Most people prepare for surgery by showing up. You get the date, you stop eating at midnight, and you trust that the surgeon will take it from there. When we prepare to have a baby, we pack a bag, prep the house, and plan the first weeks at home. For surgery, one of the biggest physical stressors most of us will ever go through, we do almost nothing.
Dr. Rebecca Knackstedt wants to change that. She’s a plastic and reconstructive microsurgeon at Duke and a member of the Duke Cancer Institute, where most of her practice is breast reconstruction for women facing breast cancer or a high genetic risk of it. She earned both her MD and PhD at the Medical University of South Carolina, trained in plastic surgery and microsurgery at Cleveland Clinic, and while she was there she became certified in functional medicine. Her research focus is surgical prehabilitation: using nutrition, supplementation, exercise, sleep, and stress management in the weeks before surgery to change what happens after it.
That combination is rare. And her central argument is one I agree with completely: patients have far more influence over their surgical outcomes than they’ve been told.
The patient who changed her practice
When Dr. Knackstedt started at Duke, she believed what most surgeons are trained to believe. Do good surgery, tell the patient to eat more protein and take a few supplements, and they’ll heal.
Then she met a young woman in the middle of chemotherapy for breast cancer. Upbeat, doing well, excited about her reconstruction plan. Between that visit and her surgery date, she developed metabolic syndrome, lost her hair, went through a divorce, lost her mother to breast cancer, lost her job, and became homeless. She started missing appointments.
She didn’t heal well. How could she?
That case sent Dr. Knackstedt back into the literature, past nutrition and into sleep, stress, and social support. What she found was that all of these affect surgical outcomes, and that there are evidence-based things we can do about each of them. That’s what prehabilitation is: rehab, moved to the front. Instead of waiting for the trauma of surgery and then rebuilding, you build first.
Here’s what stood out from our conversation.
1. Surgery is catabolic. Your muscle is the reserve you’ll draw from.
The moment you have surgery, your body starts breaking down protein. That’s not a malfunction. You need those amino acids mobilized to heal tissue and fight infection. This catabolic state peaks in the first two to three days after surgery, pulling amino acids out of skeletal muscle to build acute-phase proteins and immunoglobulins (Yun et al., PLoS One, 2026). It also stacks on top of everything else surgery brings: inflammation, a smaller appetite, and activity restrictions that keep you out of the gym.
Dr. Knackstedt’s way of explaining this to patients is a gas tank. Surgery is going to take a hit on your muscle no matter what. If you start higher, the dip doesn’t bottom out as low.
She also raised a point I wish more physicians talked about: skeletal muscle is the body’s main site for clearing glucose after a meal. Lose muscle and you lose some of your ability to manage blood sugar, and high blood sugar is associated with worse surgical healing. She describes it as a loop: less muscle, higher glucose, more cravings for simple carbohydrates, another spike.
This is why the old habit of writing bed rest orders after nearly every procedure did so much damage. Immobilization causes measurable muscle loss even in young, healthy people, sometimes within a few days, with the steepest decline in the first two weeks (Marusic et al., J Appl Physiol, 2021; Preobrazenski et al., J Cachexia Sarcopenia Muscle, 2023). Now picture a post-surgical patient who is inflamed, eating poorly, and maybe coming off a GLP-1 medication or months of chemotherapy. The loss accelerates.
Today, early walking is the standard for most surgeries. Most of Dr. Knackstedt’s patients are up the day after surgery, if not the same day. Early ambulation is a core part of enhanced-recovery care: it’s associated with shorter hospital stays, helps protect lean mass, and is one of the ways surgical teams work to lower the risk of blood clots. It works alongside whatever clot prevention your team orders, such as blood thinners or compression devices, not instead of it. If you’re sent home with either, use them (Patel et al., Dis Colon Rectum, 2023).
2. Train for the recovery you’re about to have
Her first instruction to patients used to be simple: build lean mass, any way you want, lift heavy. Her patients taught her something better. What helped most was strengthening the specific muscles they’d be relying on afterward.
