:19:47]:** Which leads to my next question, and I know we all hear it as doctors: “Is this even going to matter? I only have five days, or seven days. Will anything I do make a difference?”

**RK [1:20:00]:** I hear this all the time, including from surgeons when I give this as a grand rounds lecture. A surgeon will come up and say, “I treat cancer patients. They don’t have time to prehab. We need to get them to surgery.” But that’s not what the literature says. In head and neck cancer patients, who tend to be sick, just five days of immunonutrition before surgery decreased complications, got patients out of the hospital faster, and even decreased mortality. Immunonutrition is usually a mix of healthy proteins, healthy fats, and specific micronutrients. So yes, five days of nutrition alone can make a difference. And even one day: carbohydrate loading is part of prehabilitation that you can do if you hear this podcast and your surgery is tomorrow.

**GL [1:20:49]:** That’s great advice. Is it the micronutrients, the quality of the nutrition, that makes those five days matter?

**RK [1:21:03]:** Five days was really just an arbitrary number chosen in the head and neck literature, and then more studies recapitulated those findings. In those studies, patients were admitted to the hospital beforehand.

## Antibiotics, probiotics, and the microbiome

**GL [1:21:16]:** Most people who go into surgery are put on antibiotics, either before or by IV, from what I understand to prevent infection. I’m sure that affects the gut microbiome. How do you manage that risk, and what is it doing?

**RK [1:21:42]:** So many aspects of surgery negatively affect the microbiome. The standard of care is at least one IV dose of antibiotics before we make the incision, so you’re getting at least one dose. The inhaled oxygen you breathe affects your microbiome. The narcotics you take after surgery affect it. Changing your diet affects it. And as we know, the microbiome is tied to so many aspects of health. So I counsel my patients to take a probiotic. I like them to start before surgery and continue after. If you’re put on an antibiotic, just space them four hours apart so the antibiotic isn’t killing your probiotic.

**GL [1:22:25]:** Do you care about the kind of probiotic? In functional medicine, they do a lot of gut testing. Does it work? It gives you an idea of the commensal bacteria, but is it necessary for choosing a probiotic?

**RK [1:22:45]:** Probiotics are so confusing. You go to the store and there are different strains, species, CFUs, shelf-stable ones, refrigerated ones. Which do you use? What large meta-analyses suggest is that as long as you get 10 billion CFUs, which is a big dose you actually have to seek out, the strain or species doesn’t matter. Most of those studies used some strain of Lactobacillus or Bifidobacterium, but beyond that, just aim for 10 billion. That’s what the studies suggest is necessary.

**GL:** Any fermented foods?

**RK:** I love fermented foods. They’re a fantastic addition to a normal healthy diet. They can be hard to eat while you’re recovering from surgery. Patients aren’t waking up asking for sauerkraut.

**GL:** At least not yet.

**RK:** Not yet. But I’d love for patients to have fermented dairy products, sauerkraut, kimchi. If you can’t, it’s easy to swallow a pill.

## The surgery go-bag

**GL [1:23:48]:** If someone is going into surgery, should they pack a bag, with their snacks in it? And if so, what’s in there?

**RK [1:23:56]:** Yes. I’ve actually had patients bring a blender to the hospital so they could make their own protein shakes on the windowsill. My residents will tell you they know who my patients are because there’s a bag of snacks and empty protein shakes in the garbage. It’s so interesting. When we’re preparing to have a baby, we have our go-bag and we prepare our home, but we prepare for surgery by just showing up. There are so many things patients can bring to the hospital. An ideal bag has things that help you sleep: earplugs, a sleep mask, relaxing music or a playlist. Things to make your time more pleasant: an audiobook, a book to read, pictures of loved ones. Studies show that flowers in the recovery room decrease stress and anxiety. And things that make you feel at home: slippers, lip balm, dry shampoo. So yes, if you’re staying overnight, you absolutely should pack a bag.

## Melatonin and sleep

**GL [1:24:49]:** I’d say most people don’t think about that, especially for a non-cosmetic surgery. What about melatonin? When I was on the hospital floors, we’d often order it. Do you think melatonin supplementation plays a role in sleep?

**RK [1:25:13]:** With any supplement I recommend to my patients, I’m talking about the short term. When I recommend a supplement, I’m not saying start it before surgery and continue it for five years. But in the short term, if melatonin works for you, it can be a great addition to your sleep hygiene routine. I do talk to patients about building a good sleep routine before surgery, before you’re in pain and waking up at all hours: winding down before bed, blue-light-blocking glasses, a calming bedtime routine, and a cool, dark room. If you have those tools before surgery, they’re easier to use after.

## Why isn’t prehab the standard of care?

**GL [1:25:53]:** That’s really good advice. We’ve covered a ton here. And by the way, for anyone preparing for surgery, we’ll put together an outline, a surgery bag checklist. The biggest question is this: we know prehabilitation improves patient outcomes, both physically and mentally. Why isn’t it the standard of care?

**RK [1:27:20]:** I’ve thought a lot about this, and I think several things need to be overcome before it becomes the standard of care it should be. The first is who’s going to pay. A lot of what I recommend, especially before surgery, isn’t covered by insurance. And as someone who takes care of breast cancer patients, when we know breast cancer and reconstruction are so financially toxic, it’s hard for me to say, “You also need to spend your money on all of these other evidence-based things.”

The second is education. We don’t learn this in medical school, as you know. We don’t learn it in residency. We don’t talk about it at our national meetings. So we don’t have the knowledge within surgical disciplines to have evidence-based discussions with patients. And patients don’t know about it, so they don’t know to ask their surgeon, “What can I do to prepare?” If they follow me on Instagram and do ask, the surgeon will either say nothing, or “I don’t know, just stop all your supplements,” which is actually harmful advice.

The third is implementation. A lot of surgeons ask me after my talks, “I don’t know how to integrate this into my practice.” I also work at a very busy academic center. I don’t have time to talk to every patient about this, and that’s why I created my Instagram page. How do we find the time? How do we integrate it into the workflow?

And the last challenge: say I’ve gotten a patient to buy in that she needs pre-operative physical therapy, and her surgery is four weeks away. Our physical therapists aren’t booking four weeks out. They’re booking six months out. So how do I get her the help she needs? There are a lot of challenges to overcome before this is the standard of care.

**GL:** But you’re hopeful.

**RK:** I’m hopeful. Studies continue to come out, including studies showing, if an insurance company is listening, that investing in prehabilitation actually saves money on that patient. A small cost for prehabilitation helps avoid complications, prolonged hospital stays, emergency room visits, and additional surgeries. It’s a shift from reactive healthcare to preventive healthcare.

**GL:** That’s really wise. What’s your Instagram?

**RK:** It’s @surgical_recovery.

## Closing

**GL [1:29:32]:** We’ll put it in the show notes, and we’ll link it on YouTube if you’re watching there. Dr. Rebecca Knackstedt, I really appreciate your focus on prevention, and how much you care about outcomes for these patients. It makes a difference. As a surgeon, this is something you do every day. But for the person showing up at the hospital, it’s a life moment they’ll never forget.

**RK [1:30:06]:** Absolutely. It’s another day at work for me, but it’s the biggest day of their lives, and it’s an honor and a privilege to be part of that.

**GL [1:30:14]:** Thank you so much for coming on. I look forward to your book coming out.

**RK [1:30:17]:** Thank you so much for having me.