What is getting in the patient's way, and how do we fix it? This question has driven the work I have been involved in since 2006.
In 2006, I joined a small plastic surgery practice in San Antonio and committed to doing one thing at an exceptionally high level: microsurgical breast reconstruction. Specifically, the DIEP flap: a technically demanding procedure that reconstructs the breast after a mastectomy using the patient's own abdominal tissue, preserving the underlying muscle, and offering results that age naturally and last a lifetime.
At the time, most surgeons were generalists. Microsurgical reconstruction was complex, time-consuming, and concentrated in a handful of academic centers. Patients who wanted access to it often had to travel hundreds of miles or go without.
The gap between what was technically possible and what patients could actually access was not a clinical problem. It was a system problem.
We chose depth over breadth. The volume followed. PRMA grew into one of the busiest breast reconstruction practices in the world. Patients came from across the country and beyond, not because there was no one closer, but because a reputation built on consistent outcomes at scale becomes self-reinforcing.
Our outcomes were excellent, and consistently so. The next challenge was to ensure the system could deliver that same standard beyond a small number of surgeons, as the team grew.
Over time, two failures became impossible to ignore.
The first was in how patients made decisions. They were arriving at consultations having already partially decided, shaped by incomplete information, a hurried referral conversation, or whatever they had found online after a diagnosis. By the time they sat down with a surgeon, the real decision was often already made. Constrained choice, not informed consent.
Breast Advocate® was not built to add more information. It was built to fix a decision-making failure. Patients spend about 1% of their decision-making time with their care team. The other 99% happens outside the clinic, where the weight of a diagnosis and its implications actually land.
The second failure was in survivorship care. Patients coming through reconstruction and cancer treatment asked a question the clinical system had no good answer for: what do I use on my skin now? The products available were either cosmetically formulated, clinically unproven, or not designed for the reality of people with hormone-sensitive cancer in recovery.
InviCible Skincare™ started as a scar treatment formulated for post-reconstruction patients, built to the clinical standard I would apply to any recommendation made to a hormone-sensitive cancer patient. Patients kept using it long after their scars faded. The market found the product before I went looking for a market.
In September 2023 I was diagnosed with Psoriatic Arthritis. Active, severe, and refractory to multiple lines of therapy. By 2024 I had stopped operating.
For a microsurgeon, this is not a career inconvenience. The hands are the capability. Fine control over 9-0 nylon sutures, anastomosing vessels smaller than a matchstick. This work has no acceptable margin for imprecision. When I could no longer guarantee that standard consistently, I stopped. Patient safety is binary.
PRMA continued to deliver consistent outcomes. Not through any individual surgeon. Through our system.
That confirmation was the clearest possible evidence of everything I had believed about systems over individuals. Not as management philosophy, but as clinical infrastructure with real consequences for real patients.
I now lead clinical operations at ARSA, building the clinical platform that extends physician-led, outcomes-driven reconstructive surgery across multiple markets. Becoming a patient myself, navigating a chronic, refractory disease under active management, reinforces everything I am trying to build now.
Build for the moment you will not be in the room. Because eventually, one way or another, you won't be.
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