Operative Technique in Plastic Surgery – Kevin C.Chung

joints. The 8th to 10th ribs are referred to as “false” ribs as they lack direct
sternal attachments, whereas ribs 11 and 12 are termed the “floating” ribs (FIG
1).
■ The musculature is composed of two main groups—axial and appendicular
muscles (FIG 2).
■ Most axial muscles can be divided into two subtypes based on their role in
respiration—inspiratory (sternocleidomastoid and scalene) and expiratory
(rectus abdominis, internal oblique, and external oblique)—although the
trilayered intercostals participate in both respiratory processes.
■ The appendicular muscles are required for manipulation of the scapula
(trapezius, serratus anterior) and humerus (pectoralis major/minor, latissimus
dorsi).
■ The serratus anterior originates from the superolateral borders of the first 8 or
9 ribs and inserts onto the costal surface of the medial scapular border to create
7 to 10 distinct digitations or slips (average dimension 10 × 20 cm).2
■ The distribution of serratus digitations is as follows: 7 (13%), 8 (48%), 9
(26%), and 10 (13%).3
■ Arterial supply (Mathes and Nahai type III)
■ Superior 3 to 5 slips: The lateral thoracic artery (0.5 to 1.5 mm),4 which
originates from the axillary artery posterior to the pectoralis minor, follows
the inferolateral border of the muscle to supply the first 3 to 5 slips.
■ Inferior 3 or 4 slips: The thoracodorsal artery (2 to 4 mm),5 which originates
from the subscapular artery, gives off one (40%), two (50%), or three (10%)
serratus branches (1.5 to 2.5 mm)6 to supply the inferior 3 to 4 slips. The
average pedicle length is 11 cm but may be as long as 15 cm if taken to the
subscapular artery.3
■ Veins: Paired venae comitantes run parallel to their arterial counterparts (FIG
3).
■ Nerves: Innervated by the long thoracic nerve, which arises from the C5 to C7
anterior rami and passes through the cervicoaxillary canal, it runs posterior to
the brachial plexus and axillary artery/vein where it follows the inferior surface
of the muscle and eventually diverges on the vascular pedicle as it travels
inferiorly.6
■ Preserve the first 4 or 5 muscular slips to avoid damage to this nerve, which
would produce a winged scapula deformity.
■ Innervation of the optional skin paddle is provided by the lateral cutaneous

branches of the intercostal nerves (FIG 4).
PATHOGENESIS
■ Congenital
■ Pectus excavatum (PE), pectus carinatum (PC), Poland syndrome, anterior
thoracic hypoplasia, pentalogy of Cantrell, asphyxiating thoracic dystrophy,
spondylothoracic dysplasia, and sternal clefts
■ Acquired
■ Trauma, tumor resections, postoperative complications, wound infections
involving musculoskeletal components, and chronic empyemas
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History
■ As with any other reconstructive procedure, a thorough evaluation of
comorbidities, especially those that place the patient at risk for VTEs (ie,
history of VTEs, obesity, diabetes, smoking, Caprini score greater than 8)7 or
vascular complications, is critical for preoperative medical and anesthesia
optimization.

Scapula - Suprascapular notch Acromion Coracoid process Glenoid cavity Neck / Subscapular fossa 3 4 5 6 True ribs (1-7) - False ribs (8-12) Floating ribs (11-12) Anterior view True ribs (1-7) Rib Head Neck Tubercle Angle Body False ribs (8-12) 8 9 10 12 Floating ribs (11-12) Posterior view Jugular notch Manubrium Angle - Body Xiphoid process Costal cartilages Clavicle Acromion Supraspinous fossa Spine Infraspinous fossa Sternum Scapula

FIG 1 • Skeletal anatomy of the chest wall.
■ Congenital: It is important to acquire any genetic workup or syndromic
diagnoses in order to identify additional comorbidities and underlying
structural abnormalities not readily apparent on physical exam that may
complicate or alter the surgical approach.
■ Acquired: History of insults to the chest wall soft tissue and skeletal integrity
is critical for identifying the full extent of the defect as well as any factors that
may influence the treatment plan.
• Trauma: Consider imaging (magnetic resonance imaging [MRI], computed
tomography [CT], vascular imaging) studies if there is a potential for
aberrant/obscured anatomy or foreign bodies.
• Infection: Consider tissue quantifications and cultures to identify any
pathologic microbes and to guide preoperative planning regarding plating
and/or other hardware utilization.
FIG 2 • Musculature and neurovascular anatomy of the

