Podcast: Healing Better and Faster with Prehabilitation Expert Dr. Rebecca Knackstedt

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Functional medicine expert and plastic surgeon Dr. Rebecca Knackstedt explains prehabilitation: how to actually prepare your body and mind for surgery so you heal better and faster.

From protein-loading (not starving) to supplements that support recovery without increasing bleeding risk, get the real roadmap to a smoother surgical experience.

Follow Dr. Knackstedt on Instagram @surgical_recovery and @rknackstedtmdphd

Learn more about Duke plastic and reconstructive surgeon Dr. Rebecca Knackstedt

Learn more about Clara Recovery

Sign up for Clara Recovery’s newsletter to receive Preparing Mind and Body for Surgery, her free e-book with expert guidance for a smoother recovery.

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Transcript

Dr. Gallus (00:02):
You’re listening to another episode of All the B’s with me, Dr. G, and my scrub tech, Bri. Good morning everybody. I’m Dr. Kat Gallus and you’re listening to All the B’s, our unfiltered plastic surgery podcast that also includes some celebrity gossip. And lucky for you non-recorded us screwing around with technology.

Bri (00:24):
We’re just girls.

Dr. Gallus (00:27):
Hey, Bri.

Bri (00:28):
Hi.

Dr. Gallus (00:29):
Today we are going to talk about prehab protocols that’s prehabilitation with Dr. Rebecca Knackstedt. Am I saying that right?

Dr. Knackstedt (00:39):
Yeah, it’s good. No one ever gets it right. In fact, my husband tells me that I say it wrong, so I’m fairly certain whatever you say is pretty good.

Bri (00:48):
That’s great.

Dr. Gallus (00:48):
That’s awesome. Okay. Why don’t you tell us a little bit about where you’re from, because you’re so gracious to come on our highly technically functional podcast and talk to us about this, but I know you’re on the East Coast, correct?

Dr. Knackstedt (01:05):
Yes. I’m a practicing plastic surgeon at Duke.

Dr. Gallus (01:09):
Okay. That’s where I went to undergrad. That’s as far as I got at Duke. And then they were like, “You can move along now.”

Bri (01:16):
You’re done.

Dr. Knackstedt (01:19):
It’s lovely here. Yeah, I’m starting my fourth year in practice, but I did most of my training in Cleveland, so it’s nice to be somewhere where that does not get quite as much snow.

Dr. Gallus (01:28):
Somewhere that’s not Cleveland. Let’s just be real.

Dr. Knackstedt (01:31):
It has also that.

Dr. Gallus (01:33):
Where did you grow up? Please don’t say Cleveland.

Dr. Knackstedt (01:38):
No, I did not. No. I grew up in Pittsburgh though, which is not that much better. And then I moved south to South Carolina for my MD, my PhD, and then I returned north for plastic surgery residency and micro fellowship.

Dr. Gallus (01:51):
All right. So we normally start this stuff off with some celebrity gossip. And I do want to, in the light of having the Stranger Things season finale wrap up, I definitely want to talk about Millie Bobby Brown, whose name is now Millie Bonnie Bonjovi, who was in this obviously in season five of Stranger Things. It’s been 10 years since they started. She’s going to change how she looks because she’s older. However, Comma.

Bri (02:20):
It’s just so good because the evolution of her over the years, and she looks so gorgeous and so beautiful, but she has the one face the entire season. She cannot move. And I’m here for it. I want to be as frozen as possible. But for all of her facial expressions, she’s like the whole time, the whole time.

Dr. Gallus (02:42):
It’s a Nicole Kidman knockoff where it’s just all the eyes, all eyes.

Dr. Knackstedt (02:47):
I’m a big fan of a frozen forehead, but when you’re an actress, it makes it a little bit challenging.

Dr. Gallus (02:53):
Yeah. I think this is probably one of those situations when they started out with Stranger Things and they were working with these child actors. No one thought to put it in the contract that you can’t do Botox or fillers because she was like 12 or something. So at that point, now it’s 10 years later and they’re like, “Oh, oopsies.”

Bri (03:17):
She also married a pretty bougie dude if I have not heard her say it on a podcast that she was on before.

Dr. Gallus (03:24):
Yeah. And then the lip filler, same thing. There was nothing in the contract that said, “Hold off on the lip filler until we’re done wrapping this.

Bri (03:32):
Yeah. It’s very not in tune with that show specifically, seeming how they’re in the middle of absolute nowhere and somehow she got filler.

Dr. Gallus (03:40):
Also in the 80s, there was no filler or Botox. Let’s be real.

Bri (03:45):
So she looks fabulous, but-

Dr. Knackstedt (03:47):
She also lives on a farm. So that’s also so weird to me. All of her pictures are with her and chickens and then just lots of lip filler.

Bri (03:56):
So bizarre.

Dr. Gallus (03:57):
Yeah. I did want to talk about Tom Brady and Alex Earl. I’m sorry because it’s so disgusting.

Bri (04:03):
Okay. Let’s hear it.

Dr. Gallus (04:06):
Did you hear about this?

Bri (04:08):
I did. Okay. If I was Alex Earl, I’d be on Tom Brady too,

Dr. Gallus (04:13):
But … Yeah, no.

Dr. Knackstedt (04:15):
No, that’s fair.

