How to Prepare Your Body for Surgery: Protein, Prehab and the 5 Days That Change Your Recovery | Dr. Rebecca Knackstedt

20:58Okay, so have friends and loved ones.

21:02Dr. Gabrielle Lyon:As a physician, I spend a lot of time talking to patients about healthy aging. And one of the most important factors is maintaining skeletal muscle. I know it's unsimple, but simple isn't the same as easy. And many people struggle to consistently consume enough high-quality protein to support muscle health, recovery, and long-term metabolic function. And thank you to one of the sponsors of the show, Perfect Amino. That's one reason why I personally use and recommend Perfect Amino by Body Health. Perfect Amino provides all of the essential amino acids your body needs for protein synthesis and beyond.

21:42Dr. Gabrielle Lyon:It is a highly bioavailable form of amino acids. It's easy to take and can be a practical option for individuals looking to support muscle health, especially when meeting protein goals are difficult. Remember, muscle is the organ of longevity, whether you're training hard in the gym or simply focused on staying strong and independent as you age. Giving your body the building blocks it needs is an absolute non-negotiable for your long-term health. Go to bodyhealth.com and use the code LION20 for 20 % off your first order. That's bodyhealth.com, code LION20. When it comes to exercise, if you are sitting down and we're kind of circling back to this prehabilitation because individuals are really interested in muscle mass optimization, are there movements that you think are really important?

22:43For example, overhead press, just kind of their ability to move through life. Absolutely. So once again, it was my shift from just increase your lean muscle mass.

22:53Dr. Gabrielle Lyon:Did they think you were crazy? No, they loved that. Your colleagues didn't give you pushback. They were like, no, here comes back again with the weight. I mean, they might have said that, but hopefully behind my back. But really shifting to just doing the exercises that are going to help you move after surgery. Because we talked before a little bit about how patients used to be told to be on bedrest after surgery. Will you explain that to people? Because we would write those orders. Yeah. And so for some surgeries, we still do suggest bed rest. That's certainly not within breast reconstruction.

23:23But there was this idea that you're just letting your body heal. You're not stressing it out by moving. But now we know that early ambulation decreases your risk of blood clots. It's going to get you out of the hospital faster. And importantly, it's going to decrease that loss of lean muscle mass that you would see with that prolonged amount of bed rest.

23:41Dr. Gabrielle Lyon:People would get, they'd come to the ER or they would get admitted to the hospital or they would be on post-op. And one of the orders that we would write is bed rest. So there's ambulation, which just means getting up and walking. And we would write bed rest or ambulate with assistance. And it was routine for every single surgery if someone broke their arm. Right. And that just is so counterintuitive. And maybe I'm being a little dramatic, but most of the time patients were put on bed rest. And you can imagine the acceleration. So if someone comes in and let's say they're on a GLP-1 and they're not training and they've lost a bunch of weight and now you put them on bed rest, there is an accelerated loss of lean tissue, quality tissue, if individuals are older.

24:36Absolutely. Even for young patients, studies show that immobilization of young men leads to a loss of muscle mass. So think then about your post-surgical patient who's inflamed, potentially cachectic, then yes, they are going to have significant loss of lean muscle mass.

24:52Dr. Gabrielle Lyon:So one of the markers that you look for that I think is more unique is you were mentioning vitamin D. What do you think would be or what does the literature indicate would be more optimal for vitamin D? The challenge is that there is not good literature within surgery to guide those lab values and once again if we think about our lab values of vitamin d when you are normal air quote that once again is going to prevent things like rickets and allow for good bone health but it is not getting to those levels of vitamin d that are going to encourage healing or some studies show even prevent cancer and so it's much higher than what the traditional medical world views as normal but we just don't have literature yet to really guide those numbers So I've worked with Mark Hyman for many years and I'm friends with a lot of the guys at the Cleveland Clinic.

25:41Dr. Gabrielle Lyon:One of the targets for them is they're like, well, I would like to see vitamin D between 60 and 80. I would agree with that. I would love to see 70 for all patients prior to surgery and then after surgery. And it makes sense. It makes sense from a muscle standpoint, right? There are vitamin D receptors in muscle. There are vitamin D receptors everywhere. Are there any other lab values that are a little bit more specific? And this could be either functional medicine or surgical outcomes. And I say that very carefully because it might not be the outcome, but perhaps facilitate better outcomes. So once again, prealbumin, albumin, looking at protein stores.

26:19Dr. Gabrielle Lyon:Why prealbumin? It's not the greatest indicator of protein stores, but it gives a hint. But it's also an acute phase reactant. So it's going to be elevated if a person's inflamed. So it's not super helpful. I usually do rely on albumin. And then for my women who are finishing up chemo, I also look at their absolute neutrophil count. So your neutrophil or your white blood cells that are going to prevent infection and plummets during chemotherapy. But then you have surgery and we want to prevent infection. So that's something that I look at as well. Are there any ways to improve neutrophil count?

26:52There aren't. There are medications that we can give, but it really just artificially inflates the number. And so there aren't studies showing if it actually decreases infection. It kind of just makes us feel a little bit better.

27:04Dr. Gabrielle Lyon:What about screening? There's a lot of questions that we get. Should someone get a breast mammogram? What about thermography, which I hear a lot about? Have you, people are very concerned that breast imaging can cause breast cancer? Well, great question. Yeah, this is definitely something that's all over social media, at least on my algorithm, probably yours too. But yes, so the current recommendations are that mammograms start at the age of 40 and mammograms have shown to prevent breast cancer deaths. And that is something that gets twisted a lot on social media. Are there other options? Yes, sometimes we employ things like ultrasounds or MRIs, especially for our high risk individuals, we might start to employ MRIs earlier.

27:50But the gold standard right now is mammograms.

