Every venture I’ve founded or helped shape started with the same question:
What is getting in the patient’s way, and how do we fix it?
Not a market opportunity. Not a trend. A patient in front of me who deserved better than what the system was delivering. That was the trigger every time.
The pattern held across everything I’ve been part of: PRMA Plastic Surgery, the Advanced Reconstructive Surgery Alliance (ARSA), Toliman Health™ (and its flagship product, the Breast Advocate® app), and InviCible Skincare™. Some I founded. Others I joined and helped build. Different problems, different domains, identical starting point.
Two early bets.
PRMA was founded in 1994 with a specific mission: to bring autologous breast reconstruction, specifically microsurgical techniques, to San Antonio. When I joined in 2006 as the fourth surgeon, the practice was already committed to doing complex work that most groups wouldn’t touch.
PRMA had already made that bet before I arrived: microsurgical breast reconstruction as a core identity, not as one tool among many. I joined because I believed in it, and built my practice focus entirely around it too. Specifically DIEP and perforator flap procedures. As the thing I would do better than anything else.
The other decision was on access. I was convinced that patients would travel for the right procedure if they knew it existed. The gap between what was technically possible and what patients could actually reach was enormous. Microsurgical reconstruction lived in isolated centers. If you happened to be near one, you could get it. If you weren’t, you probably didn’t even know it was an option.
My first move was to take the practice online. My partners said “patients will never travel for surgery.”
They were wrong.
Out-of-town referrals started coming. Then out-of-state. Then international. Complex referrals arrived because of results. Results built deeper expertise. Deeper expertise attracted more complex cases. The flywheel started turning.
Then came the next wall.
The model worked, but it was geographically constrained. The best microsurgical breast reconstruction in the country shouldn’t require a flight. That realization became ARSA: a physician-led platform built to extend the same clinical infrastructure and standards across multiple markets, with physician autonomy built into the structure, not bolted on as an afterthought.
The wall at PRMA was access by geography. The wall at ARSA is access at scale.
The wall that technology could fix.
Patients were arriving at consultations having already partially decided. They’d been shaped by a hurried referral conversation, incomplete online research, or what a friend had experienced. By the time they sat down with a surgeon, the real decision was often already made. Constrained choice, not informed consent.
A paper I contributed to, published in Plastic and Reconstructive Surgery in 2016, examined patient satisfaction and decision regret in breast reconstruction. The data confirmed what I was already seeing in the clinic: the quality of the decision upstream significantly influences the quality of the outcome downstream.
Breast Advocate® was built to close that gap. The first shared decision-making app specifically for breast cancer surgery and reconstruction. It presents every option, including going flat and doing nothing. Not because all options are equal, but because a patient who understands her full range of choices is a patient making a real decision.
Toliman Health™ is the company I founded to take that infrastructure further: scaling decision support across specialties and health systems.
And the wall that was hiding in plain sight.
Patients completing reconstruction and cancer treatment were asking 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 after being diagnosed with a hormone-sensitive cancer.
InviCible Skincare™ started as a scar treatment formulated for post-reconstruction patients, built to the clinical standard I would apply to any recommendation for a patient with hormone-sensitive cancer. Patients kept using it long after their scars faded. The market found the product before I went looking for a market.
The pattern.
Each of these ventures started with the same wall. A patient who deserved better. A decision point: accept it, work around it, or fix it.
If you pay close enough attention to the patient in front of you, the next problem worth solving usually makes itself obvious.
The question is whether you’re willing to be the one who fixes it.
Related reading: What to Ask Before Saying Yes to Breast Reconstruction →
Informed Choice Is the Intervention →
Lymphedema After Breast Cancer: The Treatment Exists. The System Doesn’t Scale It Yet. →