Bri (04:16):
Thank you.

Dr. Gallus (04:18):
I would go for that. It’s definitely an upgrade from her last football boyfriend, except that he’s 48. I also love the fact that they got busted because he grandpawed it by having his flashlight on, on his phone, in his pocket. And that’s how they got caught. People were like, “Hey, Tom, you’re flashlight.” It’s on-

Bri (04:39):
Oh, I didn’t know that part. That’s actually really funny.

Dr. Gallus (04:41):
You’re like, “What a dumb dumb.”

Bri (04:42):
Or maybe it didn’t on purpose.

Dr. Gallus (04:44):
No.

Dr. Knackstedt (04:44):
Weren’t they on the Bezos yacht though? I mean, that’s also- No.

Dr. Gallus (04:48):
Actually, no. They were on some other crypto guy’s yacht who is married at least the original yacht with some other dude.

Bri (04:58):
What is happened there?

Dr. Gallus (04:59):
Because I just heard about how he was on a yacht with … Or Alex Earl was on a yacht with … Who are all the other hooey people? Nina Dobrev and …

Bri (05:10):
Also single.

Dr. Gallus (05:11):
Yeah.

Bri (05:11):
All these heartbroken girls.

Dr. Gallus (05:13):
Glenn Powell and his new girlfriend. Is she

Bri (05:16):
From Landman?

Dr. Gallus (05:17):
Yeah. She’s so cute. And then Miles Teller and his wife.

Bri (05:22):
Love.

Dr. Gallus (05:22):
But maybe that was a different yacht than Tom Brady. I don’t know. I mean-

Bri (05:26):
All the yachts are blending. I just know I didn’t get an invite to a yacht.

Dr. Gallus (05:31):
Yes. And then the only other thing I thought was interesting was that some of the mom talks from Secret Lives and Mormon Wives were not in Encinitas, in San Diego over the last week.

Bri (05:44):
We’re not stalking you, but if you were seen …

Dr. Gallus (05:48):
If you were seen at Urban Plates in …

Bri (05:52):
The Forum?

Dr. Gallus (05:53):
Yes, at the Forum. Anyway, we’re watching you. That’s enough. That’s enough. Okay. Back to you. How do you have your patients address you?

Dr. Knackstedt (06:05):
Anything that’s not hey you. I mean, honestly, whatever. Becky is totally fine.

Dr. Gallus (06:10):
So do you say Dr. Becky or Dr. K?

Dr. Knackstedt (06:14):
I say Dr. Knackstedt, but I also tell my patients they can call me Dr. K. It’s too many consonants. German, it’s a hard language to master.

Dr. Gallus (06:23):
Yeah, it is. We’re going to refer to you as Dr. K because I don’t want to have to trip over Knackstedt each time.

Dr. Knackstedt (06:29):
Perfect.

Dr. Gallus (06:30):
So you’re a plastic surgeon like myself, but also certified in functional medicine. So what is functional medicine? Break it down for us.

Dr. Knackstedt (06:38):
Yeah. Functional medicine is, I think, a term that’s often misunderstood. Functional medicine is something that people can get certified in. There’s actually certification processes. And I think it’s just a holistic look at patients. So functional medicine providers believe that a lot of health and wellness stems from the gut and also exposures, history, childhood exposures to things. But once again, I think just as an easy way to understand it, it’s just taking a holistic look at patients and treating more root causes, which I know everyone hates the word root cause. I hate the word root cause too. There’s just no other alternative way to say it, but treating conditions from a holistic perspective. The challenge with functional medicine is that … So I’m an MD PhD. So when I did my functional medicine training, I had a lot of postgraduate education. A lot of people can become certified in functional medicine, like chiropractors and acupuncturists.

(07:36):
So I think there is a lot of voodoo out there being spread by people who call themselves functional medicine providers. So that’s why I’m always, when I explain functional medicine, I always do give that little asterisk explanation and just looking at people’s credentials as to where you’re getting that information from. Long-winded answer to your question.

Dr. Gallus (07:56):
No, I mean, I think there’s a similar parallel when you talk about plastic surgeons. Sometimes when a news story hits the fan of plastic surgeon gone wrong or whatever, the first thing I always check and see is, are they actually a plastic surgeon or are they cosmetic surgeon, which is like a pediatrician maybe- Wanting to do lipo. Yeah. Doing lipo or something. Yeah, absolutely. So yeah, it’s all about the credentialing. So what was kind of your aha moment when you were like, “Hey, we’re missing something when we’re just moving forward with

Dr. Knackstedt (08:30):
Surgery.” I have always really been interested in nutrition. My PhD focused on vitamin D. I’ve always had a personal interest in nutrition and exercise and always just did a lot of research myself. And then when I was in residency, that’s when I reached out to the functional medicine department. I became certified in functional medicine, did some research with them. And when I started my practice, I sincerely thought that if I just told a patient to take some supplements, they’d be good. They’d heal no issues. That’s sort of our approach. It’d be a lovely approach. It doesn’t work. It doesn’t work. And I take care of mainly breast cancer patients. And so as I got to know my own patients, which you don’t do as a resident, I realized just how much is going on in their lives. They’re stressed out, they’re anxious, they’re not sleeping, they’re having a divorce, their childcare issues, they’re not working.