For breast reconstruction, that means planning around the fact that you won’t be able to use your arms normally for about six weeks. If you’re having a flap reconstruction, where skin and fat from the abdomen are transplanted to build a new breast, your core is also compromised. So you prepare your legs. Squats. Getting up from a chair without pushing off with your hands. Getting on and off the toilet without help.
She doesn’t formally measure muscle mass before surgery. Instead, she asks about daily function: What do you do for exercise? Do stairs give you trouble? In her experience, patients who have more functional strength and move through daily life easily are the ones who recover best.
And if the surgery is prophylactic, meaning a risk-reducing mastectomy with no cancer present, there’s often time to prepare. She’ll sometimes recommend a safe delay so a patient can build strength and fix her nutrition first. A cancer diagnosis is different, and treatment can’t wait. But as you’ll see below, even a short runway counts.
3. Protein is the priority, and most people are further behind than they think
Most surgical patients are never given a protein target. Dr. Knackstedt regularly hears from patients who asked their surgeon how much protein they should eat before surgery and were told “I don’t know, just eat your usual healthy diet.”
Her target, before and after surgery, is 2 grams per kilogram of body weight per day, which is close to 1 gram per pound. That sits at the upper end of the range nutrition guidelines describe. Guidelines generally put well-nourished surgical patients at about 1.2 to 1.5 grams per kilogram per day, and move toward 1.5 to 2.0 grams for patients under the greatest physiologic stress, including older and muscle-depleted patients (Cederholm and Bosaeus, New England Journal of Medicine, 2024). Her patients are often coming off chemotherapy and the metabolic changes that can come with it, so aiming high fits the population she treats.
Wherever you land in that range, most women start well below it. The average woman eats roughly 60 to 70 grams a day, according to NHANES data, which is enough for about a meal and a half. My recommendation for anyone heading into surgery, cosmetic or medically necessary, is no less than 100 grams a day. For a 150-pound woman, that works out to about 1.5 grams per kilogram.
Her first step is one I love, and she gives it to surgeons at her lectures too: track your food for three days without changing anything. Most people are surprised by how little protein they’re actually eating. Then close the gap with whatever is easiest. A shake in the car, a protein bar, beef jerky.
She’d rather protein come from whole foods, and so would I. But she’s practical about it. Before surgery, patients are stressed and not sleeping and want comfort food. After surgery, they’re in pain and possibly nauseated. A whey shake with six ounces of milk or water can deliver 20 to 30 grams even on a rough day. When appetite drops off entirely, clear essential amino acids are often easier to get down than a thick shake. I saw this constantly in geriatrics, with patients who wouldn’t touch even a milkshake.
Her rule for building a post-surgical plate is simple: start with protein and meet your target, then fill in with healthy fats and complex carbohydrates.
4. Five days can move the needle. So can one.
The question every surgeon hears: “My surgery is in a week. Does any of this even matter?”
Dr. Knackstedt hears it from surgeons too, especially those who treat cancer patients and feel there’s no time for prehab. Her answer is that the literature disagrees. In head and neck cancer, a population that tends to go into surgery quite sick, roughly five days of immunonutrition before surgery (a mix of protein, healthy fats, and specific micronutrients) reduces postoperative complications, including infections (Matsui et al., Annals of Surgery, 2024). Studies have also reported shorter hospital stays and lower mortality. Those two results vary more from study to study (Howes et al., Cochrane Database of Systematic Reviews, 2018; Başmisirli et al., Medicine, 2026), so fewer complications is the most consistent benefit.
And there’s something you can do the day of surgery. Carbohydrate loading means drinking a set amount of simple carbohydrate, about 50 grams in the studies she cited, shortly before your fasting window begins. Counterintuitively, it can help with blood sugar regulation around surgery, shorten hospital stays, and reduce post-operative pain and nausea (Sebestyén et al., Scientific Reports, 2025; Şanlı et al., BMC Anesthesiology, 2025). It’s part of many enhanced-recovery protocols, and most patients have never heard of it. Two important caveats. It isn’t appropriate if you have diabetes or poorly controlled blood sugar. And timing matters: enhanced-recovery protocols usually give the drink about two to three hours before surgery, so follow the specific fasting instructions from your surgical and anesthesia team.
