He spent the next seven years at Johns Hopkins Hospital in Baltimore doing his plastic surgery training, well aware that breast reconstruction patients — as well as the challenges, nuances and rewards of breast reconstruction surgery — would always be at the root of his passion for the specialty.
"DIEP flap reconstruction has been around for five or six years," Dr. Williams says.
"Out here, in the West, there is really no one who does DIEP; so, I have been trying to develop a following for it since I came out here a year ago."
"Women who are very active especially benefit from this surgical option that uses the patients' own tissue for breast reconstruction, he explains.
"Certainly using your own tissue to reconstruct your breast, as opposed to an implant, results in a much more natural look on the chest wall and feel. But having the TRAM (transverse rectus abdominus myocutaneous) flap and taking your whole rectus abdominus muscle in order to move up that tissue is a huge price to pay, especially for active people," he notes.
In the TRAM flap procedure, surgeons use the patient's abdominal tissue, leaving it attached to the underlying muscle. They then transfer the tissue, either microsurgically or by tunneling the tissue from the abdomen up to the breast area.
"The problem with the TRAM technique is that you lose the muscle, so that the abdomen becomes weak," Dr. Williams explains.
The DIEP flap spares that entire muscle and focuses on using skin and fat. Dr. Williams dissects a 1 mm or 2 mm perforator and uses it to perform the reconstruction. He microsurgically anastomoses that vessel into a vessel that is in the chest and immediately reconstructs the breast at the time of mastectomy.
The blood supply for new breast tissue post-DIEP is better than it is post-TRAM, according to Dr. Williams.
"It definitely is a technique that has a steep learning curve," Dr. Williams acknowledges.
"You have to be skilled in microvascular surgery because you are sewing blood vessels together that are in the 5 mm-range. Secondly, dissecting out the flap itself is a tedious experience because you are dealing with one or two tiny blood vessels that supply all that skin and fat."
Dr. Williams recommends that surgeons who perform the DIEP be patient, so that they do not rush this critical dissecting portion of the procedure.
"Then, it is a matter of experience doing the DIEP a number of times, so that you get used to variations in the anatomy. Blood vessels can appear in the muscle, around the muscle — in a variety of different areas," he notes.
Offering what he says are better quality of life options to reconstructive patients — despite the fact that the traditional approaches might be easier to perform — gives him great satisfaction.