(09:21):
Just so much is going into how she’s feeling and how she’s taking care of herself. And this happened about two years ago. And for me, it was just a huge paradigm shift where I realized that I can’t just do surgery on someone who’s going through all of this and expect her to heal as well as she could have healed if we had chatted about some of those things and addressed some of those things preoperatively. And so that’s when I started looking into the literature, started learning about prehabilitation and learning from other surgical specialties, because it’s not really used in plastic surgery, but taking those principles and then applying them to my own patients.

Dr. Gallus (09:59):
Nice. Yeah. I think that’s interesting because I do remember as a general surgery resident and then as a plastic surgeon when I did breast reconstruction that I thought somebody should do a study on the divorce rate and people newly diagnosed with breast cancer because it’s, I don’t know, I thought it was alarming. “Oh, you got cancer, babe, I’m out. “What? Because the number of women who came in by themselves with their spouse or with a girlfriend were probably equal. And you would’ve thought if you were guessing, your spouse would be coming with you if you have a new diagnosis of breast cancer. But a lot of times they were coming in with their friends because the spouse was not available or in the process of divorcing them. So that was one thing. And then the second thing is that I do remember we used to do our pre-op H&P in the holding area when I was a surgical resident, right?

(10:52):
The patient’s already booked for surgery, and that was when I learned what a boilermaker was. Do you know what one of those is?

Dr. Knackstedt (10:59):
Like an alcoholic boiler maker? Like a drink?

Dr. Gallus (11:02):
Yes. Because I asked my patient,” Oh, do you drink? “And he said,” Yes. “And I said,” Oh, okay. Well, what do you drink? “He’s like, ” I have six boilermakers a day. “And I was like,

Bri (11:13):
What’s in it?

Dr. Gallus (11:14):
I don’t know what that is. And then I had to ask, and it’s a beer and a shot of whiskey, so that’s 12 drinks a day. And I was like, ” Ooh,

Bri (11:23):
Just combine two drinks to make it one?

Dr. Gallus (11:24):
So I was like, ” Huh, that’s the opposite of prehabilitation. “I was like, ” Well, I went to my attending who had zero fear about anything and it was a cancer operation. And I was like, are we concerned about the level of alcohol that he drinks on a daily basis? “And he’s like, ” Kat, it’ll be fine. Just put them on protocol. “It’s fine. So of course he went into DTs, but we had already had him on that protocol. It was kind of a nightmare. So yeah, I would say that’s the opposite end of being prepared for your surgery. What is the most common thing you think patients aren’t told before surgery?

Dr. Knackstedt (12:05):
I think the most common thing that patients aren’t told is just that you should prepare for surgery. When I think about preparing for childbirth, you have your bag packed, you have your hospital bag packed, your room is babyproofed, have your help around the house set up before you give birth. You think about that for months. And then the average patient having surgery just like shows up the day of surgery, NPO with fingers crossed, thoughts and prayers, maybe, maybe NPO.

Bri (12:33):
Hopefully NPO.

Dr. Knackstedt (12:34):
Or maybe had a boiler maker. But I think that patients just aren’t told that if you do some things before surgery, whether or not you have a day, a week or nine months, even little things can make a huge difference in how you recover objectively from a complication perspective or just how you feel, how quickly you get back to baseline. Patients are almost never told that, especially in plastic surgery.

Dr. Gallus (13:00):
I think in our office, we tend not to sugarcoat the recovery. No?

Bri (13:03):
Yeah. No, I fully agree because I feel like a lot of people come in here and they expect to just have surgery and then they’re going to wake up the next morning and they’re going to have these amazing results and not realize it’s a process and not like … You have to put in the time and effort, like what you do and how you care for yourself before and after surgery, I always say it’s equally as important to having surgery. If you don’t want to wear your garments, if you don’t want to listen to the actual post-op instructions, if you want to start doing things that are going to affect your results, you have to take care of yourself equally after. Don’t spend all this money on having plastic surgery and then don’t wear your garments, don’t, I don’t know, plan a trip somewhere. Don’t plan a trip two days later. Don’t go right back on your GLP-1s and then expect you’re going to heal properly. That’s not going to … Because you want to be skinny after surgery.

Dr. Knackstedt (13:57):
Absolutely.

Dr. Gallus (13:58):
Yeah. And I do think we try to educate our patients about all of that, but a lot of times … Well, we all know in general, humans need to hear things multiple times and in multiple frameworks. So maybe me telling them, our nurse, Danielle, going over it again with them, they get it in an email, which they usually delete without reading.

Bri (14:21):
They get a pamphlet.

Dr. Gallus (14:23):
They get it written. So what do you find is the most effective way of communicating some of these things with your patients?

Dr. Knackstedt (14:30):
That’s hard, especially with a new diagnosis of breast cancer. Studies have shown that women forget 80% of what’s discussed, so that’s terrible. And to your point, oftentimes they’re coming by themselves, so they don’t even have a loved one that’s a second set of ears. So what I found is I’ve made a huge prehab guide that I send my patients home with as reading material. When I started practice and had 10 patients in clinic, I’d spent all day talking about nutrition. I don’t have time now. That’s part of the reason why I started my social media page too, is because I tell patients, if you want just a 30 second little tip or trick, you can find that on social media too, but it’s challenging and it’s only going to get worse, especially in an academic setting with healthcare reimbursement going down. I’m being asked to see more and more patients and do more and more surgeries.

