EPISODE 112: Board-certified Plastic Surgeon | Dr. Rebecca Knackstedt

Summary

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The Fit and Fabulous Podcast

Episode 112: Board-Certified Plastic Surgeon – Dr. Rebecca Knackstedt

Host: Dr. Jaime Seeman | Date: May 8, 2025

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Episode Overview

In this engaging episode, Dr. Jaime Seeman sits down with Dr. Rebecca Knackstedt, a board-certified plastic surgeon with expertise in implant-based and microsurgical breast reconstruction, integrative and functional medicine, and research on nutrition and prehabilitation for breast cancer. Together, they explore the intersection of conventional and integrative approaches to breast cancer care, the role of nutrition and vitamin D, misconceptions surrounding breast cancer screening and reconstruction, and practical advice for patients navigating breast cancer treatment and surgery recovery.

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Key Discussion Points & Insights

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1. Dr. Knackstedt's Journey & Integrative Approach

[02:41]

• Dr. Knackstedt shares her unconventional path: a foundational interest in nutrition, a PhD focused on vitamin D and inflammation, and certification in functional medicine.
• Collaborated with Dr. Mark Hyman’s team at the Cleveland Clinic, “That experience taught me to look at my patients in a holistic way that I wasn't doing before that.” – Dr. Knackstedt ([02:19]).

Host’s Perspective:
Dr. Seeman echoes the lack of holistic approaches in traditional medical training and applauds Dr. Knackstedt for bringing integrative options to her breast cancer patients.

“We are seeing the pendulum swing... people are looking for other things they can do to improve their quality of life and outcomes.” – Dr. Seeman ([02:54])

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2. Vitamin D: Anti-inflammatory Power & Deficiency

[03:42 – 08:06]

• Most people are deficient due to lack of sun exposure and poor diet.
• “Everyone is deficient in vitamin D and vitamin D is so anti-inflammatory... almost everyone would benefit from vitamin D supplementation.” – Dr. Knackstedt ([03:17])
• Optimal vitamin D levels far exceed standard lab “normal”—should be 2-3x higher than 30 ng/mL for true preventive benefit.
• Supplementation is helpful but cannot replace healthy dietary foundations. It’s “an expensive band-aid” without a nutritious diet ([06:39]).
• When supplementing, choose third-party validated brands and always take vitamin D with K2:

  “K2 is like the directions. It tells the vitamin D where to send the calcium... so it ends up in your bones, not your arteries.” – Dr. Knackstedt ([08:06])

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3. Prehabilitation: Preparing Mind & Body for Surgery

[09:05 – 11:56]

• Prehabilitation is proactive preparation—via nutrition, exercise, stress management, and social support—before surgery or chemotherapy.
• Even a few days of targeted preparation can improve surgical outcomes.
• Limitations in clinical settings: Doctors have little time for holistic guidance. Dr. Knackstedt uses handouts and social media to spread valuable pre-op advice.

Quote:

“All of those things—nutrition, stress, sleep, social support—impact how people heal after surgery.” – Dr. Knackstedt ([11:36])

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4. Combating Misinformation in Breast Cancer Screening

[15:38 – 17:04]

• Dr. Knackstedt addresses myths on mammograms vs. thermography:

  “We have no clinical evidence that mammograms cause any type of cancer... and no data supporting thermography’s reliability for detection.” – Dr. Knackstedt ([16:17])

• Mammography remains the gold standard for breast cancer screening.

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5. Nutrition Before & After Surgery

[18:39 – 21:43]

• Five days of high-protein, targeted nutrition can significantly decrease complications and hospital stay after surgery:

  “Even five days of targeted nutrition—high protein, arginine, glutamine, omega 3s—can decrease complications and even mortality after surgery.” – Dr. Knackstedt ([19:16])

• Post-op: Aim for 2g protein per kg body weight, robust probiotic supplementation (≥10 billion CFUs/day), increased multivitamins.
• Hospital nutrition severely lacking; patients are advised to bring their own nutrient-dense snacks/protein shakes.

Quote:

"Boost—if I see it in a patient's room, I will throw it away. First two ingredients are sugar and glucose syrup—it's not what you need to heal.” – Dr. Knackstedt ([35:16])

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6. Probiotics, Microbiome, and Surgery

[21:43 – 22:18]

• Efficacy depends on the probiotic dose, not specific strains:

  "As long as you're taking 10 billion CFUs per day, that was really the cutoff that was shown to impact surgical outcomes.” – Dr. Knackstedt ([21:58])

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7. Exercise: Tailoring for Prehab & Rehab

[22:48 – 24:12]

• Pre-surgery exercise should target muscle groups that will be limited post-op (e.g., squats for breast reconstruction patients).
• Maintaining muscle mass is key for better functional outcomes and metabolic health.
• Incorporating even simple movement (e.g., squats, box jumps during radiation) can improve cancer outcomes.
• Dr. Seeman:

  “Muscle is a great metabolic organ. If we save you from breast cancer and then you get osteoporosis... something’s going to kill you. So don’t let it be things you have the ability to prevent.” ([24:53])

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8. Keto Diet & Cancer Outcomes

[27:25 – 28:42]

• Ketogenic diets help patients better tolerate chemotherapy and radiation, reduce metabolic syndrome risk, and may improve overall outcomes.

• “Sixty percent of women who have neoadjuvant chemo develop metabolic syndrome. That's before we’re taking them to surgery.” – Dr. Knackstedt ([28:15])

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9. Chemotherapy: Risks & Mitigation

[31:03 – 33:46]

• Neoadjuvant chemotherapy (before surgery) can offer time for patients to optimize health.
• Chemo affects all rapidly dividing cells, leading to GI symptoms, hair/nail loss, fatigue.
• Strategies include high-dose vitamin C for fatigue and cold caps for hair preservation.

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10. Hospital Food: Systemic Nutrition Failure

[34:51 – 36:13]

• Even renowned hospitals like Cleveland Clinic fail at providing healing nutrition; fast-food options abound.
• Empowerment: Patients should bring their own supportive foods.