5. “Stop all supplements” is blanket advice, and some of it is wrong
Most patients are told to stop every supplement two weeks before surgery and for two to four weeks after. There’s a real reason behind that: some supplements, such as vitamin E and ginkgo, can increase bleeding risk, and consensus guidance recommends holding them before surgery (Cummings et al., Mayo Clinic Proceedings, 2021).
Omega-3s are the example Dr. Knackstedt pushes back on, and the evidence is on her side. Pre-op instructions often call them out specifically. But large analyses show omega-3s don’t meaningfully increase bleeding or transfusion risk around surgery, and a consensus statement explicitly supports continuing them (Javaid et al., Journal of the American Heart Association, 2024; Cummings et al., Mayo Clinic Proceedings, 2021). They’re also strongly anti-inflammatory, producing resolvins that help the body resolve inflammation, and surgery is essentially a burst of uncontrolled inflammation. She tells her patients she’s comfortable with them continuing omega-3s, and that if they’d rather stop, they can restart the morning after surgery.
Her filter for any pre- or post-operative supplement has three parts: it has to make a meaningful difference, it has to be at a dose that matters (not a standard multivitamin dose), and it has to be safe around surgery. The nutrients she considers evidence-based for healing include protein, probiotics, vitamins A, B, C, and D, zinc, arginine, and glutamine. She thinks of these as short-term support for the surgical window, not something to take indefinitely.
A few more of her specifics:
- Probiotics. Surgery hits the microbiome from several directions: the IV antibiotic dose before the incision, inhaled oxygen, post-operative narcotics, and a changed diet. Perioperative probiotics and synbiotics (a probiotic paired with a prebiotic) have been shown to reduce postoperative infections (Chowdhury et al., Annals of Surgery, 2020). Her practical rule, based on the meta-analyses she follows, is that dose matters more than strain: look for at least 10 billion CFUs, which is higher than many products on the shelf. Researchers are still refining the ideal strain and dose, and synbiotics may add benefit, so it’s worth asking your team about product choice. Start before surgery and continue after. If you’re on an antibiotic, take the two about four hours apart.
- Iron. It’s important for oxygen delivery and healing, but more isn’t automatically better, and too much can raise infection risk. She doesn’t recommend high-dose supplementation without a reason, such as documented deficiency or anemia.
- Vitamin D. This is one of the few labs she routinely checks, along with albumin as a rough marker of protein stores. A recent study of abdominally based breast reconstruction found that women with low vitamin D had more surgical-site infections and other complications (Aryanpour et al., Plastic and Reconstructive Surgery, 2026). Randomized trials haven’t yet shown that supplementing vitamin D before surgery improves outcomes (Patel et al., BMJ Open, 2024), and no surgical data defines an optimal level. That’s exactly why she frames her number carefully. Her personal preference is around 70 ng/mL before and after surgery, well above the standard “normal” cutoff, which was designed around preventing rickets and supporting bone. She’s clear that this is her clinical target, not an established guideline.
Your surgical team has your full history, so any change to supplements around surgery should be a conversation with them.
6. Prepare the mind, not just the body
Sleep deprivation is one of the biggest drivers of cravings for simple carbohydrates, and few things deprive you of sleep like surgery (being a surgeon and being a mom are close runners-up). Even one bad night increases those cravings, which sets up the same blood sugar spike-and-crash cycle she described with muscle loss. Her fix is to set up a sleep routine before surgery, while you’re not in pain and waking at all hours: a cool, dark room, a calming wind-down, blue-light-blocking glasses, and melatonin in the short term if it works for you. Habits built beforehand are much easier to keep afterward.
She also normalizes something that catches many patients off guard: feeling low after anesthesia and surgery. Your body has been through major stress, you’re in pain, and you’re not sleeping well. That kind of post-operative low mood is common. If it feels like more than you can handle, tell your team so they can connect you with support. In her view, every surgical patient should talk to a counselor, and there’s no shame in it.
Two more things from her practice:
- Social support matters. Patients who bring a loved one to appointments, someone taking notes and remembering the questions, do better. She notes that the research points the same way.