(15:20):
So your time with patients is limited. And in private practice, time is money. So if you spend all that time with one patient, it just doesn’t work.

Dr. Gallus (15:29):
Yeah. I mean, we do spend a fair amount of time with our patients, but it is nice to have it reinforced in different settings. And we do have patients who are like, oh, we do a lot of labioplasties, and they’ll be like, oh, I listened to your labioplasty podcast and also read the stuff on the website. And so yes, hearing that information in different forms. I do know Dr. Tim Martin, who’s a pretty famous plastic surgeon, does a lot of faceless. If you go watch him, he has a book. And one of the facial plastic surgeons that we work with, have you seen his book?

Bri (16:04):
No.

Dr. Gallus (16:05):
Oh my gosh. I took a look at it. So he gives his patients a book too, similar to what you’re saying, except his covers everything. And it is, as you would imagine, extremely detailed.

Bri (16:15):
Maybe we need a book.

Dr. Gallus (16:16):
We might need a book. Both of them are cover things. And you probably talk to your patients about this or have this included, but one of the things is the emotional rollercoaster after surgery. I know I’m switching gears a little bit, but I do remember Dr. Martin definitely covers that because there are some kind of expected highs and lows. And I can imagine after breast cancer reconstruction, it’s even maybe more exaggerated. Absolutely.

Dr. Knackstedt (16:44):
Yeah. It’s so hard. And that’s why I’m a huge fan of direct to implant because at least it gives them a semblance of something when they wake up versus doing tissue expanders, which everyone hates. But yeah, it’s hard. I love counseling. I wish I could send every patient to counseling, both pre and post-op because there are just so many emotions associated with reconstructive and cosmetic procedures. You look different. It’s not you in the mirror when you see that person anymore, and that can be very jarring for a lot of people.

Dr. Gallus (17:15):
What’s the biggest mistake you see when people think they’re prepping for surgery?

Dr. Knackstedt (17:20):
I think that when we have either an education in healthcare or when you work in a healthcare space, we take for granted what we know. And so I think a lot of patients think that they are being healthy, whatever that means to them, a healthy diet, a healthy exercise. But for some patients, healthy is like starving yourself, not eating. I had one patient tell me, “I’m going to eat really healthy before my breast reduction. I’m just going to eat eggplants.” Weird choice, but also she thought that was healthy. So then we had to do a little re education as to what protein is. I think that we forget things that are just so intuitive to us when it comes to health and wellness, you have to remember that if you have someone comes in without any healthcare background, you just got to break it down and really simplify things and just make sure that you’re on the same page, even about the simplest type of pre or postoperative instructions.

Dr. Gallus (18:18):
Did she really like eggplants? That’s so bizarre.

Dr. Knackstedt (18:20):
I don’t know. Does anybody really like eggplants?

Bri (18:23):
I bought an eggplant casserole at Trader Joe’s last night.

Dr. Knackstedt (18:26):
Oh, you did?

Bri (18:27):
I did. I do love eggplants, but not raw or- Not

Dr. Knackstedt (18:31):
Exclusively.

Dr. Gallus (18:31):
Not exclusively.

Bri (18:32):
They need to be sauteed covered in cheese and all the things. Yeah.

Dr. Knackstedt (18:36):
She was just eggplanting.

Dr. Gallus (18:39):
That’s like the banana girl or whatever. Wasn’t there some girl who only ate bananas? Yeah,

Dr. Knackstedt (18:43):
She died.

Bri (18:44):
I’m sure.

Dr. Gallus (18:44):
Yeah.

Bri (18:47):
I feel like I say this all the time to patients because I’m like, you have to, I don’t know why this is my thing, feed your fat. And with that, I mean like protein, like if your fat cells don’t, if you’re going to spend all this money and get your body done and then put your fat into your butt or your breast or whatever, and then you’re not going to have any nutrients or nutrition, you need all those fat cells to survive. And when I say feed the fat, I don’t mean eating a milkshake, cheeseburgers and three things of French fries.

Dr. Gallus (19:17):
Yeah. Got

Bri (19:17):
To have protein.

Dr. Gallus (19:19):
But I think to your point, we assume, I think a lot of times we’ll do an Instagram reel or TikTok or something on something very basic like this is what suture is or whatever. And I think whatever. But then I’m reminded that not everybody knows that. It’s just part of what we do.

Bri (19:40):
In all fairness, the first time I had a breast aug before I even worked in plastic surgery, right after surgery, I was like, “Oh, I’m not hungry. I’m on my pain meds. I’m feeling super skinny. I’m not going to eat. I’m just going to use this time to lose five pounds.”

Dr. Gallus (19:53):
Because you’re not exercising.

Bri (19:55):
You’re not exercising. You’re not eating. You don’t think about it. And nobody tells you about it. Nobody really gives you an after surgery guide besides where your garments come for your post-op and take your antibiotics.

Dr. Gallus (20:07):
Which is already a lot of information, right?

Bri (20:09):
Yeah.