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11. Addressing Misinformation and Social Media

[37:55 – 40:04]

• Social media's double-edged sword: Opportunity for community but rife with dangerous misinformation, particularly in patient forums.
• Preying on vulnerable patients with unproven “miracle cures” or “detoxes” is alarmingly common.
• Cancer is not 100% preventable; guilt- and blame-based narratives are both false and harmful.

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12. Reconstruction Options & “Breast Implant Illness”

[41:11 – 48:09]

• Reconstruction can be implant- or tissue-based (from the patient’s body).
• “Breast implant illness” (BII): A broad constellation of non-specific symptoms; evidence is unclear on causality.
• Only confirmed reason to remove the implant capsule: ALCL lymphoma (rare, linked to textured implants).
• Predatory “BII doctors” charge huge fees for unproven removals; the placebo and nocebo effects are real.

“There are people marketing themselves as breast implant illness experts who charge women an unethical amount… preying on desperate women who want to feel better.” – Dr. Knackstedt ([43:21])

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13. Final Advice for Patients

[49:04]

• Choose providers you trust and with whom you can be open:

  “Make sure you are comfortable with your treatment team... so you don’t have to go to social media to ask questions.” – Dr. Knackstedt ([49:04])

• Be wary of costly, unproven overseas clinics.

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Notable Quotes & Memorable Moments

• “Supplementation is going to be putting a band-aid. An expensive band-aid.” – Dr. Knackstedt ([06:39])
• “We don't teach surgeons and doctors how to have nutritional conversations with patients.” – Dr. Knackstedt ([27:13])
• “Patients want that information. They want to feel they have one ounce of power in this situation in which they're powerless, and that can be nutrition.” – Dr. Knackstedt ([30:06])
• “Everyone on social media is trying to make money... There’s so many preying on breast cancer patients. These are desperate people.” – Dr. Knackstedt ([38:48])

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Timestamps for Key Segments

• Intro & Background – [00:00 – 02:41]
• Vitamin D & Inflammation – [03:42 – 08:40]
• Prehabilitation/Optimizing Outcomes – [09:05 – 13:54]
• Combating Misinformation on Screening – [15:38 – 17:04]
• Nutrition (Pre/Post Surgery), Probiotics, Hospital Food – [18:39 – 21:58], [34:51 – 36:13]
• Exercise Strategies – [22:48 – 24:12]
• Keto & Metabolic Health – [27:25 – 28:42]
• Chemotherapy Risks/Side Effects – [31:03 – 33:46]
• Misinformation & Social Media Risks – [37:55 – 40:04]
• Breast Reconstruction & Implant Illness – [41:11 – 48:09]
• Final Advice & Where to Find Dr. Knackstedt – [49:04 – 51:09]

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Where to Find Dr. Rebecca Knackstedt

• At Duke University
• Instagram: @surgical_recovery
• New Account: @breastrecon_mdphd

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Key Takeaways

• Integrative, evidence-based lifestyle changes—nutrition, exercise, stress management—can powerfully augment breast cancer treatment and surgical recovery.
• Vitamin D deficiency is widespread; supplementation is valuable but must be paired with healthy habits and taken with K2.
• Even minimal “prehab” time (5 days) significantly benefits surgical outcomes.
• Social media is a resource for information but is rife with dangerous misinformation, especially around screening and treatment alternatives.
• Hospital and conventional system failings mean empowered, informed patients (and supportive providers) are more important than ever.
• Recognize, vet, and choose advice and providers carefully—beware of predatory actors offering miracle cures.
• Strong, trusting provider-patient relationships empower patients and support optimal healing.

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Transcript

[A]

Foreign. Welcome to the Fit and fabulous podcast with Dr. Jamie Seaman. Hello everybody, it's Dr. Jamie. And welcome back to the Fit and Fabulous podcast. It is so wonderful to have you here today. I'm excited. I mean, I feel like I'm excited about every episode, but that's because I get to interview some of the world's most amazing doctors and humans that have information that I think you and your friends and family can get a lot out of. And it may just in fact change your life and change your health and change your whole world. So please let me introduce you to Dr. Rebecca Nexted. She is a board certified plastic surgeon specializing in implant based and and microsurgical breast reconstruction. She's currently an assistant professor in plastic and reconstructive surgery at Duke University. She completed her MD and PhD at Medical University of South Carolina where her PhD thesis focused on vitamin D and inflammation. She pursued an integrated plastic surgery residency and microsurgery fellowship at the Cleveland Clinic during which she became certified in functional medicine. Her her research interests are pre habilitation for breast cancer, particularly for women undergoing neoadjuvant chemotherapy. Dr. Rebecca Nexted, welcome to the Fit and Fabulous podcast.

[B]

Thanks so much for having me. I'm really excited to be here.

[A]

Well, I think your resume speaks for itself. Maybe it doesn't impress other people, but I think it's fantastic. So I'm interested to know. So because you were at Cleveland Clinic, is this an option for people that train there? I'm assuming this is like Mark Hyman's program program or whatnot.

[B]

So funny story, when I was there I had a background in nutrition, was always very interested in it and I saw that it was something that really wasn't being addressed with patients in the pre surgical or post surgical areas. So I sent an email to Dr. Hyman one night and I thought he will never respond to me. And I basically introduced myself, said I would love to collaborate with you on a research project. And within 12 hours he wrote back. He introduced me to my whole, his whole research team. We started doing projects together and through that I decided to become certified. So I had that background of knowledge myself and I really, really love that experience because I think that it taught me to look at my patients in a holistic way that I wasn't doing before that.

[A]

Yeah, I mean I had the same experience in traditional medical training. I've done a fellowship in integrative medicine and they, you know, maybe a little peppering of, you know, things that were out there, but I think the attitude towards some of Those adjunctive alternative type therapies. I think there's definitely, it's not the most positive attitude in, in medicine. And so I think it's incredible that you have done this training and that you have other options to, you know, offer to your patients. Because I think we're seeing the pendulum swing that people are looking for other things that they can do to not only prevent some of these things, but when they get a diagnosis like breast cancer, how can they improve their quality of life? How can they maybe improve their outcomes? So we're going to dive into that. Okay, tell me a little bit about your, your PhD thesis with vitamin D and inflammation. What should people, what should people know about vitamin D that you discovered through your, through your training and research?