27:52Dr. Gabrielle Lyon:So thermography is, is it heat patterns? Correct. Yes. And it is not, it does not yet have the data that mammograms have. Will it eventually someday? Potentially. But right now your best option is still to get a mammogram and then sometimes an ultrasound. Do patients come and ask you about that because they're concerned about a mammogram? That's a great question. Usually they don't ask me because I'm so far down the line that they've either been identified as high risk and they're probably getting MRIs and mammograms or they've been diagnosed with breast cancer. So now they already have a tissue diagnosis.

28:26But I know for a fact that that is a question that our radiation oncology doctors get and our medical oncologists and PCPs. So it's a tricky question because it, for whatever reason, is really just associated with a lot of emotions for some people.

28:39Dr. Gabrielle Lyon:Is it fair to say that thermography as it stands right now is not an appropriate screening tool for early detection of breast cancer. Correct. Mammograms is still the gold standard. It still has evidence in the literature to prevent breast cancer deaths. And there was no question in your answer. I also feel the same way. In terms of the risk of getting a mammogram, is there an associated risk of radiation exposure? Mammograms objectively have radiation the same way that riding on a plane does. And there have been really great studies looking at the number needed to treat to cause cancer versus prevent breast cancer deaths.

29:20And the numbers are staggeringly different. So it has a much greater chance of preventing a breast cancer death than causing a breast cancer.

29:29Dr. Gabrielle Lyon:When I was in my medical training, there was a psychiatrist that didn't want to get mammograms. And then once she got that, she actually got a diagnosis of breast cancer. She was just very against mammograms. It was in Arizona at the time. And she decided to take treatment into her own hands. And instead of going the route of traditional chemotherapy, radiation, or surgical removal. She went on a pretty aggressive nutrition plan. She went all raw foods, no protein, and it was very extreme. And unfortunately, she died. By the time she wanted an intervention, she had missed that window. Yeah, and I think that's one of the the failings of our healthcare system is that there's such a separation between Western medicine and complementary medicine.

30:26People feel like they have to choose. And really, this is where rehabilitation speaks to, you're going to get the best outcomes if you combine it. You know, take your muscle-centric view and your targeted nutrition and your sleep and some of the fluffy things like stress and anxiety, but combine that with evidence-based tools. But at the end of the day, every patient has to choose what they're most comfortable with. And even if you do the exact recommendations, some people still have a recurrence. And so you have to choose the treatment plan that you're going to be okay with, regardless of the outcome that could happen.

31:02Dr. Gabrielle Lyon:If someone is listening to this, how do you suggest they make decisions? And again, I understand that's a really broad question, but let's say someone comes to you and they're now a surgical candidate and they say, but I really want to do things naturally, or I'd love to hear some of the questions that they say to you specifically, how do they think through it? So if someone cannot see you at Duke, how can they begin to have agency and think through it? I get a lot of this in clinic. You know, patients will come to me and saying, I have a hormone receptor breast cancer. I really want to maintain my hormone replacement therapy.

31:40my doctors won't prescribe it what should I do and so the the conversation that I have with patients is I don't have a glass ball so I don't know even if you do the western standardized medicine approach could you be a patient who recurs and then you're going to think to myself gosh I really wish I would have stayed in my hormone replacement therapy I would have felt better so it's predicting into the future which is impossible to ask someone to do but it's trying to figuring out what you'll be most at peace with if the different outcomes occur. Once again, how can we ask patients to make those decisions?

32:14And then finding out as much information about actual statistics, actual numbers. I always tell patients, ask your medical oncologist about what is your absolute risk reduction and your relative risk reduction.

32:26Dr. Gabrielle Lyon:And what's the difference between absolute risk reduction and relative risk reduction? This is something that is also all over social media too. So they'll say, you know, if you do this treatment or do exercise, it will reduce your risk of breast cancer occurrence by 50%. And that sounds amazing, right? 50%. But if it's really just taking it from 2 % to 1%, that doesn't seem like it's moving the needle a lot, right? And so it's understanding those numbers and actually what they mean for you. It's a really good point because if someone is going to make a big decision like this, they should know what the prognosis is.

33:05Dr. Gabrielle Lyon:Has survival rates when people have been diagnosed with breast cancer, have we improved? We have improved and we continue to improve. And we need to continue doing good research and randomized control trials. And what I think is a super exciting area of research right now is de-escalation therapy. Meaning if someone has certain types of cancers or precancers, could we safely just watch for a little bit and maybe delay surgery or never need to have surgery? And so we are continuing to do research. Wow, that's interesting. What would that, what kind, are they subtypes? DCIS. So there's studies right now looking at can you just do medical therapy and monitor and maybe not need surgery versus, you know, jumping the gun and doing a mastectomy or a lumpectomy.

33:51But there's a lot of exciting things of research right now. With the prehabilitation, most women, most people have never heard that

34:00Dr. Gabrielle Lyon:word when it comes to surgery. You have them lifting, I'm assuming, two to three days a week. As much as they can, yes. As much as they can. I'm sure you address their nutrition. Absolutely. How do you address their nutrition in terms of the, I think, back to your patient who just it seems as if everything had gone wrong. I talked to them about what their baseline nutrition looks like. You know, what do you eat in a day? What are your protein sources? Are you open to eating animal products? And then we kind of go from there. I would love for all patients to have two grams per kilogram of day of protein as they're preparing for and recovering from surgery.

34:39Dr. Gabrielle Lyon:The challenge is close to one gram per pound. Correct. Correct. The challenge is, is that I'm asking them to make all these healthy protein choices in a time when they're stressed out. They're not sleeping. They want a donut. They want comfort food. And then after surgery, they're in pain. Maybe they're nauseous. So it's a time in which protein matters so much, but it's hard. Do you tell them to take essential amino acids or shakes? Do you have kind of a, okay, so you're not going to eat all this protein. Here is your beef jerky plan. I'm going to give you, I kid you not, we do canned chicken.