Dr. Gallus (20:09):
People get overwhelmed with when can I shower? How long do I have to wear this garment? In Southern California, most of my patients are pretty active so that it’s quickly followed by when can I go back to working out? Yeah. Or sneaky ways of asking that same thing over and over again. So can I do this? No. Can I go hang gliding? No. Can I go scoop? Nope.

Bri (20:32):
Wildest things.

Dr. Gallus (20:33):
Yeah, no. But I’ve also had patients who came in and are like, “I meal prepped. I arranged for somebody to take care of my dog. I have all this resources in tow and some of my mommy makeovers that recover the fastest have their daughters running things.”

Bri (20:52):
Amen. Nobody let your husband around you because when I had surgery, mine didn’t know he had to help me. So he dropped me off, went to work and my son was in there helping me use the bathroom. And I was like, “You motherfucker.” He’s like, “I just thought that I was going to … ” I was like, “You make your own schedule. You couldn’t have stayed home?”

Dr. Gallus (21:14):
Yeah.

Bri (21:14):
It’s like, I didn’t know.

Dr. Gallus (21:16):
I will just say when I had my first kid, I had a scheduled C-section because she was breach. And so I had to stay in the hospital for whatever their mandatory requirement was, like three days. So the third day I’m dying to leave. My husband, who’s also a surgeon, scheduled a case that morning. So I was climbing the walls. I wanted to leave. I love that. And it was at a hospital I worked at. So people kept popping in to say hi and see the new baby. And I’m like, “Ah, I just want to go home.” And I got stuck there waiting for him because he was in a case. I’m like, “I’m never going to let you forget that. You left me here.”

Bri (21:55):
That’s hilarious.

Dr. Gallus (21:57):
So he’s learned since then. I was like, “As soon as they say go, I’m out of here.” So okay. Well, speaking of that, because you talked about how with pregnancy you do have your go bag. They break down at one month what you should be doing, what two months pregnancy, blah, blah, blah. How far in advance could someone reasonably prehab? I mean, if they knew. If you don’t know you have breast cancer, you’re on a crunch.

Dr. Knackstedt (22:25):
Right. I hear when I give these types of talks like grand rounds, I often hear from surgeons, “My patients are cancer patients. I don’t have time to prehab them.” So I think on one end of the spectrum, what if you have no time? Then I look at all of the literature in head and neck reconstruction. And once again, these are really sick patients, sicker than your cosmetic patient, even sicker really than my breast recon patients. But those studies show that just five days of supplements before surgery in these patients decreases mortality. So decreases complications, crazy outcomes that they’re looking at. So that’s five days. I tell patients, even if you have a day, just getting your house in order, although it’s not technically prehab, it’s preparing, even that is going to drastically improve your recovery when you go home. For me, I do a lot of free flaps for breast reconstruction, which is a big surgery with a long recovery.

(23:20):
And they book out nine months. So I tell patients from an exercise lean muscle mass perspective, like start today, build up your lean muscle mass for the next nine months. When you think about like really honing down on diet and really like exercise, stress, anxiety, four to six weeks, I would love if all of my patients had four to six weeks. I know it’s not always doable, but even things like getting your sleep hygiene set, figuring out how you sleep best, how are you going to sleep after surgery when you need to sleep on your back for six weeks? Start now. So I would say as much time as someone has, you can use.

Dr. Gallus (23:55):
That’s awesome. And then do you give them … Again, that’s one of those things like building muscle mass. Do you give them specific instructions on how to do that?

Dr. Knackstedt (24:05):
Yeah. So once again, things I’ve learned as I’ve kind of talked to patients, initially I would just tell patients like, “Look, just like lift heavy things. Anything that builds muscle is great. Add some creatine, build muscle.” But feedback that I got from patients, once again from deeps, because those are my biggest surgeries. It’s like a mommy makeover on steroids. I told them, or they told me when they did squats, it really helped. And that kind of was a light bulb to me because I thought, right, like your core’s out, you’re in pain, you’re walking hunched over. I tell you you can’t lift with your arms, you can’t push to get out of a chair, so how are you getting off the toilet? Like you’re using your legs and your glutes. So yes, increasingly muscle mass, but focusing on the muscles that you’re going to be relying on after surgery I think is really critical.

Dr. Gallus (24:53):
Oh, that’s a good tip.

Bri (24:55):
Squat, squat, squat. I’m going to do some squats right after this.

Dr. Knackstedt (24:59):
It’s like you don’t need a fancy gym. You can literally have a chair and if you’ve never worked out before, do 10 body weight squats. And studies are now showing that just doing that regulates your blood sugar in a really profound way. So everyone should be squatting, but especially if you have surgery.

Dr. Gallus (25:14):
That’s a good tip. So let’s talk about your research. You did your PhD research on the relationship between vitamin D and inflammation. Talk to me about inflammation, because I feel like that’s a buzzword right now anyway, right? It always comes back around. There’s the anti-inflammatory diets, there’s GLPs might lead to decrease inflammation. What’s vitamin D you got to say in all of this?

Dr. Knackstedt (25:39):
Yeah, good question. So I knew that I wanted my PhD to be something nutritional. And the lab that I could find at MUSC that was closest to nutrition was a colon cancer lab that looked at natural products and how they influenced colon cancer development. They largely looked at green tea actually, but they wanted to go into some of the vitamins. So my PhD focused on vitamin D and colon cancer and colitis. So I had mice with bloody diarrhea for three years. It was not a high point.