[B]

I really wanted to do my PhD on anything related to nutrition and I really loved the lab that was able to do my PhD and they were a nutraceutical lab. So they were looking at all different types of natural products and how it could influence, influence colon cancer. It was a colon cancer lab. And through my own research and just the literature that I read in those years, the take home message is everyone is deficient in vitamin D and vitamin D is so anti inflammatory and it's been linked to preventing so many disease states or improving so many conditions that I think that unless you're getting an absurd amount of sunlight that most of us aren't getting, almost everyone would benefit from vitamin D supplementation.

[A]

Yeah, I think we started to hear a lot about vitamin D during the COVID and during pandemic because we knew that low vitamin D levels were certainly associated with susceptibility to getting it and getting severe disease. So why, why are most people so low in vitamin D? Why is it a problem?

[B]

There's a lot of theories behind this and I think that the overarching idea is just the way our lifestyle has shifted. If we look back at our lifestyle hundreds of years ago, we were spending most of our day outdoors in the sun getting all of that vitamin D from the sun. And most of us have desk jobs now we're working inside. So that's one reason is just less vitamin D conversion from sunlight. And then it also has to do with our nutrient intake. Vitamin D is a fat soluble vitamin that we can get in our food. But unless you're strategically consuming, consuming those foods that have high vitamin D which aren't processed foods, then that's another reason why as a population we tend to be vitamin D deficient.

[A]

And do you have like a optimal vitamin D level that that you, from a, from an evidence standpoint, is there. What is the optimal, I mean, every, you know, range on a lab is going to be different. But what for people listening, what, what

[B]

should ideally it be similar to other macro and micronutrients? What is recommended to be normal? Really? What is optimal? So if you go and get your labs drawn and it looks at your vitamin D level, I think a normal range is somewhere around 30. That normal range is to prevent diseases like rickets. No one's really getting rickets these days. But if you want that vitamin D level that's going to decrease your risk of getting Covid or cancer or improve your bone health, it needs to be at least two to three times higher than that, which is really hard to do without strategic supplementation or really ensuring that you're having those foods that are so rich in vitamin D. Does supplementation

[A]

truly improve outcomes or is it kind of like putting a band aid on it? I mean, if people aren't eating these nutritious foods and they're not getting the sunlight for the conversion and things like that, I mean, is it, is it really the same?

[B]

That is an excellent question. And studies have shown that vitamin D supplementation can improve outcomes. But I think that the biggest message is that supplementation cannot do better if you're not having a healthy diet as a baseline. So I think the first thing is always foundations, you know, exercise, nutrition. If you're not doing that, supplementation is going to be putting a band aid. An expensive band aid.

[A]

Yeah. Is there anything that people should be looking for in vitamin D supplements? You know, we hear so like, oh, the supplement world is so bad and patients ask me all the time, which one should I take? And if I told them this brand, they would absolutely go get that. What should people look for in vitamin D supplements?

[B]

I think the main thing when you're looking at supplements in general is looking at the quality of the supplement. So is it a third party validated supplement? Where was it produced? Was it produced in a US facility, which sometimes is hard to find if you're going to Amazon. So that's why I encourage patients to look on the supplement brand website. The other thing that I think is often lost with vitamin D supplementation is the need to take it with vitamin K2. If you don't take an with vitamin K2, you're not going to get as many beneficial effects as you are aiming for. And I think that that is very commonly lost, especially on social media.

[A]

Yeah. Can you tell people why the addition of K I give people D3 and K2. But can you tell people why that is important?

[B]

Yeah. When you take vitamin D, it's going to encourage calcium absorption, which is really important for things like bone health. But without taking the K2. The K2 is like the directions. It tells the vitamin D where to send the calc. So taking them in concert is going to ensure that that calcium ends up in your bones where you want it and not your arteries where you don't want it.

[A]

Yeah. And of course, if you look to nature, these things often come packaged together when we get them in our food.

[B]

It's so convenient how it works like that.

[A]

Right, right. Okay. So we talked about when I was introducing you, this, this research interest of pre habilitation. I think everybody is listening. They've heard of rehab. You go to the physical therapist and you rehab your shoulder or your knee, or you go to rehab for alcoholism. But pre habilitation, prehab for breast cancer, tell people what that is.

[B]

It's the same concepts of rehabilitation just done pre an event. That event could be something like surgery, it could be chemotherapy anytime you have time to prepare. Now, as we know in the surgical field, that's not always an option. If you have a trauma event or some need for urgent surgery, you don't have that luxury of time. But even a couple days of targeted supplementation, strategic eating, some of the lifestyle modifications, really can have drastic outcomes on your surgical outcomes and your medical outcomes as well after surgery.

[A]

Yeah, I mean, I know in my experience it's like, oh, well, you, you know, need your gallbladder out. We'll see you on Tuesday at 3 o', clock, you know, and of course, you know, when people get a breast cancer diagnosis, it's not something they're expecting. Right. You just get a phone call on a Tuesday to go meet with your breast surgeon. So I always think, even though, you know, even if a couple days makes a difference, just thinking about. I wrote a book called Hard to Kill and it's just like you never know what is going to happen when, what, like, and it's going to like the ball is going to drop on you at some point in your life. Whether it's like a death, an accident, a broken leg, a cancer diagnosis, Covid like whatever it is. I feel like, you know, preparing every single day for something like that is important. But of course that's not how most of the world is. So. Okay, so you definitely have a different mindset and a different approach to breast cancer treatment. But talk to me about, you know, you offer Alternative, the rest of the world is offering conventional medicines. How can this optimize surgical outcomes? Because let's say patient gets diagnosed with breast cancer, it's required to have a lumpectomy or mastectomy or reconstruction or whatever it is. How can what you do improve outcomes compared to the conventional approach?