35:15Dr. Gabrielle Lyon:Because a lot of times people, either they don't like the texture, but they'll be willing to do other things. Do you have a game plan for them? I tell patients, and actually I tell surgeons this too when I give this lecture to surgeons, track your food for three days. Just don't change your diet, track your food, put it into an app and just see where you're at. And I almost guarantee that you will be surprised how little protein you're eating. And then after that, figure out, here's where I'm at. I need to get to whatever it is, 100 grams, 120 grams. Maybe I can throw in a quick shake in the morning when I'm driving to work, or I can throw in a protein bar, something that's easy.

35:51And I would love for protein to come from whole foods. But during this period of time, we just got to get you to that number.

35:57Dr. Gabrielle Lyon:According to the NHANES data, the average woman gets between 60 to 70 grams of protein a day. Right. That's not enough. That is enough for one and a half meals, maybe. And especially if she's under stress, no less than 100 grams a day of protein, if you guys are listening to this and whether you are getting surgery for cosmetic or surgery because it is a medical requirement or necessity no less than 100 grams a day we also recommend if you're not going to eat it from whole foods which we love whole foods but if their appetite decreases you know post-surgical if they're on pain meds um essential amino acids are critical i always recommend which i'm i'm sure you've heard i talk about body health critical and so we saw this in the older population so i did my training in geriatrics and they had no appetite right there was no and they wouldn't even it was so difficult to get them to take a shake i even tried milkshakes and please cover your ears so it looked like an old school milkshake with the caramel on top or something you know like the frappuccinos frappuccinos um and they still want to drink it but if you give them and I'll give you some to try.

37:13Dr. Gabrielle Lyon:If you put the clear essential amino acids, it has maybe a little flavor to it. I mean, it's just from a recovery standpoint, it's so much better. Why does recovery get harder? Why do gains become more elusive? The truth is you can't train your weight completely out of aging, but especially out of aging muscle, you can slow it down. Every moment, every workout, every lift depends on mitochondria producing energy efficiently. As we age, those mitochondria become less effective, impacting how our muscles perform. That's why I use Timeline, powered by MitoPure. MitoPure contains urolithin A, a nutrient shown to support mitochondrial renewal and muscle health at the cellular level.

38:03Dr. Gabrielle Lyon:This provides your muscles with the energy they need, of course, to get results. Who doesn't want that? If you're already investing in training, protein, and recovery, do not overlook the cellular energy that powers it all. It's essential. At a time when everything feels more expensive, Timeline cut the everyday price of MitoPure. Today, you can get an additional 20 % off that new lower price at timeline.com slash lion. in. Don't miss it. In terms of supplementation, are there other supplements that you think are, or not supplements is the wrong word, nutrients? Yeah. So when I think about what nutrients or supplements I want a patient to prioritize before and after surgery, especially if it's a supplement versus getting it from food, I want to make sure that it's going to make a difference, move the needle in a meaningful way.

38:57It's at a dose that matters. So not your standard multivitamin dose and that importantly it's safe to consume before or after surgery we might talk about this in a little bit but there's definitely some supplements that are not safe around the time of surgery so you don't want to be taking those so you want to make sure it's safe effective and it's actually going to help your body heal so some of those things are protein like we talked about probiotics vitamin a b c d zinc arginine glutamine all of those things are evidence-based to be so critical for healing and help you with that surgical recovery.

39:31Dr. Gabrielle Lyon:What kind of supplement should they not take near and around surgery? And for how long are you talking about? Four weeks? Does it depend on the half-life of the supplement? The standard answer that most patients will get is stop all supplements for two weeks before surgery and usually two to four weeks after. And the reason for that is that there are some supplements that will increase your risk of bleeding vitamin e ginkgo what about omegas oh i love that question so no and it's funny because when you see those stop all supplements before surgery it'll say stop all supplements especially omega-3s and omega-3s actually have been shown in meta-analyses to not only not increase your risk of bleeding before after surgery or increase your risk of transfusion but they're super anti-inflammatory And surgery is uncontrolled inflammation.

40:22But omega-3, with its cool little resolvins that it brings along, can help resolve that inflammation and help you have that inflammation work for you after surgery. This is the moment where pushback can happen within the institution.

40:37Dr. Gabrielle Lyon:Absolutely. And that's one of the challenges of working at an institution where I have anesthesiologists who will give those blanket statements. And so I tell my patients, here is the supplements that I recommend you take before and after surgery. You will get a blanket statement of stop all supplements. I am fine with you continuing these supplements, but you do whatever you feel best with. If you want to stop them, just start them the morning after surgery. In your practice, do you do an omega check? I don't. You don't? I don't. But I would love to. What about iron stores when it comes to recovery?

41:09Dr. Gabrielle Lyon:Ferritin, total iron. Is that important from a recovery aspect? It's important in that it's going to help move your red blood cells around, you know, and carry oxygen, really. And so it is critically important. There really haven't been studies looking at supplementing. The challenge is that too much can actually increase your risk of infection. So you really don't want to be supplementing with super therapeutic doses, but it is definitely a critical micronutrient for healing. When you give them a nutrition plan after, right, what kind of things are you telling them to have after? In regards to nutrition and what they're eating?

41:47Yeah.

41:47Dr. Gabrielle Lyon:For example, you know, post-surgery, we've been making protein ice cream. I love that. Although I did make it with a vegan protein powder because I was just messing around and it was green. Needless to say, it wasn't a fan favorite at all because it was kind of a green frozen. and we'll make the team try it, see how they do on it. So I love easy protein options. So one of the resources that I give my patients is a list of animal-based, vegetarian, and vegan easy protein options that are either easy to whip together after surgery or easy to prepare before surgery. So once again, prehabilitation is preparing your mind and your body and your spirit and your home.

42:25And one of those things is getting healthy groceries, preparing your meals, so that after surgery, when your carb craving is high. Do you know why that is? Is it? Yeah. Tell me. So it's largely related to sleep deprivation. So what is more sleep depriving than surgery or perhaps being a surgeon? Being a mom. Being a mom, yes. So those are the top three things. But even one night of sleep deprivation is going to make you crave those simple carbohydrates. So at a time when your body needs protein and complex carbohydrates, you are craving simple carbohydrates. that's going to lead to a blood sugar spike, which will lead to a blood sugar crash.