Bri (26:10):
Fun.

Dr. Gallus (26:12):
Glamorous.

Dr. Knackstedt (26:13):
It was super glamorous, but a means to an end. But somewhat not surprisingly, inflammation really, which was regulated by vitamin D, could sway that development from colitis, which is inflammation of the colon to cancer or kind of keep the disease at bay. We all know that vitamin D is a buzzword. It’s anti-inflammatory, good for bone health, all that good stuff. Inflammation’s a buzzword too. And I think that there’s a lot of people on social media that are making money selling things to regulate inflammation or anti-inflammatory this, that, like you said, anti-inflammatory diet. Some inflammation is good. When you have surgery, you need inflammation. It’s going to amount your immune response. Tell your body like, “Hey, something’s going on. Please address this. ” But what you really want is you want there to be enough inflammation to start that healing process, but not too much where it’s uncontrolled and it’s chronic because that leads to prolonged swelling, incisions opening up, complications and fluid collections, infection.

(27:18):
So actually one of the supplements that I recommend the most for anti-inflammatory effects is omega-3s. I have my patients take them before surgery. There’s so many studies showing that they do not increase bleeding risk before and after surgery, so that’s super antiquated, but it really is good at allowing your body just to have enough inflammation, but a kind of quieting down that response so that it doesn’t get out of hand. Also supporting your body with a good protein diet, leafy greens, all of those micronutrients, but I really love omega-3s for that.

Dr. Gallus (27:53):
Huh. Good to know. Good to know. So that’s one supplement you recommend. Do you have other supplements that you do recommend and then ones that we usually tell people to stop taking everything. We do recommend a supplement. It’s called HealFast because it has a lot in it that’s nice and Arnica we’re big fans of, but what’s your go- to for now because you’re working on a supplement, right?

Dr. Knackstedt (28:19):
Yeah. It’s going to be better than HealFast.

Bri (28:24):
We’ll have to get it in office.

Dr. Knackstedt (28:26):
So I love supplements because for a couple reasons. One, your patient after surgery is not having salmon. They’re barely getting food down when they’re in pain and uncomfortable. So your diet is going to be suboptimal after surgery. So the supplements are going to support that decrease in your usual diet, but it’s also just going to load your system because your body needs so much more after surgery than it did three minutes before surgery. So it’s supporting those increased needs. I recommend a lot of supplements. I think the ones that have the biggest bang for your buck is I love protein as a supplement. I love probiotics. Probiotics have been shown to decrease pretty much every complication after surgery, including infection. I love the different vitamins, A, B, C, D, not E, E is associated with bleeding. Some of the essential amino acids like arginine and glutamine, which have an increased need after surgery.

(29:24):
I like curcumin after surgery to help with inflammation. I actually like bromolin over Arnica. The reason for that is that bromolin, which is an enzyme from pineapples, has been shown in randomized control trials to decrease bruising and swelling, especially in facial plastic surgery. Arnica, some patients can get allergic reactions to, and the dosing is just like, no one can understand it. That weird homeopathic 50 Cs, what does that even mean?

(29:52):
So I’ve been recommending supplements for years. And the feedback that I always got from patients was, “This is confusing, this is expensive, and you’re telling me to buy 13 different bottles. What? And I’m buying two much, I have to buy four months and all I really need is maybe two months. My husband, he’s a dermatologist, so he’s a doctor as well. We created a company called Clara Recovery. We’ll be launching it. They’re being packaged right now, so within the next two or three weeks, but it’s a gravity box. And then every day you just take out your little sachet and those are your five pills that basically serve everything that I recommend. So it’s not a white label. I created it from the ground up and it’s really, really high doses, still safe, but ones that have been shown to be safe around the time of surgery and then just support healing, whether it’s tissue repair, decreasing inflammation, just supporting your body in that healing process.

(30:51):
Supplements are expensive, but I think that if you’re paying tens of thousands of dollars for your facelift, mommy makeover, whatever, 60 bucks for some supplements is literally a drop in the water.

Dr. Gallus (31:02):
Yeah. We ended up just giving it to our patients because-

Dr. Knackstedt (31:06):
That’s awesome.

Dr. Gallus (31:08):
The HealFast also isn’t that expensive, but it’s just like-

Bri (31:12):
They’re like, “Why am I paying for surgery and then paying for supplements?”

Dr. Gallus (31:15):
Yes. And we’re like, “We feel strongly that you should take this, so we’re going to give it to you. ” The downside is sometimes when you give people stuff for free, they’re like, and it ends up in a box somewhere and they don’t take it. But I think some of that’s more about education.

Dr. Knackstedt (31:28):
Yes.

Dr. Gallus (31:29):
So how far before surgery would you ideally like patients to take Clara?

Dr. Knackstedt (31:36):
So there’s really not good evidence on which to base that recommendation. I’m a huge fan of evidence. I love literature. I love randomized control trials. And I really think it’s important when you disclose that you don’t have good evidence. So I would say two weeks. And I use that based on the studies in head and neck, which use anywhere between five days and two weeks. And it’s just enough to get some of those fat soluble vitamins into your fat. It’s going to keep those stores up like vitamin D. And it just gets you in that routine of taking your supplement every day. And then after surgery though, I feel pretty strongly that you should take it until your incisions are healed, which is very variable. A little two centimeter breast dog incision with the new preserve thing. Maybe you don’t need a lot of supplements, but if you’re having a tummy tuck or a deep, that could be four to six weeks of incisional support for healing.