[B]

I certainly adhere to a conventional treatment standards and I think the most important thing for patients to recognize is that you have conventional, you have alternative. And really what is best is when they're complementary and they can really augment each other to improve your recovery. So when I'm thinking about preparing a patient for surgery, whether it's five days or nine months, it's talking about things like nutrition, increasing their lean muscle mass, which is so important for surgical recovery. But also some of the conventionally fluffier things that surgeons don't always talk about. Things like stress and anxiety management, optimizing your sleep, discussing who your social support is, who's going to be taking care of you and your family after surgery. All of those things have shown to impact how people heal after surgery. So really addressing all of those is so critical before surgery.

[A]

So as somebody that practices in the clinic, I'm not just like an Instagram doctor, which I think is so important. When you're listening to people on social media, like, are these people really, you know, do they really understand the intricacies of clinical medicine? But one thing that I think is frustrating in conventional medicine is like, we don't really have the time. I mean, we're, you know, patients are being rushed through, even though we're being, you know, we can bill on time. It's just, it's really truly not enough time to address all of these things that we're going to talk about, you know, on the podcast today. How do you integrate that in the real world when a patient comes to your office or your clinic?

[B]

I wish I had a good answer. I will tell you that when I started my practice a couple years ago and I wasn't as busy, I would spend all the time in the world discussing these things with patients. But now that I'm expected to see 40 patients a day, I just don't have time to do that. So when I found that happening in my own practice, I was really frustrated because I knew that that information was so vital to my patients. So I personally did a couple things. I have handouts that I give to my patients that's very vague, it's like a 50,000 foot view, but addresses things like stress and sleep and nutrition. I have a Very low threshold to send patients to therapy or counseling before surgery. If I see that they're struggling with their cancer diagnosis or anxiety or complaining of difficulty sleeping, they should talk to someone about that. And that's so important. And then that was really what prompted me to make my social media page. Because even in a day, if I can talk to five patients about something, that's so much less than the reach that I can have through social media or being on podcasts or giving grand rounds or writing a book. So that really is my personal plan, is just to get the message out, both to patients, but also to providers, so they are empowered to have these types of conversations with their patients.

[A]

I love that. Because what people don't understand is you and I right now are giving our time. Nobody's paying us for this podcast. We are giving our time to record this podcast, to give people information, because we can. We can truly reach so many more people through social media platforms than we can in the clinic. And it might be somebody's mom that heard this podcast and has a family member going through or I'll tell you right now, when I get a patient that gets diagnosed with breast cancer, they are online and they are looking and they are searching and they are asking lots of questions. And so that's why. Thank you for coming on and giving us this information, because that really is truly how we have. You know, we have to educate the consumers and we have to educate the patients, because in the doctor's office, it's just not going to happen. And once patients start to take some personal accountability, I really honestly think our health system will change. But in the meantime, thank you for what you're doing. And. And I don't want to forget it at the end. So I'm going to say it now. But you have a social media. It's surgical underscore recovery and then our next step, MD, PhD. But if you go. I looked at her page, you go to the surgical underscore recovery. She's got lots of great information, not only for breast cancer patients, but, I mean, if you're undergoing surgery, a lot of what she says for breast cancer patients also applies for recovering from any other surgical procedure. So thank you for doing what you do. Okay, so when it comes to breast cancer screening, do you have an opinion? It's becoming controversial. I'm getting lots of patients. Come into my office. Doctor, I don't want a mammogram. I heard mammograms are going to cause breast cancer. I want to get a thermogram and then now we're hearing about this newer technology, qt scanning using 3D ultrasonography for breast cancer detection. Do you have an opinion? I get a lot of questions about this.

[B]

I do. And I will preface it by saying that what is so frustrating for someone who so strongly believes in the complementary approach to medicine is all of the misinformation that is on social media. And it's frustrating on one hand when it's an influencer who might be taking some piece of information that they kind of misunderstood and spreading it. But was even more heartbreaking to me is when I see people who have MDs, PhDs, advanced nutritional training, that are then using that background, that credibility and then spreading misinformation. And thermography is one of those areas. So there are people, MDs who are just happen to own thermography suites that are going on social media saying that mammograms cause cancer. We have no clinical evidence that mammograms cause cause any type of cancer. That radiation dose that you're getting is less than a plane ride that you take. So we have no evidence in our literature that it is concerning from causing cancer or worsening a cancer. We also don't have any data looking at the reliability from a sensitivity or specificity for thermography. So it is not something that is recommended. Oftentimes insurance does not pay for that as well. So now we're talking about something that you're paying out of pocket for. So no, I don't recommend it.

[A]

Yeah, you know, I tell patients something is better than nothing. But at this time, mammogram still remains the gold standard for screening and detection. Certainly every single test that we do comes with pros and cons and risks. And we have to look at what is the individual risk factor for this patient. When should screening start? How often should it be done? Should they have multiple screening modalities? Some patients do qualify for breast MRIs and things like that, but certainly it's a much more expensive test. So. And of course, you know, breast cancers are curable when they're caught early and when they're advanced stage, they're not. So certainly catching those things is important. Okay, so let's talk about how a patient can best prepare for surgery. Talk to me about nutrition. What impact does that have on surgery and healing?

[C]

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[B]

When the idea of prehabilitation started, the two main components of prehabilitation was some type of nutritional intervention, whether it was diet advice or actually supplementation, and some type of exercise or physical therapy before surgery. So those really are the two foundations of prehabilitation. And what the literature shows is that can make a tremendous impact on your surgical recovery. And while I would love for patients to have three or six months to prepare for surgery, studies have shown that even five days of targeted nutrition before surgery, meaning high protein, arginine, glutamine, sometimes omega 3 fatty acids, even 5 days can decrease complications, decrease hospital length of stay, and in some sicker patient populations, even decrease mortality after surgery.

[A]

Wow. And most people do have a five day warning because it takes generally 10, 14 days sometimes to part off with insurance. So five days is like nothing. And then of course, you know, post op, too, same thing. You're, you're talking collagen protein. Like, what nutrients are super important post op.

[B]

I think that the main supplements that are most evidence based are protein. Protein is so important after surgery, it's so important for life, as we know. But your body needs so much protein to, to improve healing after surgery. Studies have shown that you need somewhere around 2 grams per kilogram of protein, which is a lot of protein. As you know, some of the other supplements that are most evidence based are probiotics, have been shown to decrease pretty much all complications after surgery. And then the standard micro macronutrients that we're all familiar with, things like magnesium, zinc, vitamin A, the B vitamins, your standard multivitamin, just in higher doses because your body is going through so much, it needs more than it needed before surgery.