43:02And then you're going to crave more simple carbohydrates. So it's important to recognize that and discuss that with patients, but then have those easy protein snacks just ready to go.

43:10Dr. Gabrielle Lyon:What are your go-tos? For me, I'm a huge fan of beef jerky. I rarely eat during the day just being in surgery. So I have a lot of different protein bars and beef jerky that I take. Once again, I would love for all of my food, you know, protein to come from food, but it's hard to carry around a chicken breast when you're getting ready to do surgery. No, you could totally put it in your purse. Absolutely. For post-surgical, do you give them something that is maybe dairy or easy to digest? Do you find that they get constipated? Maybe they don't want a heavy meal? Usually I tell patients, you got to find something that's appetizing.

43:47So experiment. See what's sitting well with your stomach. Prioritize protein. But that's why protein shakes are so easy. Even if you're feeling kind of nauseous after surgery, you can whip together a little whey protein shake and get 20 to 30 grams and six ounces of milk or water. And so it's experimenting, seeing what works for you, and then just having lots of options available.

44:07Dr. Gabrielle Lyon:Do you care about carbohydrates and fats post-surgical intervention? There's not great science to support this. Yeah, I haven't seen much. But we know that carbohydrates and fats are important for healing. So I encourage patients once again to choose whole food diets. I really have them start with the protein and then kind of fill in after that. But that's once again where targeted supplements can help and just kind of meet those micronutrient needs after surgery when it might be hard to have your usual healthy diet. You said something interesting, preparing the mind for surgery. How do you take your patients through from a mental perspective, pre-surgical, pre-hab, prehabilitation?

44:52This was once again that game-changing patient for me. You know, she might have been physically in an okay state because she was eating protein and taking my supplements, but she was stressed out. She's anxious. She's not sleeping. And so I talked to my patients about the importance of, first of all, normalizing, that it is okay to be stressed. It's okay to be anxious, but it's figuring out if you have the tools in your toolbox to manage that, whether it's a meditation practice or quiet time or a calming bedtime routine optimizing your sleep or do we need to get you to talk to somebody which there is no shame in doing and in my opinion every surgical patient should have to count talk to a counselor but we need to have those tools in our toolbox ideally before surgery so that when you're having pain and you're stressed and you're anxious and you have anesthesia-associated depression, you're not taken aback by that and you know what to do.

45:47Dr. Gabrielle Lyon:What is anesthesia-associated depression? Yeah, so a lot of patients after anesthesia, and I don't understand the actual science, I don't actually know if we know it, but they can feel the blues and it's normal. And it's something that I talk to patients about where first off, your body has been through this tremendous stress, you're probably in pain, you're probably not sleeping well, and it's okay to feel those feelings. But once again, if those are feelings that you don't feel that you can handle on your own, you need to talk to your team so we can get you into someone that can talk about you with those things.

46:19Dr. Gabrielle Lyon:Do you think that there's one linchpin for patients? Because I've heard you use words like strength, resilience, and even the idea of confidence before surgery is unusual for a surgeon to think about it or to have that in their repertoire. Yeah, I think that we view surgery is something that happens to us. You know, we need to have surgery or we're choosing to have, say, an elective cosmetic surgery. And we're trusting our surgeon to do a good job. But oftentimes, patients don't fully understand the surgery. They don't know what's going to happen. They don't know what to expect postoperatively.

46:53And once again, they're not preparing. They're not doing anything to prepare their mind, body, their spirit. And so you got to be in control. You got to advocate. You have to know that information because once again, you deserve to know that information. It's your body. But like you said, it's going to build your confidence. You're going to go into surgery feeling emotionally strong and ready to have this emotional and physical stressor to your body. Do you find that it's best to say, okay,

47:23Dr. Gabrielle Lyon:you are going to have breast reconstruction. I'm just picking that one. Let's watch it together because it can be very graphic. Again, I think that a good doctor is good at diagnosing patterns, but I think a great doctor is someone who's really good at looking at people and seeing the patterns of people. And you've probably experienced this. There's some patients that showing them what this looks like reduces the burden, the stress, and others are like, listen, I don't want to see anything. You know, like Matt, my videographer, he's so squeamish. He would be someone who's like, I don't want to see any of that.

48:01Dr. Gabrielle Lyon:Just tell me what the outcome, what is the bandage going to look like? What can I expect? Do you find that there's certain archetypes of people? And archetypes might not be the right word. Oh, absolutely. I have patients who come in wanting to know if I'll film their surgery because they want to see it. But I think that it's aggressive and the answer is always no. But I do show my patients pre and post-op photos because I and I asked them that's what it help you And I can tell you I've only had one patient who said I can't look at this right now and that's okay But I like to show them where scars will be what scars will look like and what they can expect And then I have them look at their breasts once a day after surgery and that's to look out for complications But I also tell them if you're not ready to look that's once again, okay but you need to have someone look.

48:50The reason why I want my patients to give, for me to give them that information is because if I don't, someone else will. And then they're going on social media and they're seeing a picture of a woman who had a breast augmentation and bringing in this photo and saying, this is what I'm gonna look like after surgery, right? I can't tell you the number of times that's happened. And so I think that one of the biggest things I can do with a surgeon is talk about expectations, what is a realistic outcome, because I would never want a patient to wake up from surgery and think, this isn't what we talked about.

49:21This is not what I expected.

49:22Dr. Gabrielle Lyon:When it comes to recovery, how long after can they start being mobile or training? It depends on the surgery. For most of my patients, they are walking the day after surgery, if not the day of. And then for breast reconstruction, this is once again different than the minimally invasive breast augmentation where you're back to the gym in a week. I usually have activity restrictions for six weeks. And that's to prevent things like wounds opening up, fluid collections. But especially for my older population, you can get some issues not moving your shoulders aggressively for six weeks. And so I really love physical therapy, early physical therapy, getting them back to movement as fast as possible.