Dr. Gallus (32:27):
Awesome. I love that.

Bri (32:28):
There’s no downsides. So just take the supplements, guys.

Dr. Gallus (32:32):
I know. As long as they’re approved. We don’t need you taking, like you said, vitamin E is a no. There’s plenty of … I mean, I think that’s why fish oil gets kicked off. It’s always on the no fly zone because increases bleeding. There’s a lot of stuff out there that’s unregulated. And is there probiotics in your supplement that you’re … Nice.

Dr. Knackstedt (32:53):
Yeah. And probiotics are one of those confusing ones too. There’s like a gazillion strain species dosing. It’s CFUs. The encouraging thing is that the meta-analysis of studies have shown that the strain and species don’t seem to matter as long as you get 10 billion CFUs, which is a big dose.You’re not walking into Walmart and getting that. But 10 billion does not matter strain in species, really evidence-based to decrease complications after surgery.

Bri (33:23):
I walked into sprouts two days ago to actually get some. And I was like, I sat there looking at the refrigerator for like five minutes and I was like, well, my options are I could get 50 billion CFUs, I could get 100 billion. So I was like, just assume the 100 billion is better, right? You just don’t know. I was like, “What is the difference?” Yeah,

Dr. Knackstedt (33:44):
I agree. And I take 100 because I’m like, it’s the same price as the 50.

Bri (33:49):
Yeah, that’s what I was, I was like, for $3 more, do I want more? But it is, it’s incredibly confusing and there’s so many different brands and things and I’m like, I don’t even, I don’t know.

Dr. Gallus (34:03):
I mean, what’s the equivalent … I prefer to just drink kombucha or … I mean, I would try to add it into my diet if I could figure out a way to add kimchi.

Bri (34:13):
Oh, I forgot to take my probiotic this morning. Day three. Shit.

Dr. Knackstedt (34:20):
It’s so hard to remember supplements. I am religious about my supplements. My husband who has to hear me with the spiel basically every day never takes his supplements. So it’s hard to remember. I love fermented foods, kumbata, yogurt, different fermented types of vegetables like kimchi. The challenge is that we don’t know what the dose is. There have been some studies looking at how many CFUs, which is how we measured the grammage basically. It’s how many colony forming units or spores or whatever are there. It tends to be much lower in food. So some cultures that have kimchi every day with every meal, they’re probably getting enough. But if you’re just having like a tablespoon of fermented sauerkraut or something as a side dish once in a while, it’s really not enough. It’s great for overall health and wellness, but not if you’re really in that like right before or after surgery.

Dr. Gallus (35:16):
That makes sense. Yeah. Yeah, I know. It’s sort of like green tea. We know it’s good for you, but then when you read the studies, you have to have 18 glasses a day. No one’s doing that.

Dr. Knackstedt (35:26):
You’d be peeing green. Yeah, no.

Dr. Gallus (35:27):
All right. Well, let’s switch out of nutrition and supplements, but what about mindset and like how, because that’s part of functional medicine or integrated medicine. Can you talk to us about how you guide patients on that?

Dr. Knackstedt (35:47):
Yeah, absolutely. It is not uncommon for my patients to cry in clinic. It’s breast cancer. It’s a 32 year old whose world was just shattered with a new diagnosis. So it’s stress, it’s anxiety, it’s depression, all of that leading into sleeplessness, which worsens stress and anxiety and depression. And then you’re in this endless cycle where when you’re in that mindset too, you’re not taking care of yourself. When you feel like crap, you’re not eating well. So it’s just this endless cycle and how do we get out of it? So I think that I try to talk to my patients about acknowledging their feelings and like addressing them. I think especially for breast cancer, I’ve had some patients who have an emotional breakdown like a year after treatment’s been done, their breasts look great and then all of a sudden just like hits them. They’ve been on adrenaline for the last 12 months.

(36:41):
And so I think that regardless of surgery, cosmetic, elective, urgent, reconstructive, I love journaling. I think that journaling is great for a couple things. One is when you’re overwhelmed, it’s really great to put down your thoughts. What are your questions? What do you still need addressed by your healthcare team? What did you just learn from that visit? What’s now confusing now that you’ve left that visit? Also, just journaling can be really great for gratefulness and for recentering. If you have some type of meditation practice or religious practice, that could be really helpful too. But even within breast cancer, journaling has been shown to help with how women feel about their bodies, like just one episode of journaling.

Dr. Gallus (37:23):
That’s a good tip.

Dr. Knackstedt (37:24):
It is a good tip. I’m going to start journaling.

Dr. Gallus (37:28):
I know I can’t. I’ve tried it before. I think it’s the important thing probably is to find something that you can consistently do, right? Absolutely. It probably works for a ton of people and it’s definitely worth giving it a shot, but maybe that doesn’t … Maybe you need to go for a walk or meditate, let’s say, or find … Maybe for some people it’s taking a really long shower or a long bath or something to just let your mind quiet down.