chest wall.
• Oncologic: Ensure clear pathologic margins or identify additional resection
requirements and treatment goals respective to tumor type.
• Radiation: Identify plans for postadjuvant radiation therapy to guide
reconstructive decisions (ie, local/regional vs free flap design, timing).
■ Physical exam
■ In general, identification of defect dimensions and involved tissue types is
critical for preoperative planning and flap design.
• Skin: Note scars or contractures from prior procedures. Identify lacerations
for potential utilization as or integration with incision design. Evaluate for
skin integrity including turgor, elasticity, and signs of radiation damage or
dermatologic disease.
• Muscle: Assess muscle bulk and dimensions to identify tissue limitations
and guide preoperative flap design.
• Bone: Identify extent of skeletal defects to determine requirements for
structural stabilization with plates, grafts, or bone-containing flaps.
IMAGING
■ CT or MRI studies may be beneficial in the preoperative evaluation of patients
undergoing tumor resection as well as those with trauma to identify the extent
of musculoskeletal defects and any complicating foreign bodies.
■ Vascular studies such as CT angiography may be warranted if tumor resection
or trauma has compromised the natural vascular anatomy or extent of vascular
involvement is unknown.
■ Dynamic three- and four-dimensional CT imaging can facilitate
individualized flap design by identifying angiosome filling patterns up to the
subdermal plexus level, recruitment of neighboring angiosomes through
communicating branches, and venous drainage.8,9
■ As previously mentioned, three main serratus perforator branching patterns
from the thoracodorsal artery have been identified in anatomical studies, so
CT angiography can be utilized to identify patient-specific anatomical
variants for facilitating intraoperative perforator identification and dissection.3
SURGICAL MANAGEMENT
Preoperative Planning

■ Location and size of the defect are ideally identified prior to incision to guide
decisions regarding flap design (ie, transposition or free flap) and required
vascular pedicle length.
■ Direct closure of the donor site, stability of the thoracic wall, and protection
of the thoracic viscera are all variables that need to be integrated into the
decision to utilize a muscle transposition, myocutaneous, or chimeric flap.

FIG 3 • Vascular branching patterns of serratus
perforators from thoracodorsal artery.
■ Involved tissue types
■ Skin: Identifying skin involvement is important for determining if a flap with
a skin paddle or skin graft is required. The decision to include a skin paddle
will alter the dissection to preserve the lateral cutaneous perforators of the
posterior intercostals that would otherwise be transected during exposure of
the serratus muscle.
■ Muscle: Determine which muscles are involved and the level of functionality

that exists with the current muscular composition.
■ If resection, radiation, or infection compromises a muscle that would
otherwise be available as flap, this is critical to know prior to taking the
patient to the operating room so that a different flap or surgical approach may
be chosen.
■ Bony defects larger than 5 cm or involving more than 3 or 4 contiguous ribs
are likely to benefit from structural support in addition to soft tissue
coverage.10
■ A defect’s age (ie, acute vs chronic wound) often influences the quality of
localized tissue vascularity, extent of fibrosis, and local wound healing
capabilities as a result of inflammation-dependent changes in regional
“physiosomes.”
FIG 4 • Thorax anatomic cross section.
■ The presence of irradiated skin, previous scars/contractures, localized

infection or inflammation, and acute trauma all influence the regional tissue
integrity and subsequently require consideration while determining the
reconstructive approach and complexity.
■ Patient lifestyle and functional status help to identify the measures to be
implemented for preservation of postoperative muscular functionality and the
overall type of reconstruction performed.
■ Certain activities (ie, boxing, golf, baseball, and swimming) and labor-
intensive occupations (ie, construction) depend on the serratus anterior for full
functionality, and this must be taken into consideration when choosing the
donor muscle.
■ Prognosis: Life expectancy and patient-specific goals vary significantly for
each patient and, as a result, must be considered when determining the
complexity of reconstruction.
■ Patient who have had the serratus anterior muscle harvested may have a
“winged” scapula and discomfort.
■ Those with poorer overall prognoses may be better treated with less complex
reconstructive techniques that minimize intraoperative risks while facilitating
faster recovery times.
Positioning
■ The patient may be placed in partial or complete lateral decubitus position
depending on the location of the defect relative to the donor site.
■ Defects juxtaposed to the donor site allow for full lateral decubitus positioning
with a beanbag setup.
Approaches
■ Incisions overlying the anterior border of the latissimus muscle allow ready
access to the serratus anterior muscle.
■ Transverse or oblique incisions may lend to a more favorable donor site scar.
■ Anterior access is necessary to adequately harvest the entire serratus muscle.
T E C H N I Q U E S
■ Landmarks and Markings

■ It is important to identify the anterior border of the latissimus dorsi and the
inferior border of the ninth rib to ensure the incision will appropriately
expose the latissimus and inferior serratus slips.
■ Create a template of the defect to identify the required dimensions for
reconstruction.
■ Trace the anterior border of the latissimus muscle as well as a straight line
from the anterior axillary line to ASIS to delineate the ideal anteroposterior
boundaries for the incision (TECH FIG 1).
■ If a skin paddle is going to be incorporated into the flap design, transpose
the defect template into this defined region and identify perforators with
US Doppler to optimize the flap position relative to underlying vasculature.