50:03Dr. Gabrielle Lyon:Is that standard that, I mean, up walking right away, again, I'm not in the surgical field. That seems so different than what the recommendations used to be. I love that idea. Is that now the standard? It is for most surgeries. And once again, it's been shown in the literature to decrease blood clots so we don't have to send patients home on blood thinners anymore, decrease the loss of lean muscle mass. So at least we're recognizing that as a surgical specialty. And that is a huge change for patients and patient outcomes. In functional medicine, it's interesting. Many times they're ahead of the curve.

50:40Dr. Gabrielle Lyon:The clinical data hasn't caught up. So, for example, Dale Bredesen. Dale Bredesen is, he was at Cleveland Clinic. I don't know, is he still? No, no. Okay, so Dale was, he's a big Alzheimer's guy. And he was talking about zinc-copper ratios, a lot of DHEA status, hormone status years before it was evident in the literature. Do you find that there is maybe something within the functional medicine space? For example, red light therapy. or sauna or cold exposure that maybe traditional medicine hasn't adopted yet, but you suspect they will? When I think about those types of interventions, I'm always thinking about what are the risks and what are the potential benefits?

51:27I love red light therapy. I do it myself. I recommend it to my patients. Unless they're on some medication, which increases their risk for hyperpigmentation, it's generally regarded to be safe. So potential benefits, really no risk. So you like it? I love red light therapy. Absolutely. Saunas, love saunas. They're not going to melt your breast implants. That's another myth that I see. Oh, that's a good one.

51:48Dr. Gabrielle Lyon:I have heard that, that red light, that people were concerned about going to the sauna if they have implants because it would increase. Like the leaking of toxins. I had never thought it's right. Never been shown to be true. So I love those types of interventions. I hope that there's more research, really good studies on peptides because I think that that's one of the fields where certain functional medicine doctors are really getting into peptide therapy. And I think that it holds promise. But right now, we don't know safety. We don't know efficacy. Once again, I deal with cancer patients. How is it going to impact cancer?

52:25But I would love for there to be well done studies on that. As we get more and more data, there may be modalities

52:31Dr. Gabrielle Lyon:that allow for red light therapy for healing. What about hyperbaric oxygen or the wound vax? Oh, yes. Okay. Talk to me about, again, these are other modalities that are used in different areas. Absolutely. So hyperbaric is definitely evidence-based for helping healing after surgery. The way that we use it is typically if there's pending or evident skin necrosis, which means skin death, usually from a lack of blood flow. So that is definitely something we will use hyperbaric for or helping with radiation changes. It can also soften the tissue after radiation. Oh, what I'm hearing you say is not the chamber, but actually the location of smaller machines?

53:15No, this is they are going into a full dive. Yes. And that is an important distinction because when I recommend my patients have hyperbaric, they are going to the basement of Duke and having medical grade hyperbaric therapy. That's very different than some of the ones where people have in their homes or have at the corner clinic. So making sure that you get high quality hyperbaric oxygen. Woundvax, I love Woundvax. Woundvax are, I envision them as kind of like super fancy, expensive Band-Aids. And they emit negative pressure either over an incision or even over a wound and is shown to help healing be faster, potentially clear some infectious modalities, decrease fluid collections.

53:54I love Woundvax and I use them very frequently in my practice.

53:57Dr. Gabrielle Lyon:Has that science advanced over the last 10 years in terms of the utility, what it's doing over again over the last 10 years yes it's really expanded so I primarily use two different types of wound vacs one is called an incisional one where as the name implies you literally put it on top of an incision and it helps an incision feel heal faster how much faster I don't think that's really been studied objectively but I'll tell you anecdotally at one week post-surgery I can tell who had a wound vac and who didn't do you think that that should be considered standard of care? I considered it my standard of care for wounds that I'm concerned about.

54:34I use it a lot in big belly incisions when I do my flap surgeries because it's made a distinct difference in healing.

54:41Dr. Gabrielle Lyon:The speed of healing or the quality of say the scar? Both because it is just making those tissues come together better, increasing blood flow. So I think that that is a great modality and it's very well tolerated by patients which is important too. The other thing that's new, I would say, within the last 10 years is I actually wrote the papers when I was a resident of using a installation wound vac. So a wound vac that allows for fluid to go in and out. Think of it as 24-hour-a-day cleaning. And we use that as a way to help implant salvage after an infection. Oh, okay. So implant salvage is someone gets, is it typically post-operative or are there other reasons why?

55:20So it would be one of the main complications after implant-based breast reconstruction is infection. and it's really feared because this skin fat that's left over has decreased blood flow. You put in a foreign body. They've just had neoadjuvant chemo. So you're at a high risk for infection. And the standard of care used to be just to remove the implant. And now the woman's flat for at least three months. That's emotionally devastating for women. And so what we show is that if you put in this wound vac that allows for frequent cleaning for one to five days, it can increase your rates of salvage, which is amazing for women.

55:54And I do use that in my practice as well.

55:56Dr. Gabrielle Lyon:Does insurance cover any of these modalities like hyperbarics or wound vax? Wound vax, yes, because it's considered part of your surgical care. Hyperbaric, it depends on what the indication is. I've seen a lot of women on social media lately paying for hyperbaric before or after surgery just to augment their healing. And that won't be covered by insurance. But if we're using it to treat something like skin necrosis or radiation changes, then yes, it is covered by insurance. And it needs to be in a hard chamber. Correct. At least that's what the data shows so far. That's what I've seen. And when you said it can soften tissue, is that mean, can you explain a little bit more?