Dr. Knackstedt (37:58):
Absolutely.

Dr. Gallus (38:00):
All right. So we’re going to kind of try and wrap things up because I feel like you’re right. We could talk for like two hours about all this stuff. Let’s say we have a patient who’s got surgery scheduled and only remembers three things from this episode and it’s not Tom Brady and Alex Earl. What would be-

Bri (38:19):
No judgment if it is.

Dr. Gallus (38:21):
What would be the three things you’d want them to remember?

Dr. Knackstedt (38:24):
The three things would be you can prepare for surgery and you should prepare for surgery. This is not something that you should just wake up and walk into and that preparing really needs to be holistic. It needs to be not just what you eat. It’s what you’re thinking. It’s preparing your home. It’s getting your childcare or your dog care set up, all those things. And it really takes time to productively think through those topics. That’s the first thing. The second thing is I would tell patients to advocate for themselves. Some of my partners don’t believe in prehab. I get it. Not all surgeons are going to discuss this with patients. Not all surgeons are going to know how to answer the question about like, what should I do before surgery? So I would tell patients to go into your consultation with a couple questions like, “What can I do to prepare for surgery?” And if the answer is nothing, then have more targeted questions like, “What is the biggest complication for this surgery and what can I do to prevent it?

(39:22):
” So it’s asking in a different framework. I think most surgeons would have an answer for that, but they might not have an answer for what can I do to prepare for surgery. So I think that those would probably be number one and two. And number three, I would say kind of like what we were just talking about, to not underestimate the importance of the mind, body connection and just what you’re thinking really does manifest. I mean, there are studies showing that optimistic outlook is associated with positive postoperative outcomes and the flip side. So even if you are struggling on the inside and putting on a smiling face, that’s not helping. So it’s being honest with yourself about when you need to ask for help, whether it’s physical help, like preparing your home for surgery, or whether it’s more emotional and mental help, like, do you need to talk to a counselor or someone, but just not forgetting that.

(40:14):
And it’s okay to ask for help. I mean, how many women want to ask for help? None, right? We think we can do it all ourselves, and it’s not a sign of weakness to ask for help. That’s number four. It’s not a sign of weakness to ask for help. Okay.

Bri (40:26):
Amen. That’s a good one. Amen.

Dr. Gallus (40:28):
That’s so true though. I feel like there’s still probably 10% of patients who are like, “Oh, I need a ride home after. I need somebody to watch me. “

Dr. Knackstedt (40:40):
Yes. Like not Uber, right?

Dr. Gallus (40:42):
Yeah. Yeah. And again, we do do a lot of labioplasties and I would say the majority of my patients do it under straight local because-

Bri (40:50):
Heterosexual. What was it? Heteroma.

Dr. Gallus (40:52):
Heteronormative local.

Bri (40:54):
Okay. That was in your armamentarium of words.

Dr. Gallus (40:59):
Mouthful. They do it under straight local because it is well tolerated, right? It’s so comfortable. It’s easier than a dental appointment. However, their motivator is that they just want to drive themselves home. So if they don’t take the oral sedative, so then they don’t need anybody. So yeah, we do love to do things on our own without any assistance. So I think trying to reach out and make sure you get support because it’s your time to do that and lean in for that stuff.

Dr. Knackstedt (41:27):
Yes.

Dr. Gallus (41:27):
So where can people find you online to learn more about what you do?

Dr. Knackstedt (41:31):
I am on social media. I’m once again, not tech savvy. So it is really just a place to learn about tricks and tips for surgery, get some free resources. It’s @surgical_recovery. Instagram is my main one. It’s where I have all the freebies and stuff, but I’m also on TikTok and YouTube.

Dr. Gallus (41:48):
Cool. And then your supplement will be launching hopefully soon?

Dr. Knackstedt (41:52):
Yeah.

Dr. Gallus (41:53):
Where can we find that?

Dr. Knackstedt (41:54):
We’re supposed to get it in like two weeks. So I will announce it on social media, but if you sign up too, you’ll get an email. It’s www.clararecovery, C-L-A-R-A. It’s named after Clara Barton, who was a very famous nurse. I think it’ll be a really great way for people to take care of themselves after and before surgery that’s very easy.

Bri (42:16):
Awesome. I love that. That’s what everyone needs.

Dr. Gallus (42:18):
Yeah. I love that has probiotics in it.

Bri (42:20):
Simplify whatever you can.

Dr. Knackstedt (42:22):
Absolutely. Yeah.

Bri (42:23):
Because nobody’s going to listen.

Dr. Gallus (42:28):
All right. Awesome. If you’re listening today and you have any questions, please reach out, leave a comment like and subscribe.

Bri (42:35):
Invite me to your yacht.

Dr. Knackstedt (42:38):
All the things.

Dr. Gallus (42:39):
Yeah, all the things. If anybody has a yacht, they want to bring us on, let us know. All right. Thanks so much. We’re going to scrub in.

Bri (42:48):
And scrub out.

Dr. Gallus (42:49):
Thank you. If you’re listening today and have questions, need info about scheduling, financing, reviews or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. To learn more about us, go to restoresdplasticsurgery.com or follow us on Instagram @RestoreSDPlasticSurgery. If you enjoyed this episode, please share it and subscribe to All the B’s on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts.