Duke Surgeon: How Well You Heal Is Decided Before the Operation | Dr. Rebecca Knackstedt

Episode Overview

• Host Dr. Gabrielle Lyon (a physician trained in geriatrics who worked with Dr. Mark Hyman for many years) interviews Dr. Rebecca W. Knackstedt, MD, PhD—a Duke faculty microvascular, plastic, and reconstructive surgeon operating on breast cancer patients, MD-PhD researcher, and certified functional medicine provider who completed her plastic surgery residency and microsurgery fellowship at Cleveland Clinic (where she researched prehabilitation with the functional medicine department).
• The conversation explores surgical prehabilitation ("prehab"): how targeted nutrition, supplementation, functional exercise, sleep, and stress management before and after surgery significantly improve surgical outcomes, speed recovery, and reduce healthcare costs.
• The narrative progresses from the metabolic and physical toll of surgery and breast cancer treatments to evidence-based nutritional protocols, debunking common surgical supplement myths, and evaluating post-operative recovery modalities and wound care technologies.
• This episode is directly relevant to anyone preparing for an upcoming surgery, breast cancer patients navigating oncology and reconstruction decisions, and healthcare providers looking to shift from reactionary to preventative surgical care (which Dr. Knackstedt also shares on her Instagram page, @surgical_recovery, created due to time constraints in academic medicine).
• Disclosed sponsors and ties include PerfectAmino by BodyHealth (Dr. Lyon personally uses and recommends it; promo code LYON20 for 20% off at bodyhealth.com), Timeline powered by Mitopure / Urolithin A (Dr. Lyon uses it; promo URL timeline.com/lyon for 20% off), and Lola Blankets (promo code DRLYON for 40% off at lolablankets.com); Dr. Knackstedt also notes her husband is a dermatologist.

Key Concepts

• The Economics and Holistic Scope of Prehabilitation: Investing in prehabilitation shifts healthcare from reactionary to preventative, saving money by avoiding complications, prolonged hospital stays, emergency room visits, and additional surgeries. Literature also demonstrates that poor sleep (even one night of deprivation triggers simple carbohydrate cravings, causing blood sugar spikes and crashes), stress, and lack of social support negatively impact surgical outcomes, whereas evidence-based interventions—even having flowers in the recovery room to reduce stress and anxiety—help patients heal.
• Surgery as a Catabolic Event & The Role of Skeletal Muscle: Surgery immediately triggers protein breakdown to mobilize amino acids for healing and infection prevention. Because skeletal muscle is the primary sink for glucose, losing muscle mass (which immobilization studies show happens even in young men) leads to high blood sugar, which impairs surgical healing. Although clinics do not objectively measure muscle mass percentages—relying instead on subjective questions about daily activities like climbing stairs or getting off a toilet unassisted—patients with better functional muscle mass recover better.
• Activity Restrictions vs. Early Ambulation: While breast augmentation patients may return to the gym in 1 week, breast reconstruction patients cannot use their arms and have activity restrictions for 6 weeks to prevent wounds opening up, fluid collections, and shoulder issues. Furthermore, body-based belly reconstruction (a microsurgical "flap" transplanting belly fat and skin) weakens the core. Despite upper-body restrictions, early ambulation (walking the day of or day after surgery) decreases blood clot risk (eliminating the need to send patients home on blood thinners), shortens hospital stays, and reduces lean muscle loss from bed rest.
• Breast Cancer Trends, Screening, and Risk Interpretation: Breast cancer rates are rising across all age groups, with more young, premenopausal women needing reconstructions that last 6 to 7 decades. Known risk factors include BMI, family history, and genetic predispositions, though someone with optimal BMI, exercise, and zero alcohol can still get breast cancer, and Dr. Knackstedt notes we do not yet know why rates and diversity in young women are rising. To prevent deaths, gold-standard mammograms are recommended starting at age 40 (high-risk individuals may use ultrasounds or MRIs earlier); mammogram radiation is comparable to riding on a plane, with a staggeringly greater chance of preventing death than causing cancer, whereas thermography does not yet have the data to be a standalone screening tool. When evaluating treatments, patients must understand relative versus absolute risk reduction (e.g., a 50% relative risk reduction may only lower actual recurrence risk from 2% to 1%), and current research is investigating "de-escalation therapy" for conditions like DCIS (Ductal Carcinoma in Situ) to see if medical therapy and monitoring can safely delay or replace mastectomy or lumpectomy.
• Chemotherapy and Hormone Therapy Nuances: Contrary to warnings about weight loss, 60% of women develop metabolic syndrome during neoadjuvant chemotherapy without changing their diet or exercise. Regarding hormones, Dr. Knackstedt does not know the exact percentage of hormone-receptor-positive breast cancers off the top of her head due to the number of subtypes, and notes we lack short- or long-term oncologic outcome data on whether hormones improve outcomes in non-hormonal breast cancer. However, following the reversal of the FDA "black box" warning on menopausal HRT, standard of care dictates hormone-receptor-positive patients cannot take systemic hormones (though some choose to after risk-benefit discussions), but vaginal estrogen is safe and keeps mucosal tissue healthy—preventing UTIs and fatal sepsis caused by lower estrogen and off-balance vaginal pH, especially in young women placed into medical menopause at age 30.
• Surgical Nutrition, Immunonutrition, and Lab Markers: Remarkably, there is no standard protein recommendation for surgical patients, though NHANES data shows the average woman eats only 60 to 70 grams daily, and both doctors note there is not great science to support specific post-surgical carbohydrate and fat ratios. However, in sick, pre-admitted head and neck cancer patients, just 5 days of pre-op immunonutrition (healthy proteins, healthy fats, and micronutrients) decreases complications, hospital stays, and mortality. To assess baseline status, Dr. Knackstedt checks albumin (and sometimes prealbumin, an acute-phase reactant elevated by inflammation) and absolute neutrophil count (which plummets during chemotherapy, though there are no natural ways to improve it and no studies showing if artificially inflating it with medication decreases infection). While there is not good surgical literature guiding Vitamin D levels, Cleveland Clinic functional medicine practitioners target 60 to 80 ng/mL, and Dr. Knackstedt likes to see 70 ng/mL before and after surgery.
• Supplement Myths, Micronutrients, and the Microbiome: Standard surgical packets tell patients to stop all supplements 2 weeks before and 2 to 4 weeks after surgery because items like Vitamin E and Ginkgo biloba increase bleeding risk. However, meta-analyses prove Omega-3s do not increase bleeding or transfusion risks and contain resolvins that resolve surgical inflammation. Evidence-based healing nutrients include protein, probiotics, vitamins A, B, C, D, zinc, arginine, and glutamine. Iron is critical for carrying oxygen and healing, though it hasn't been studied specifically for surgical recovery and supratherapeutic doses can increase infection risk. Additionally, the microbiome is harmed by the standard 1 IV dose of pre-incision antibiotics, inhalational oxygen, post-op narcotics, and diet changes, making a 10-billion CFU probiotic (typically Lactobacillus and Bifidobacterium strains, where meta-analyses show the specific strain or species does not matter) valuable.
• Advanced Wound Care, Pain Control, and Recovery Modalities: During mastectomies, removing fascia off the pectoralis muscle is hypothesized by Dr. Knackstedt (though never shown in science) to cause pectoralis tightness/contracture, requiring aggressive physical therapy. For wounds, negative pressure wound therapy ("wound vacs") clears infectious modalities, reduces fluid collections, and speeds healing (anecdotally visible at 1 week post-op, though exact speed increases haven't been studied objectively), while an instillation wound vac (flushing fluid for 24-hour cleaning over 1 to 5 days) increases breast implant salvage after infection, avoiding implant removal and leaving a woman flat for 3 months. Medical-grade Hyperbaric Oxygen Therapy (HBOT)—1 to 2 daily dives in a hard chamber for 1 to 2 months—is evidence-based for treating skin necrosis and softening radiated fibrotic tissue. Saunas are safe and will not melt implants or leak toxins, and red light therapy is safe unless a patient takes hyperpigmentation-inducing medication. Conversely, peptide therapy lacks safety and efficacy data (especially in cancer patients), acupuncture lacks high-quality evidence due to difficulty conducting sham-controlled trials, and the science behind post-anesthesia depression/blues remains unknown. For pain, Journavx (suzetrigine) is a non-opioid medication Dr. Knackstedt doesn't use yet due to insurance/cost, relying instead on multimodal therapy and a long-acting intra-operative local anesthetic that numbs the area for 2 to 3 days.

Quotes

• At 0:00:07 - "There are studies showing that if you invest in prehabilitation, you actually save money on that patient, avoiding complications, prolonged hospital stays, emergency room visits. So it's once again a shift from this reactionary type healthcare to preventative healthcare." - Dr. Knackstedt explaining the clinical and economic justification for surgical prehabilitation.
• At 0:07:12 - "I mean, there's no standard recommendation, and that's mind-blowing. And I get so many messages on Instagram where patients will reach out to me and say, 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." - Dr. Knackstedt highlighting the gap in standard surgical nutrition guidance.
• At 0:09:26 - "But the feedback that I got from patients was that it was most helpful to work on the muscles they would be relying on after surgery. So for breast reconstruction, I tell them, you can't use your arms for six weeks. If you have a body-based belly reconstruction, your core is taken out." - Dr. Knackstedt detailing why pre-operative exercise must target the specific muscle groups required for post-op mobility.
• At 0:12:53 - "But importantly, vaginal estrogen is safe, and that is a conversation that I routinely have with my patients because, thinking about the holistic care of a patient, is it going to impact her surgical outcomes? No. But is it going to make her feel better if she can maintain her vaginal estrogen? Absolutely." - Dr. Knackstedt discussing safe hormone support to prevent mucosal atrophy and UTIs in breast cancer patients.
• At 0:19:00 - "But actually, what the studies show is that 60% of women will gain or get metabolic syndrome through their neoadjuvant chemo, and that's without changing diet or exercise. It's just the effects of chemo." - Dr. Knackstedt sharing counterintuitive research on the metabolic impact of chemotherapy.
• At 0:23:28 - "But now we know that early ambulation decreases your risk of blood clots, it's going to get you out of the hospital faster, and importantly, it's going to decrease that loss of lean muscle mass that you would see with that prolonged amount of bed rest." - Dr. Knackstedt explaining why immediate post-operative walking has replaced historical orders for bed rest.
• At 0:27:29 - "So the current recommendations are that mammograms start at the age of 40, and mammograms have shown to prevent breast cancer deaths. And that is something that gets twisted a lot on social media." - Dr. Knackstedt clarifying evidence-based breast cancer screening guidelines.
• At 0:40:00 - "When you see those 'stop all supplements before surgery,' it'll say 'stop all supplements, especially omega-3s.' And omega-3s actually have been shown in meta-analyses to not only not increase your risk of bleeding before or after surgery or increase your risk of transfusion, but they're super anti-inflammatory." - Dr. Knackstedt debunking the myth that Omega-3 fatty acids cause surgical bleeding.
• At 0:42:47 - "But even one night of sleep deprivation is going to make you crave those simple carbohydrates. So at a time when your body needs protein and complex carbohydrates, you are craving simple carbohydrates." - Dr. Knackstedt connecting pre- and post-operative sleep quality directly to nutritional regulation and blood sugar control.
• At 1:05:19 - "So surgery in and of itself is a catabolic experience. As soon as you have surgery, you are going to experience protein breakdown. And that's good, we need that mobilization of amino acids to help with healing, prevent infection, but we're dipping into our protein stores." - Dr. Knackstedt explaining the physiological necessity of building protein stores prior to an operation.
• At 1:07:56 - "But studies have shown that 50 grams of simple carbohydrates right before you're not allowed to eat or drink anything else can help actually, ironically, with blood sugar regulation around the time of surgery, get you out of the hospital faster, actually decrease the amount of pain you feel after surgery." - Dr. Knackstedt describing the benefits of pre-surgical carbohydrate loading for non-diabetic patients.
• At 1:08:48 - "The literature says for head and neck cancer patients, which tend to be sick, just five days of immunonutrition before surgery—immunonutrition is usually a mixture of healthy proteins, some healthy fats, and different micronutrients—in that patient population, decrease complications, get you out of the hospital faster, and actually even decrease mortality." - Dr. Knackstedt illustrating that even a 5-day window of targeted nutrition before surgery yields profound clinical benefits.

Takeaways

• Audit and Increase Your Protein Intake: Track your food for 3 days without changing your diet to find your baseline, then increase protein intake before and after surgery to 2 grams per kilogram of body weight per day (roughly 1 gram per pound, or at least 100 to 120 grams daily). If you feel nauseous post-op, use a whey protein shake to get 20 to 30 grams of protein in just 6 ounces of milk or water.
• Train the Muscles You Will Rely On Post-Op: Before surgery, strengthen the compensating muscle groups you will need during recovery—such as doing squats and leg strengthening to get out of bed or off the toilet unassisted if your arms and core will be restricted for 6 weeks after breast reconstruction—and begin walking the day of or day after surgery to prevent blood clots and muscle loss.
• Optimize Pre-Op Supplements and Lab Targets: Work with your clinician to target a Vitamin D blood level of 60 to 80 ng/mL (ideally 70 ng/mL) and check albumin and neutrophil counts. Stop bleeding-risk supplements like Vitamin E and Ginkgo biloba 2 weeks before surgery, avoid supratherapeutic iron doses, and skip unverified peptides, but continue anti-inflammatory Omega-3s.
• Protect Your Microbiome Around Surgery: Take a probiotic containing at least 10 billion CFUs (with Lactobacillus and Bifidobacterium strains) before and after surgery to counter the effects of IV antibiotics, oxygen, and narcotics, making sure to space the probiotic 4 hours apart from any oral antibiotics.
• Carbohydrate Load the Night Before Surgery (If Non-Diabetic): If you do not have diabetes or unregulated blood sugar, consume 50 grams of simple carbohydrates right before your pre-surgical fasting window begins to improve perioperative blood sugar regulation, reduce post-operative pain, and shorten your hospital stay.
• Protect Incisions and Scars Properly: Follow all post-op activity restrictions (avoiding early tension on incisions for 6 weeks), engage in early physical therapy if experiencing post-mastectomy pectoralis tightness, apply silicone sheets or gels once healed, and use SPF sun protection on scars for at least the first year to prevent darkening.
• Leverage Social Support and Advocacy at Appointments: Bring a loved one to medical appointments to take notes—which both clinical observation and literature link to better surgical outcomes—and proactively ask your care team about vaginal estrogen for menopausal symptom/UTI prevention, long-acting intra-operative local anesthesia to minimize narcotics, and mammogram screening starting at age 40.