TECH FIG 1 • Preoperative markings.
■ Exposure
■ Make a curvilinear incision from the axilla to rib 8 or 9 while avoiding
anterior or posterior deviations beyond the previously identified A-P borders.
The location and appearance are similar to those of a classic lateral
thoracotomy incision.
■ Dissect down to the deep fascia overlying the latissimus muscle.
■ Following exposure of the anterior projection of the latissimus dorsi, reflect
the latissimus posteriorly to expose the underlying serratus anterior muscle
while preserving the thoracodorsal neurovascular pedicle (TECH FIG 2).
■ Dissect out the thoracodorsal artery to identify and preserve the serratus
artery branches.
■ After isolating the serratus perforators, continue to expose the inferior 3 to 4
serratus slips.
■ The long thoracic nerve also travels superficial to the muscle and must be
identified to avoid inadvertent damage.
TECH FIG 2 • A. Incision and initial dissection. B.
Postdissection wound in a patient with a complicated

empyema who underwent open window
thoracomyoplasty.
■ Flap Harvest
■ Dissect posteriorly and superiorly toward the axilla following the serratus
slips to their scapular attachments.
■ Identify and preserve the lateral thoracic artery and long thoracic nerve as
the dissection travels posteriorly toward the axilla.
■ Divide the muscular insertions on the scapula using electrocautery (TECH
FIG 3A).
■ Both the thoracodorsal perforators and lateral thoracic artery can be
preserved for flap perfusion or selectively divided depending on the required
pedicle length, arc of rotation, and vascular integrity.
■ If skeletonizing the pedicle(s), it should be performed cautiously to preserve
sufficient perivascular adipose tissue to reduce the risk for vasospasm and
avoid damaging the paired venae comitantes that accompany the artery.
■ Identify the origin for each slip on the corresponding rib.
■ For a muscle transposition or myocutaneous flap, this costal muscular
insertion can be divided for elevation of the serratus muscle (TECH FIG
3B).

TECH FIG 3 • A. Retraction of latissimus and
exposure of serratus. B. Serratus flap elevation. C.
Optional rib harvesting step. D. Elevated serratus

anterior flap on pedicle. E. Intraoperative photo of
serratus anterior muscle flap elevated on lateral
thoracic artery pedicle.
■ If the rib is also desired for reconstruction, mark the anterior osteotomy
site.
• Sharply dissect onto the rib after identifying the superior and inferior rib
boundaries.
• Dissect in the subperiosteal plane on the posterior costal border while
ensuring the intercostal neurovascular bundle, posterior periosteum, and
adjacent pleura remain intact.
• Perform the anterior and posterior osteotomies to elevate the flap (TECH
FIG 3C).
■ Following flap elevation, continue to proximally dissect the vascular pedicle
to the desired length with or without skeletonization depending on inset
goals.
■ Up to 15 cm pedicle length and 4 mm vessel diameter are possible if
dissection is carried up to axillary insertion for the thoracodorsal-based
pedicle (TECH FIG 3D,E).
■ Ensure constant visualization and isolation of the long thoracic and
thoracodorsal nerves to avoid injury.
■ The skin paddle is innervated by the lateral cutaneous branches of the
intercostal nerves, which can be readily identified and preserved during
flap elevation to preserve sensation to the skin flap.
■ Flap Inset
■ Close attention must be paid during skeletonization to preserve some
perivascular adipose in the pedicle, which will reduce the risk for vasospasm
and pedicle kinking.
■ Ensure sufficient pedicle length has been dissected to prevent excessive
tension on the pedicle during flap transposition or insetting.
■ Maintain awareness of the position in which the vascular pedicles lie to
ensure that no kinking or twisting has occurred, which may compromise
blood flow to the flap immediately or early in the postoperative period.