[A]

Yeah. And then, you know, on the protein thing, it's also, you know, you're obviously going through surgery. And I always talk about protein as like Legos. Like, you can't build Elsa's castle if you're missing half the pieces. But, you know, some of these patients are older, which means they already came in with higher protein requirements. And then of course, when you have surgery, a lot of times you're in a bed, you're immobile, you're not moving as much, and so when you get into that catabolic state where it's breakdown, breakdown, breakdown, it's hard to think about building things back and healing and recovering. Okay, so. Oh, and then you said probiotics, which made me think about the microbiome. A lot of patients are starting to ask about that. They're, like, really freaked out about these antibiotics that the surgeon's going to give them. I've literally. I'm going to refuse that. I'm like, ma', am, you're going to die of sepsis. You know, over. Like, we have a strategy that we can implement. You know, is there a specific, like, strain of bacteria? Is there? You know, what should people be looking at when it comes to a probiotic?

[B]

There was a really nice meta analysis that was done a couple years ago, and it looked at all surgical studies that had used any type of probiotic. And the most commonly used strains were the bifidobacterum, the lactobacilli, and sometimes saccharomyces. What the meta analysis found is that the strains weren't as important as the dose. So as long as you're taking 10 billion with a B CFUs per day, that was really the cutoff that was shown to impact surgical outcomes more importantly than what strain or species you were actually taking.

[A]

Interesting, interesting. Okay, okay, okay. We talked about nutrition. What. What about exercise? Because, you know, postoperatively many patients are going to have, you know, a weight limit or activity restriction. What can patients do, prehab and rehab, as far as exercise and movement that can help recovery?

[B]

When I started in practice, when I was talking to patients about optimizing their lean muscle mass before surgery, my rationale of doing that was exactly what you said before. Surgery is a catabolic state. You need those building blocks to heal after surgery, and you need so many more than you needed just a week before surgery. That was my whole rationale. But as I started to talk with patients more, I realized that it's so much more than that. It's really their functionality after surgery. So before, I would just tell patients, just increase your global lean muscle mass. Do whatever resistance training cardio is convenient to you. But what I found is that it really depends on what type of surgery you're having. So for me, when I do microsurgical breast reconstruction, we do surgery on your breasts. They're on a please do not lift more than 10 pounds for six weeks. So their arms are kind of out. And then their core was just destroyed with the surgery that we did. So what they needed to do before surgery were squats, because that's what's going to get them out of bed, off of the toilet, walking around. And it never really hit me until a patient told me and that that's what she did before surgery and it so drastically improved her functionality after surgery. So now when I talk with patients, I think, what surgery are you having? What's going to be out for a little bit? So what do we need to increase before surgery to help with your recovery?

[A]

I remember going to a conference a few years back, Metabolic Health Summit, and there was a radiation oncologist there. I'm to trying to. I'm really trying to remember his last name. His first name is Colin. But he gave a whole presentation on a cohort that he had in his clinic that did box jumps and squats and some different things like that while they were going through radiation for their breast cancer. And not only from like a functional standpoint, obviously, but they had better breast cancer outcomes because he was able to maintain their lean tissue. Mass and muscle is, is. Is a great metabolic organ. And then, of course, a lot of the treatments of breast cancer demineralized bone and put these patients at increased risk when you're, when you're lowering estrogen. It was fascinating. I'm like, this is incredible. Like, literally all he did was like, open this little gym space next to his clinic and they would just come in and they would do this with the trainer. I mean, this is like fantasy world, right? Like, one day when we'll have like a place where you go and you pick up your meals and you do your workout and you still get your breast cancer treatment. I mean, it's just like. But it's so incredible that, you know, it's unfortunate. What I hear sometimes from patients is they'll get a cancer diagnosis and it might be a very, you know, grim outlook. It's, you know, an advanced stage cancer. And these doctors will say, well, you know, you only have so much time, so just do whatever you know you want. Just have the ice cream. And, you know, and it's just like, it's so sad. It's so defeating to not be able to, like, you know, empower these people that they can still, even in whatever time they have left, you know, have an amazing life. And I tell people you're going to die of something. So if we save you from your breast cancer and then you get osteoporosis and break hip, I mean, you know, it's like something's going to kill you. So, you know, don't let it Be things that you have the ability to prevent. So. Okay. All right.

[B]

Yeah, one of my. That's okay. No, I love it. It's a great soapbox. One of my salient memories from med school. I'm writing a book and this is in my book. It was. I wanted to be a radiation oncologist. So I spent a lot of time in the radiation oncology clinic. And I loved head and neck. So I was, I was with a head and neck radiation oncologist. And those patients are cachexic. They lose a lot of weight. And if they lose so much weight, they have to stop their radiation treatments, which then impacts mortality. And I distinctly remember this one older guy coming in, he was losing weight. They were talking about decreasing his treatments. And this, this doctor said to him, just eat ice cream. And as a med student, you know, you sit in the corner and you're like, I can't speak unless I'm spoken to. But even then I know that was such bad advice. They don't need those inflammatory sugars and such a lack of nutrients that are so critical in this window. But doctors just aren't taught that. You know, we get less than 20 hours of nutrition education in med school, if that. So we need to empower surgeons and doctors just to have those conversations with patients in a very evidence based way.

[A]

Yeah. I am board certified in ketogenic nutrition therapy. And there is, there's so much research, especially with breast cancer, on ketogenic therapies as an adjunct. And I think it's incredible, you know, that the research shows that, you know, not only improvement in outcomes, but just the ability to tolerate the treatment, the ability to tolerate the radiation and the chemo without side effects. Have you had experience with ketogenic diets or tell me your thoughts on it.

[B]

I completely agree with the research and I love that they're doing research on this because what I do see in clinical clinic quite frequently is patients not completing their chemotherapy journey because the side effects are too much. And we keep coming up with all these new chemotherapeutic drugs which are shown to be very efficacious, but they have a lot of side effects. And Even young, healthy, 30 year olds, it just knocks the wind out of their sails. So doing something like a ketogenic diet and getting them through therapy is so important. Studies have shown that 60% of women who have neoadjuvant chemoxide develop metabolic syndrome. And that's before we're taking them to surgery. Their blood sugars are all messed up. Their insulin is all over the place. And then we expect them to heal after surgery. That's not a productive situation.

[A]

Right, right. You know, and breast cancer really is a metabolic disease. I mean, in a way. Right. And so, you know, they. They came in with clearly some risk factor, and then you, you know, you put these things on top of. Of it, and you can end up, you know, pretty bad on the other side. I completely agree with you. I think it's hard. You know, people say, well, dietary nutritional interventions are just hard from a case, you know, patient compliance standpoint. But I do think, too, that if. If patients knew they had options that could improve their life and improve their outcomes, you know, this might be hard to implement for your family. But, you know, the evidence shows this and this and this and this. I think people would be more willing to do it, but they're just not, you know, empowered with this information. And. And it's. You know, they're getting advice like, just eat a bowl of ice cream and power through it. So. And then, of course, the side effects, you know, they get nauseous, so you give them zofran, and that causes constipation. It's like.

[B]

Yeah, it's just a snowball that just keeps going and going. And I think as surgeons, we. When we are talking to patients, we at baseline feel like we're overwhelming them with the risks and the benefits and the alternatives. And you just had a cancer diagnosis, so I think a lot of us just stop giving information that's not critical in this window. So that's why we don't talk about things like nutrition. But there was a study that actually asked patients, you just had surgery. You weren't given any of this ancillary advice like nutrition. Do you wish you would have had it? And the answer was overwhelmingly yes. Patients want that information. They want to feel like they have one ounce of power in this situation in which they're powerless, and that can be nutrition. So we should be giving patients that information.

[A]

Yeah. I always tell people, control the controllables and what you eat and what time you go to bed and how much you move your body and how much sunlight you get. We have so much more control over our health than we even realize. But we make a lot of decisions in a day, and so a lot of us are just on autopilot. And so, yes, you really have to make a conscious effort to kind of change some of these behaviors. So you kind of brought up this neoadjuvant chemotherapy. Tell people what that even means. What is neoadjuvant chemotherapy?

[B]

Neoadjuvant chemotherapy just means chemotherapy that happens before surgery. The main reason that we do that is to decrease the size of the cancer or completely eliminate the cancer before surgery so that there's a greater chance of removing the cancer at surgery and getting completely negative margins at the time of surgery. Neoadjuvant chemotherapy can be weeks to months, even before surgery. So it's a really long time. We talked about the fact that so many women get metabolic syndrome through this experience. The good thing is, though, is that if you are on this chemotherapy journey, you then have months to work on your lifestyle factors, your nutrition, your lean muscle mass before that ultimate surgery, which for the vast majority of women will still take place.

[A]

So, you know, this is, this is a chemical that is, you know, targeting the cancer cells. But clearly it doesn't always kill just the bad guys. It kills some of the good guys too. So highlight what are, what are some of the risks outside of attacking the cancer? I mean, we've kind of touched on this idea that it creates a lot of metabolic disease, but give people an idea of like, what else is it doing, what else is it harming?

[B]

The way that most neoadjuvant cancer drugs is they target fastly replicating cells, which tend to be cancers. That's how cancers grow and spread rapidly. But that also means that many of the side effects of chemotherapy are on your cells in your human body that aren't cancer but that divide rapidly. Things like your gastrointestinal tract. That's why there's a lot of nausea, diarrhea, your hair. That's why a lot of women lose their hair, their eyebrows, their eyelashes. Your nails grow fast. So a lot of women have changes to their nails. So that is why a lot of these women have these side effects. It's more just an expected outcome even than a side effect. There are some things that we can do during cancer treatments to help offse side effects. Things like high dose vitamin C has shown to decrease some of the nausea and fatigue during chemotherapy. Women can cold cap, which is basically doing a cold plunge to your head for the whole time that you're doing chemotherapy. That's been shown to decrease some of the hair loss. And that really is an active area of research, because while we want the chemotherapy to be effective and do its job, we also want to preserve these women's quality of life and their sense of femininity and how they feel about themselves. And it's really hard to feel strong and motivated when you're tired, you're nauseous, you're throwing up and you're losing all of your hair.

[A]

I. I have never had breast cancer, but I lost a lot of hair several years ago after salmonella poisoning and Covid. And I was digging through research, looking at, like, what's the newest, hottest thing? How am I going to re. For people that don't know these are extensions, I'm still on a hair regrowth journey, but I found that this study on breast cancer patients, and it was some quality of life survey, and I can't remember the exact percentage. It was like, it shocked me that many of these women said that they would have rather died of their breast cancer than lost all their hair. I mean, it's such a intense identity crisis for these women. And so I think it's amazing that they're looking at cold caps and red light and all these different things that can. That can help because. Because these are the unfortunate parts of dealing with these diagnoses. Okay, you've trained at a few different places. Let's talk about hospital food. What are these hospitals doing for these patients when it comes to nutrition? It's really sad, isn't it?

[B]

It is so frustrating. And for me, the most frustrating thing is, like you said, I trained at Cleveland Clinic, where Mark Hyman started the first institute for functional medicine. If he was unable to change the food landscape at the Cleveland Clinic, what are their hopes for other countries? We had my intern year at Cleveland Clinic. There was a McDonald's. It was the busiest McDonald's in the country. At the Cleveland Clinic, this is the food that patients are eating. They are having Starbucks frappuccinos for breakfast. The hospital. For those of us who have been a patient in the hospital, we know the food offerings aren't tasty. They're not appealing. They're brought at times that aren't convenient for you. Your surgical healing, you're going to be nauseous. Your sleep wake cycle is all messed up. So that is why I tell patients if you are having a surgery where you're going to be in the hospital for a couple days, bring snacks. I've had patients bring blenders and make their own whey protein smoothies on their little windowsill. I love that. But even the protein shakes that we have in the hospital, my residents have seen me get on my soapbox. It's boost. I will literally throw it away if I see it in a patient's room. Because you don't need the first two of three ingredients in your protein shake to be sugar and glucose syrup. That is not what you need. To heal. But I go head to head against the dietitians in my hospital all the time with that.

[A]

Yeah, I mean, it's, I haven't seen one hospital that's doing it well. And I feel like it's kind of like the school lunch program. It's, it's going to be really hard to fix. And so you just have to start teaching, you know, teaching the patient and, and they got to get savvy. I recently had a pregnant patient in the hospital and she had just gestational diabetes. And I said she'd been eating some applesauce and things, and so I'm trying to give her some advice. I said, well, tomorrow, if you're gonna want fruit, then order whole fruit. So she calls down to the kitchen and she says, I want whole fruit. And what shows up is a cup of oranges in syrup. And they were like, well, these are whole orange pieces. And I'm like, no, no, I'm like this.

[B]

You know, I mean, they do, they

[A]

have, you can put a patient on like a diabetic diet, but even then the amount of carbohydrates they allow. I mean, it's like you'd almost have to work with dietary services to say like, okay, here's the, here's the parameters that my post op patients get. And they have to order in these parameters. But it's like beating your head against a wall some days, you know it is. And some patients don't want to do it. Right. Like they want the bowl of ice cream and there's nothing we can do about it, you know, so it's so frustrating. Okay, so social media, it's a, it's a double edged sword. I highlighted the amazing aspects of, of, you know, this podcast and getting this information out what, like, absolutely gets under your skin. We talked about thermography. Is there anything else out there that you just like want to put your head on your desk when you see it? When it comes to breast cancer, prehab rehab.

[B]

Oh, where to start? Yes, I would say that probably the things that are sad, to me, they're not even upsetting, they're just sad. Is the misinformation out there for breast cancer patients? A lot of them are these patient forums where patients are trying to help other patients, but they're asking questions that really should be directed to their healthcare team. Think I've seen messages like, my breast after an implant is red and swollen and there's pus coming out of it. What should I do? Facebook. Facebook is not the place to ask that but what I think that Facebook and Instagram and social media platforms can be lovely for is developing social networks which has been shown to even impact mortality after a breast cancer diagnosis. So like you said, double edged sword, good and bad, that's the first thing. And then I think the second thing is everyone on social media is trying to make money. We know that whether it's paid advertisement or they're selling some type of product, the vast majority of people are not out there just spreading information. And there's so many people preying on breast cancer patients and other cancer patients too. These are desperate people. They just had this life altering diagnosis. They're 30 years old with young kids and a thriving career and their life has just been derailed. And they go online and they see things like, this herb cured my cancer. Don't get chemotherapy, it will actually kill you. Don't have radiation and actually causes cancer. All of this misinformation which is just feeding into that stress and anxiety and guilt. I would say the third thing is not to get on my soapbox too much either. But there's also so many people out there talking about cancer being 100% preventable. And we know it's not even if you live the healthiest lifestyle. Some people just get cancer. But then I see women come into clinic and they're this healthy 30 year old that did all those things. Right. And she asks, why me? And once again, it's just fueling that stress and anxiety and guilt and depression which so negatively impacts both her quality of life in the short term, but even her oncologic outcomes.

[A]

Yeah, I mean, I think there's so many things we can do. But you know, in the industrialized world that we live in, I mean, we could talk about microplastics, we could talk about chemical fragrances. We've highlighted diet and exercise and vitamin D and sunlight. I mean, there's only so many areas of attention that you can focus on.

[B]

Yes.

[A]

And pick the ones that are important to you. But yes, at the end of the day, sometimes just geographically where we live, the DNA we inherited from our parents, like, like bad things happen to good people. And we see it, you know, working in medicine, that's for sure.

[B]

Absolutely.

[A]

Okay, so when it comes to breast cancer reconstruction, another thing on social media is breast implant illness. And of course, like, you know, you feel bad, right, because breast cancer patients, we've talked about losing their hair. Now you're talking about something that's a sexual organ. This is very, you know, important to women to have breasts and so there's lots of different ways that you can do the reconstruction. But can you, can you maybe just an overview of what, what options do people have, you know, as far as reconstruction?

[B]

So when I talk to my patients about building a breast, I talk that we need two things. We need healthy skin to cover something and then we need something to provide the volume. The vast majority of women opt for implant based reconstruction after breast cancer because it's a shorter surgery, it's a faster recovery, it's more widely available, that provides the volume. So you still do need healthy skin to cover that implant. The other way of performing breast reconstruction is using some part of your body that's expendable. So for a lot of women, it's that lower tummy area, something that most women might refer to as a tummy tuck type surgery. So we take that skin and volume completely detach it from your body and reattach it to create breasts. Breasts. It's an all natural reconstruction. It's your own body, it ages with you. It can be a very beautiful result. But it is a much bigger surgery. You're adding in a second donor site, it's a longer surgery. But those are the two main ways to make breasts implants or body based, which are sometimes called flaps or autologous, auto meaning self reconstruction.

[A]

So tell me your thoughts about breast implant illness.

[B]

Yeah. So as with all other aspects of my practice, I strive to stay up to date on the literature. And this is a ever changing area of plastic surgery research. So just as a brief introduction, what breast implant illness is, is it's women who have implants and have systemic symptoms, a whole range of systemic symptoms. Body ache, fatigue, muscle aches, hair loss, and they believe that it's coming from their implants. Oftentimes these women have a full medical workup, Lyme disease, vitamin D deficiency, checking for metastatic disease, and nothing really checks out. But they're still having all these symptoms. So they believe that it's coming from the breast implants and they want them removed. What studies have shown is that there's really three groups of women that emerge from this after they choose to have their implants out. Some women do feel better when they get the implants out. Some women feel better for a while, but then start to develop some of those symptoms again. And some women have no change in how they feel. So they feel exactly the same before surgery as after surgery. They've looked at everything from mold to biofilms, to inflammation, to silicone leaking. And what they found is that within these groups of women, there really was no difference as to who was a responder and who wasn't a responder. What the literature very well shows us, though, is that the capsule which forms around your implant, consider it the home of your implant implant. Some women feel like they need to have the implant out and the capsule, it's called a capsulectomy. Studies have shown that having or not having a capsulectomy did not influence which of those three groups you were put in. So the overall success. Why do we care? Why do I even bring that up? Removing the capsule can be a fairly bloody, somewhat dangerous surgery depending on where your implant is located, especially below the muscle. And there are people who market themselves as breast implant illness experts who charge women an unethical amount of money to remove that capsule. They just so happen to also sell red light machines or red light therapy machines and their supplements and their detox brands. So it's this wellness package that once again is preying on desperate women who just want to feel better. Why I think that's so challenging with a breast cancer diagnosis is if you have a breast augment, augmentation with implants, you still have some breast tissue that's left behind. If you have a breast cancer diagnosis and you remove that implant, you're completely flat, which for a lot of women is so, like you said, emotionally distressing and can lead to some symptoms like depression, stress, and anxiety. So that was a long winded explanation. But that is the current status of our research, which is ongoing into breast implant old illness.