56:37Dr. Gabrielle Lyon:Sure. So radiation is great at preventing cancer from coming back, but it really leads to fibrosis or scar tissue of the remaining tissues. It decreases the blood flow to that area as well, which can make it not a great home for an implant or uncomfortable or open wounds. And so in those instances, hyperbaric just likely due to the increased oxygen delivery just seems to soften those tissues and can decrease some of that scar formation and help wounds heal faster. How often does someone, so for hyperbarics, when we put say a soldier in a hyperbaric chamber, it is, it could be 30 days, an hour and a half, five days a week for an end result.

57:21Dr. Gabrielle Lyon:What is it like? Yeah. Is it the same? So usually it's one to two months of daily dives. Sometimes they'll do two dives a day, once in the morning, once in the afternoon. But that's really hard for women who are young and have a job and a family. It's a lot of investment, but it can really make a big difference. Okay, so that is, so it can make a big difference. Is there any contraindication? For example, I remember reading, and again, I don't know, it's been a while, but it was that it can build up too much, not hydrogen peroxide, That's not, it's something that is, that you could dive too much and it would increase free radicals.

57:58There are definitely contraindications, some medical conditions where you don't want to be increasing the atmospheric pressure that you're feeling, which is where hyperbaric, you know, is how it works. But I'm not aware of, at least for breast reconstruction, since it's only one to two months of the increase of free radicals causing any noticeable clinical outcome.

58:16Dr. Gabrielle Lyon:So that was a social media, you got me. Okay, fine. Thanks to one of the sponsors of the show. And this is Lola Blanket. Why do I have Lola as a sponsor of the show? Well, someone gave me as a gift one of these blankets. And it was love at first. Cuddle, hug, whatever you want to call it. I went bananas. It's fluffy, life-changing softness. Trust me. It feels like a hug. And Lola is the world's number one blanket. Crafted with ultra soft luxury faux fur. and it has a signature four-way stretch. That's right. And most importantly, they just dropped a fall collection. New colors, Western-inspired prints, weeded blankets, and pet collection too.

59:01Dr. Gabrielle Lyon:Now, I know what everyone I love will be getting for the holidays this year. It's not a puppy. That's right. And for a limited time only, you guys can get 40 % off select Lola blankets. Use the code Dr. Lion at checkout. Just head to lolablankets.com. That's L-O-L-A-B-L-A-N-K-E-T-S.com and use the code Dr. Lion for 40 % off your order. Is there anything else for recovery that is maybe not thought of, but is in the functional medicine space? So peptides is interesting. I don't know if Duke has been able to prescribe for a while that they were legal. There's just been back and forth. But was, is that been part of maybe not Duke with the functional medicine space?

59:55It is something that I see talked about a lot at functional medicine conferences. It is not something that's covered by insurance. And it once again, is not something that I would prescribe now because I think that the data is lacking, but I think that it holds promise. And there's a lot of interesting anecdotal experiences out there, but I need that safety and efficacy data.

1:00:12Dr. Gabrielle Lyon:What about skin texture quality? I know that you'd mentioned your husband is a dermatologist. Are there things that can be done for the skin? Skin laxity, skin texture changes? The main thing that I'm concerned about is scars. And there are things that you can do that are evidence-based to improve scars. The main thing you can do is follow activity restrictions and make sure you're not putting early tension on those scars. Because why? If you are putting early tension on those healing scars you can get things like scar widening or even the scars opening up so you want to make sure those scars heal in nice thin lines but other things are silicone sheets or silicone gels the number one thing that I think is overlooked is sun protection so for the first at least year after surgery that scar is susceptible to changes from the sun and in light-skinned individuals it will actually darken so I talk to my patients about SPF early and often and reapplying it But those are really the most evidence-based things for scars to heal well.

1:01:11Dr. Gabrielle Lyon:This is a little off the wall, but it's on my mind. And again, you might say, gee, please no. Fascia and stretching, is that something that you talk about that is considered? So for example, I work with a physical therapist, and she talks to me a lot about how the scars seem to change, again, maybe this is a little esoteric, movement patterns, because it's been, it has cut through the fascia and then ends up changing movement patterns. So interestingly, for a breast cancer treatment or a prophylactic mastectomy, we have to remove the fascia off of the pectoralis muscle. That has been shown to be part of the standard cancer treatment.

1:01:54So what I see a lot with women is post-surgical, even if they don't have radiation, because radiation worsens it, they get a tightness of the pectoralis muscle, probably from a contracture from the fascia being taken away. And so never been shown in science. That's my hypothesis. But once again, for those patients, early physical therapy, aggressive physical therapy to work on that tightness. But so many women after a mastectomy have decreased range of motion, whether it's due to scar contracture or cording or frozen shoulder from activity limitations. So once again, I really have a very low threshold to send my patients to physical therapy.

1:02:30Dr. Gabrielle Lyon:But that's interesting. So you've seen that you've seen, cause I hear about that a bit anecdotally that someone will go in again. I hear through also the physical therapist that their pec muscles are so tight that it then causes shoulder problems and neck problems. Acupuncture, has that helped at all with pain control? I have had some of my patients use acupuncture. Once again, when I think of risk and benefits, if they're going to a good provider, then low risk and potential benefit. The studies within acupuncture, it's hard to have a placebo controlled trial. You know, they're those sham sites, but it's still largely acupuncture.

1:03:08So I tell my patients that I'm fine with it. And I have anecdotally had have some patients get relief, but there's not high quality evidence to support it yet.

1:03:18Dr. Gabrielle Lyon:Have you heard of Gernavix? Yes. Gernavix for pain. Yes. Do you guys use it? Can you speak to some of the options for pain control? Yeah, not yet. And a lot of that is insurance coverage. It's very expensive, but I'm very intrigued by the idea. Part of the reason why we can transition so many patients to outpatient surgery and not bed rest the day after surgery is because we have become so good at post-surgical pain control. So I use a long acting anesthesia medication. It's like when you go to the dentist and they numb you, but it lasts two to three days. And then we use - I've never had that.

1:03:54Dr. Gabrielle Lyon:I need to go to your dentist. Really? So, you know, when you, when your dentist numbs you and it lasts four hours, right? I do the same thing, but it lasts two to three days. And so that with multimodal therapy, my whole goal is just to limit the amount of narcotics that a woman needs, because we know that addiction can occur and narcotics have so many side effects that we want to avoid. Yes. And the, I think that that's really smart. Gernavix is, I don't know the mechanism of action, but I think it's central. It's, um, it's a medication. My friend, Christy Hamilton, she's a plastic surgeon. She's all cosmetics.

1:04:32Dr. Gabrielle Lyon:She uses Gernavix. I've tried Gernavix. There's almost zero pain and there's no doubt. I mean, there's, you're not groggy. There's not this anesthesia effect. it's extraordinary. And it's somehow they were able to isolate what fire walkers, whatever the genetic mutation or SNP is that allows for people to walk on flames. That's amazing. And I hope that more medications like that continue to be options for patients. One thing that I want to double back on, which you had mentioned earlier before we started recording, was the impact of surgery on skeletal muscle. When I think about surgery and muscle, I like to think about what about surgery negatively impacts muscle and then what is muscle important for specifically for healing.

1:05:18So surgery in and of itself is a catabolic experience. As soon as you have surgery, you are going to experience protein breakdown and that's good. We need that mobilization of amino acids to help with healing, prevent infection, but we're dipping into our protein stores. You're probably going to have some form of activity restrictions or you certainly won't be back in the gym the next day. So dipping into your protein stores, a state of inflammation, decreased protein intake. So all of these things potentially before and after surgery is dipping into your protein reserve. So what's muscle important for?

1:05:53Obviously for helping you engage with the world and doing the activities that you want to do, doing your getting out of bed, getting dressed, just your activities of daily life. But something that I think is often overlooked is the importance of muscle and regulating glucose. So your muscle is your sink for your glucose. And if you're going to decrease your muscle mass, you're going to have high blood sugar, which is negatively associated with surgical healing. And then it's gonna make you crave those simple carbohydrates and then have another blood sugar spike. So muscle is so important. And what I like to talk to patients about is we just gotta increase your reserve.

1:06:29We gotta fuel up that gas tank. I know that this surgery is gonna have a hit on your muscles, But let's start up high so the dip is not as low as the dip would have been. And it's even worse if you're just coming off of neoadjuvant chemo and you're already in metabolic syndrome and have lost lean muscle mass.

1:06:45Dr. Gabrielle Lyon:That is really well thought out in the biochemistry and nutrition sector, but it hasn't made its way to medicine yet. And I think that that is really important. And what I'm hearing you say is that surgery is a catabolic condition, which absolutely is, decreases skeletal muscle, especially if someone is immobile. It's a major stressor, especially if they have an infection, decreasing your skeletal muscle mass, which subsequently is the house, the sink for glucose. In your surgical practice, do you then think about, do we reduce carbohydrate intake? Do we balance carbohydrate intake with protein?

1:07:31Dr. Gabrielle Lyon:How do you coach patients through that? I tell them to start with protein. Your appetite is going to be limited. So fill up on protein. Try to meet your goals. And then after that, sprinkle in the healthy fats and complex carbohydrates, except for the night before surgery. That's the only time that I actually recommend a simple carbohydrate and it's called carbohydrate loading. Now you don't want to do this if you're a diabetic or have unregulated blood sugars, but studies have shown that 50 grams of simple carbohydrates right before you're not allowed to eat or drink anything else can help actually ironically with blood sugar regulation around the time of surgery get you out of the hospital faster actually decrease the amount of pain you feel after surgery so that's called carbohydrate loading and once again it is a easy thing you can do the night before surgery and most patients aren't told about this which leads me to my next question and I know that you hear this a lot and I think that we all hear this as doctors is okay but is it even in a matter I only have five days or seven days is anything that I'm going to do make a difference I hear this all the time and I hear this from surgeons when I give this as part of grand rounds lectures I'll have a surgeon come up to me and say I treat cancer patients I don't have time they don't have time to prehab we need to get them to surgery but that's not what the literature says the literature says for head and neck cancer patients which tend to be sick Just five days of immunonutrition before surgery.

1:08:55Immunonutrition is usually a mixture of healthy proteins, some healthy fats, and different micronutrients. In that patient population, decrease complications, get you out of the hospital factor, and actually even decrease mortality. So yes, five days of just nutrition can make a difference. And then even one day, we talked about carbohydrate loading. That is part of prehabilitation that you can literally do if you hear this podcast and your surgery is tomorrow.

1:09:21Dr. Gabrielle Lyon:So is it the micronutrients, the quality of the nutrition? Is that kind of why they think not the carbohydrate loading, but the five days is going to make a difference? The five days was really just an arbitrary number of days that was chosen within this head and neck literature. And then there were more and more studies that kind of recapitulated those findings. In those studies, the patients were pre-admitted to the hospital. Anyone that goes into surgery, they seem at least most times are put on antibiotics, either before or IV. It's from what I understand to prevent infection. And that I'm sure has an impact on the gut microbiome.

1:10:04Dr. Gabrielle Lyon:What are your thoughts? How do you manage the risk? And what is it doing? There are so many aspects of surgery that negatively impact the microbiome. The standard of care is to get at least one IV dose of antibiotics before we make incision. So you're having at least one dose of antibiotics. The inhalational oxygen that you breathe actually impacts your microbiome. The narcotics that you take after surgery impact your microbiome. Change your diet impacts your microbiome. And the microbiome, as we know, is associated with so many aspects of health and wellness. So I do counsel my patients on taking a probiotic.

1:10:41I like for them to take it before surgery and then continue it after surgery. If you are put on an antibiotic, just space it out four hours apart so that your antibiotic is not killing your probiotic.

1:10:52Dr. Gabrielle Lyon:Do you care about the kind of probiotics? So for example, in functional medicine, they do a lot of gut testing. Does it work? Well, it's helpful. It gives you an idea of what the commensal bacteria is. but is it necessary to then pick the probiotic? Probiotics are so confusing. You go to the store and there's different strains, species, CFUs, shelf stable, ones that need refrigerated, which one do you use? And what the literature suggests in very large meta-analyses is that as long as you get 10 billion CFUs, which is a big dose, you have to actually look and seek those dosages out. It doesn't matter.

1:11:32It doesn't matter what strain or species. Now, most of those studies use some strain of lactobacilli, bifidobacterium. But apart from that, just aim for$10 billion. And that's what the studies suggest is necessary. Any fermented foods? I love fermented foods. I think that fermented foods are a fantastic addition to your normal healthy diet. It can be hard to eat some fermented foods when you're recovering from surgery. Patients aren't waking up and asking for sauerkraut. They're not? They're not, at least not yet. But I would love for different dairy products, fermented dairy products, sauerkraut, kimchi.

1:12:09But if you can't have that, it's easy to swallow a pill.

1:12:12Dr. Gabrielle Lyon:If someone is going into surgery, should they pack a bag that has their snack bag with them? And if so, what's in there? Yes. I've actually had patients bring a blender to the hospital so that they could make their own protein shake on their windowsill. And my residents will tell you that they know who my patients are because there's a bag of snacks and the insures are in the garbage. But yes, it's so interesting. When we're preparing to have a baby, we have our go bag. We've prepared our home. And we prepare for surgery by showing up. And there are so many things that patients can bring with them to the hospital.

1:12:45And when I think about what an ideal bag would have, it's going to be things that help you sleep. So earplugs, a sleep mask, relaxing music, a playlist, things to make your time more pleasant, an audiobook, a book to read, pictures of loved ones. Studies show that flowers in the recovery room decreases stress and anxiety. And things to make you feel more at home, slippers, a chapstick, dry shampoo. But yes, absolutely. If you are staying overnight, you absolutely should pack a bag.

1:13:12Dr. Gabrielle Lyon:I would say most people don't think about that, especially if they're going into a non-cosmetic type of surgery. What about melatonin? When I was on the hospital floors, we would often order melatonin. and it was remalte on the formulary. Do you think that melatonin plays a role with, again, supplementation of melatonin for sleep? For the recommendations that I have for my patients for supplements, I'm always talking about the short term. So it's important to know that when I recommend a supplement, I'm not saying start it before surgery and continue it for five years. But I think that in the short term, if melatonin works for you, it can be a great addition to your sleep hygiene routine.

1:13:54And I do talk to patients about before surgery, before you're in pain and waking up at all hours, you need a good sleep routine. So winding down before bed, blue light blocking glasses, a calming bedtime routine, a cold dark room. If you have those tools before surgery, it's going to be easier to implement them after surgery.

1:14:15Dr. Gabrielle Lyon:We have covered a ton of stuff here. And by the way, anyone who is preparing for surgery, we now have an outline, which we'll put together. I love it. We'll put together a surgery bag. Here are the things, a checklist. I mean, it sounds great. We know that this improves patient outcomes, both physically but also mentally. Why is it not standard of care? I thought a lot about this, and I think there's really several things that need to be overcome before this is the standard of care the way it should be. The first is who's going to pay. So a lot of the things that I recommend to my patients, especially before surgery, are not covered by insurance.

1:14:52And so as someone who takes care of breast cancer patients, and we know that breast cancer and reconstruction is so financially toxic, it's hard for me then to say, you need to spend your money on all of these other evidence-based things. So who's going to pay? The second is education. We don't learn this in medical school, as you know. We don't learn this in residency. We don't talk about it at our national meetings. So we don't have the knowledge within surgical disciplines to have evidence-based discussions with patients. Patients don't know about this. So they don't know that they should be asking their surgeon, what can I do to prepare?

1:15:23And if they follow me on Instagram and know that they should ask their surgeon that, the surgeon will either say nothing or, I don't know, just make sure you stop all supplements, which is actually harmful advice. So education. And then the third thing is an implementation standpoint. So a lot of surgeons will ask me after my talks, I don't know how to integrate this into my practice. I also work at a very busy academic center. I don't have time to talk to patients about this. That's why I created my Instagram page. But how do we have the time to talk to patients about this? How are we going to integrate it into the workflow?

1:15:57And then the last challenge is, I've got a patient to buy in that, yes, she needs preoperative physical therapy and her surgery is four weeks away. Our physical therapists aren't booking out four weeks in advance. They're booking out six months in advance. So how can I refer her to the help she needs? A lot of challenges that need to be overcome before this is standard of care. But you're hopeful. I'm hopeful. I'm hopeful. There are studies that continue to come out. There are studies showing, if an insurance company is listening, that if you invest in rehabilitation, you actually save money on that patient.

1:16:30Small cost of rehabilitation, avoiding complications, prolonged hospital stays, emergency room visits, need for additional surgeries. So it's once again a shift from this reactionary type healthcare to preventative healthcare.

1:16:43Dr. Gabrielle Lyon:It's really wise and we're gonna link your, what is your Instagram? It's at surgical underscore recovery. We will put it in the show notes. We will also link it to, if you're viewing this on YouTube, Dr. Rebecca. I really appreciate your interest in the prevention aspect, but also really caring about the outcomes for these people. It makes a difference because, you know, as a surgeon, this is something you do every day. But for an individual who is going to be showing up at the hospital, this is a life moment that they're never going to forget. Absolutely. It is another day at work for me, but it is the biggest day in their lives.

1:17:28And it's an honor and privilege to be part of that.

1:17:30Dr. Gabrielle Lyon:Thank you so much for coming on. I look forward to when your book comes out. Thank you so much for having me. Joy, I'm going to be giving you a call. Dr. Rebecca Nexted, thank you so much for joining me thank you for having me