- Set realistic expectations. She shows patients before-and-after photos, where their scars will be, and what to expect. If she doesn’t, social media will, and too many women bring in a photo of a cosmetic breast augmentation expecting that result from a mastectomy reconstruction. Reconstruction after cancer is a very different surgery.
7. Recovery tools that actually have data
We covered a number of recovery modalities, and she sorts them by the same risk-benefit lens:
- Wound vacs. Negative-pressure dressings over an incision or wound. She describes them as very fancy band-aids, and she uses them routinely on large abdominal incisions from flap surgery. The evidence backs her up: negative-pressure therapy over closed incisions reduces surgical-site infections and wound complications (Patel et al., JAMA Surgery, 2026; Zwanenburg et al., Annals of Surgery, 2020). She also co-authored early papers on instillation wound vacs, which cycle fluid in and out, as a way to save implants after infection rather than removing them and leaving a woman flat for months.
- Hyperbaric oxygen. It’s evidence-based for specific indications like threatened skin necrosis and radiation-related tissue damage, where it can support healing (Lin et al., Cochrane Database of Systematic Reviews, 2023). That means a medical-grade hard chamber, typically daily sessions for one to two months. That is not the same thing as a soft chamber at a strip-mall clinic, and elective use to “boost healing” usually isn’t covered by insurance.
- Scar care. Follow your activity restrictions, since early tension widens scars or opens them. Use silicone sheets or gel, which are first-line and supported by multiple randomized trials (Wang et al., International Wound Journal, 2020). And the step she sees overlooked most: sun protection, which she recommends for at least the first year. Fresh scars tend to darken with sun exposure, especially on lighter skin.
- Physical therapy. In a mastectomy, the fascia over the pectoralis muscle is typically removed as part of the cancer operation. Many women develop pec tightness afterward, which Dr. Knackstedt suspects is related to that fascia removal. She’s careful to call that her hypothesis, not yet proven. Add scar contracture, cording, or frozen shoulder from weeks of restricted movement, and range of motion suffers. She has a very low threshold for early, aggressive PT.
- Red light therapy and sauna. Both are low-risk in her view, and she uses red light herself. Saunas will not melt or damage breast implants, despite what circulates online.
- Peptides and acupuncture. She considers peptides promising but lacking the safety and efficacy data she needs, especially for cancer patients. Acupuncture is low-risk with a good provider, and some of her patients find it helpful, but high-quality evidence is limited.
On pain control, better pain management is a big part of why so many surgeries are now outpatient. She uses a long-acting local anesthetic that lasts two to three days, combined with multimodal therapy, to keep narcotic use as low as possible. We also talked about Journavx (suzetrigine), a newer non-opioid pain medication that works by blocking the NaV1.8 sodium channel on peripheral pain nerves (FDA label). She finds it promising but hasn’t adopted it yet, largely because of cost and insurance coverage.
On screening, risk, and guilt
Because so much of her practice involves breast cancer, we also talked about screening and prevention myths, and her answers were direct.
Mammograms remain the gold standard. Major groups, including the US Preventive Services Task Force, NCCN, and the American College of Radiology, recommend starting at age 40, and mammography has been shown to reduce breast cancer deaths (US Preventive Services Task Force, JAMA, 2024). Some organizations frame ages 40 to 49 a little differently. The American College of Physicians, for example, recommends a shared decision between patient and clinician in that decade, with screening every other year (Qaseem et al., Annals of Internal Medicine, 2026). So talk through timing with your doctor. What doesn’t change is that thermography, which maps heat patterns, doesn’t have the evidence and isn’t an appropriate replacement for early detection. Mammograms do involve a small dose of radiation, but the benefit of finding cancer early far outweighs that risk (US Preventive Services Task Force, JAMA, 2024).
You can do everything right and still get breast cancer. Breast cancer rates are rising across age groups, and she’s seeing more young, premenopausal women in her clinic. BMI, family history, and genetics raise risk, but there is no supplement or routine that guarantees prevention. She sees real harm from social media content, often attached to something for sale, that implies otherwise. Women who were diagnosed despite doing all the “right” things end up carrying guilt they never earned. Know your risk and listen to your body.
Ask for absolute risk, not just relative risk. A treatment that “cuts your risk in half” sounds dramatic. If it takes your risk from 2 percent to 1 percent, that’s a different conversation. When you’re facing a major treatment decision, ask your oncologist for both numbers.
On hormones: For hormone receptor-positive breast cancer, the standard of care generally avoids systemic hormone therapy, though some women choose it after a careful risk-benefit discussion with their oncologist. Vaginal estrogen is a different matter. Studies of breast cancer survivors have not shown increased recurrence or mortality with vaginal estrogen, which is why it’s an option she routinely discusses, including with young women placed into medical menopause to reduce recurrence risk (Beste et al., American Journal of Obstetrics and Gynecology, 2025). That data is observational. For women taking aromatase inhibitors in particular, oncologists often take a more cautious approach, because at least one large cohort suggested a possible increase in recurrence in that group. For them, it’s a decision to make with the oncologist, usually after trying non-hormonal options first (Mainar et al., Maturitas, 2026; Hickey et al., Lancet, 2024). Keeping vaginal and urinary tissue healthy matters for more than comfort: urinary tract infections that are caught late can progress to sepsis.
Whether hormones affect outcomes in hormone receptor-negative cancers is still an open question. Women were denied hormone therapy for so long that the long-term data doesn’t exist yet, but studies are underway.
When patients ask how to make decisions this big, her answer stays with me. No one has a crystal ball. Even if you follow the standard approach exactly, recurrence is possible. So choose the plan you’ll be at peace with whatever the outcome. And don’t treat evidence-based medicine and lifestyle as a choice between two sides. Prehabilitation is proof that you get the best results by combining them.
Your surgery go-bag
Pack a bag the way you would for a birth. Dr. Knackstedt’s residents can pick out her patients by the snack bags and empty protein shakes. One patient even brought a blender and made shakes on the hospital windowsill. Her list:
- Protein: shakes, bars, jerky, and clear essential amino acids for when appetite is low
- Sleep: earplugs, a sleep mask, a relaxing playlist
- Comfort: an audiobook or book, photos of loved ones, slippers, lip balm, dry shampoo
- Mood: small comforts from home, like flowers
And before you leave home, stock the fridge and pantry with easy protein so that when post-operative cravings hit, the right choice is also the easiest one.
Why isn’t this standard of care?
It should be. Dr. Knackstedt names four barriers:
- Cost: much of prehab isn’t covered by insurance, and breast cancer treatment is already financially crushing.
- Education: none of this is taught in medical school or residency, so surgeons often default to “stop all supplements.”
- Implementation: busy surgical practices don’t have time for these conversations in the workflow, which is exactly why she started her Instagram.
- Access: she can convince a patient she needs pre-operative physical therapy four weeks before surgery, but PT may be booked out six months.
She’s hopeful, and so am I. The data keeps building, including work suggesting that investing in prehabilitation can save money by avoiding complications, readmissions, ER visits, and extra surgeries. That’s the shift we need across healthcare: from reacting to preparing.
Where to start
Surgery is a regular day at work for a surgeon. For you, it may be one of the biggest days of your life. Treat it that way. If you have surgery on the calendar:
- Track your food for three days and find your real protein number, then work toward at least 100 grams a day.
- Strengthen the muscles you’ll depend on while your arms or core are off-limits.
- Ask your surgeon three questions: What can I do to prepare? Which supplements should I stop, and which can I keep? Is carbohydrate loading right for me?
- Build your sleep routine now, and pack your bag.
- Bring someone with you.
Follow Dr. Knackstedt on Instagram at @surgical_recovery, and look out for her upcoming book.
Stay Forever Strong.
Dr. Gabrielle Lyon
This content is for general educational purposes based on a conversation with Dr. Rebecca Knackstedt and reflects her clinical experience and interpretation of the research. It is not a substitute for individualized medical advice. Talk with your surgical, anesthesia, and oncology teams before changing your nutrition, supplements, medications, or fasting plan around surgery.