[A]

Yeah. Yes. I've come across the breast implant illness doctors on Instagram, and it is very predatory. You know, I tell patients that the placebo studies are real. We literally, there's literally a study where they told the patients, this medicine has nothing in it, but it's going to help your headache. And 50% of the patient's headaches went away. Even when you're told there's nothing in the medicine, 50% of the time, you get better. And I think that what this really highlights is that our brains are extremely powerful. It's why things like prayer improve breast cancer outcomes. I mean, it's why, you know, having good social support improves breast cancer outcomes. It's because our brains are incredibly powerful. And if you believe that you can recover and you can beat something and you're going to fight something, you are probably going to do much better than if your view is, is, I'm going to die, my life is over. You know, this is the end. And so if you believe that your breast, breast Implants are making you sick and you take them out a third, maybe two thirds of the time, you're going to feel better. And I think there's probably things we don't know. You know, it is a foreign body. Our immune systems are very vulnerable. But I've experienced exactly what you just highlighted. I've had patients who have taken them out, they felt better. I had patients, patients that took them out thought they were better and they weren't. They took them out, nothing got better. And then they were pissed that they took them out. I mean, so, you know, a lot of patients come to me as a gynecologist and ask me about my opinion on these things. And I don't do, I don't do breast implant surgery and I don't do removal. But I think it's important for people to hear because there's a lot of information. What about the cancer in the capsule with the breast implants? What, what should people know about that?

[B]

Excellent. So that is the only indication for oncologic or cancer purposes where we do have to remove the cold capsule. That's called alcl. It's a type of lymphoma that has been associated with breast implants. It seems to only be related to textured implants, which most of us really don't use anymore. We now use smooth devices largely because of that risk. The risk with texture devices is anywhere from 1 in 3,000 to 1 in 30,000, depending on what study you look at. But we have to remove the capsule because there are cancer cells in that capsule. And if we can't remove the capsule for whatever reason, some of those women actually go on to need chemotherapy because we weren't able to remove the capsule. So when I talk to patients and we're talking about whether or not to remove the capsule, I say that's really the only indication for which we have scientific proof that we need to do this surgery, even if it does slightly increase your risk of complications after surgery.

[A]

Do you know that before you go in? Do you biopsy? I mean, how do you know if you need to take the capsule up?

[B]

Good question. So the. God bless you. The, the main symptom of Alco, which we always tell patients about, is one sided breast swelling, typically years after their implant was placed. And this is not just a little bit of swelling, this is significant swelling. And then we take some of that fluid, usually just through a little puncture, we send it off for cytology so that we know what it is before we go into surgery. If we go into Surgery. And let's say we find something that we weren't expecting, so we send it off, and it comes back as alcl, then we just need to take the patient back to surgery and ensure that all the capsule is removed at that time.

[A]

Got it, Got it. That makes sense. Okay. Anything else we missed that patients should know about? No.

[B]

That was a really good overview of breast reconstruction and prehabilitation. I would just tell patients, you know, it's cancer, especially breast cancer. It's so overwhelming, like we talked about. It just derails your life in such a profound way, and patients are so overwhelmed. I always tell patients, make sure that you are comfortable with your treatment team. Make sure you feel like your providers are people that you can ask questions to because you want to have that relationship with your surgeon and your oncologist. So if you do have a complication, you're not one of those patients who have to go to social media to ask those questions. You have that open line of communication with your provider.

[A]

Yeah, yeah. Oh, that. That totally made me think of one more thing. I have seen patients, too. I mean, we're just talking about the predatory nature of people sometimes towards cancer patients and these alternative clinics, and many of them are not even in this country. But I've had patients in the past 10 years who. Who get an extremely, extremely poor diagnosis, and they spend the last six months of their life traveling out of the country, away from their family, taking $30,000 out of their bank account for therapies that have absolutely no, you know, scientific evidence. And so I just encourage, you know, if you get a diagnosis, your family member gets a diagnosis, you do. You have to have an immense amount of trust in your provider team, and. And of course, and the belief in whatever you're doing. And at the end of the day, patients will sometimes make decisions that. That we wouldn't choose for ourselves. But we. We all get that autonomy, of course, so.

[B]

Absolutely.

[A]

Well, doctor, next said, tell people where they can find you if they wanted to be a patient or where they can find you on social media.

[B]

Sure. So I am currently at Duke University. That is where I do my breast reconstruction. If you want to find me on social media, like you said, I'm at Surgical Underscore Recovery on all social media platforms. And I'm actually starting a new social media that will be directed just towards breast cancer and talking about reconstruction. It'll be Breast Recon, M.D. phD. So please message me. I love interacting with people and answering questions.

[A]

Thank you. Thank you, doctor. Hey, if you guys thought this podcast was helpful, please send it to your family and friends. Please leave us your comments and questions on YouTube and Spotify and Apple podcasts and all the places you guys are listening. We will catch you on the next episode. Did you guys love that last episode of the Fit and Fabulous podcast? Well, of course you did. And I want to keep bringing you the most amazing content from the most incredible people. And you can help me by subscribing to the Doctor Fit and Fabulous Channel. You guys know where the button is? Just click it. It's the doctor's orders.