■ TECH FIG 4 depicts an intrathoracic transposition insetting.
TECH FIG 4 • Intrathoracic flap insetting and
subsequent coverage with acellular dermal matrix (*)
for defect reconstruction.
PEARLS AND PITFALLS
Techniques
■ Limit harvest to inferior 3 or 4 slips to avoid damage to long thoracic
nerve.
■ The crow’s foot landmark (around 7th to 8th slip) is the point at
which the dominant serratus branch of the thoracodorsal artery enters
the muscular fascia, crosses the long thoracic nerve, and arborizes
anteriorly to supply the inferior slips that will be harvested for the
flap.3
■ The neurovascular bundle lies superficial to the muscle flap, which
facilitates safe dissection from violating the posterior costal
periosteum when harvesting a rib.
■ The subscapular system can be further modified to create a chimeric
flap involving the latissimus dorsi, scapular, parascapular muscle, and
scapular spine.
■ A skin paddle may also be taken by preserving myocutaneous
perforators if needed for defect coverage.

POSTOPERATIVE CARE
■ Occlusive-type dressings are preferred.
■ Drains are necessary to avoid seroma.
■ Local anesthetic block and muscle relaxant can be beneficial to mitigate
postoperative pain.
■ Thoracic epidural analgesia can also provide extended pain relief.
■ Flap monitoring
■ As with any other flap, the 24- to 48-hour postoperative window requires
particularly attentive flap monitoring in the form of clinical and/or US
Doppler evaluations to identify any signs of pending flap failure.
■ Specific clinical findings point to the vascular etiology and can facilitate
more efficient operative interventions.
• Arterial: Cold, pale, poor capillary refill, and minimal to absent bleeding
with pinprick test
• Venous: Warm, edematous, dusky/purple, and dark blood with pinprick test
■ Newer technology such as ViOptix tissue oximetry may be used to further
enhance postoperative flap monitoring. These systems provide continuous
flap monitoring with real-time feedback to support clinical decisions
regarding flap compromise and the necessity for flap take backs.
OUTCOMES
■ Depending on the number of serratus slips harvested, the donor site scar can
be made relatively short and well hidden laterally parallel to the adducted arm.
■ Limiting the harvest to the inferior 3 or 4 slips and preserving the long thoracic
nerve result in good retention of muscular function and overall limited donor-
site morbidity.
COMPLICATIONS
■ Postoperative complications with chest wall reconstruction include donor
and/or recipient site hematoma or seroma formation, infection, and
pneumothorax.
■ If reconstructive plates are used for chest wall stabilization, extrusion and
infection can result if the hardware is placed in a radiated bed or has
insufficient soft tissue coverage.
■ Flap
■ Failure secondary to arterial or venous congestion is more likely to occur in

cases where there was extensive skeletonization, excessive tension, and/or
kinking of the pedicle during flap insetting.
■ Donor-site morbidity may include chronic pain, loss of scapular/shoulder
ROM or functionality, and winged scapula.
REFERENCES
1. Takayanagi S, Tsukie T. Free serratus anterior muscle and myocutaneous
flaps. Ann Plast Surg. 1982;8(4):277-283.
2. Arnold PG, Pairolero PC, Waldorf JC. The serratus anterior muscle:
intrathoracic and extrathoracic utilization. Plast Reconstr Surg.
1984;73(2):240-246.
3. Cuadros C, Driscoll C, Rothkopf D. The anatomy of the lower serratus
anterior muscle: a fresh cadaver study. Plast Reconstr Surg. 1995;95(1):93-97.
4. Tashiro K, Harima M, Mito D, et al. Preoperative color Doppler ultrasound
assessment of the lateral thoracic artery perforator flap and its branching
pattern. J Plast Reconstr Aesthet Surg. 2015;68(6):e120-e125.
5. Jesus RC, Lopes MCH, Demarchi GTS, et al. The subscapular artery and the
thoracodorsal branch: an anatomical study. Folia Morphol. 2008;67(1):58-62.
6. Godat DM, Sanger JR, Lifchez SD, et al. Detailed neurovascular anatomy of
the serratus anterior muscle: implications for a functional muscle flap with
multiple independent force vectors. Plast Reconstr Surg. 2004;114(1):21-29.
7. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis
Mon. 2005;51(2):70-78.
8. Saint-Cyr M, Schaverien M, Arbique G, et al. Three- and four-dimensional
computed tomographic angiography and venography for the investigation of
the vascular anatomy and perfusion of perforator flaps. Plast Reconstr Surg.
2008;121(3):772-780.
9. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional
arterial and venous anatomies of the thoracodorsal artery perforator flap. Plast
Reconstr Surg. 2008;121(5):1578-1587.
10. Mahabir RC, Butler CE. Stabilization of the chest wall: autologous and
alloplastic reconstructions. Semin Plast Surg. 2011;25(1):34-42.

7
CHAPTER
Section II: Reconstruction
of the Abdominal Wall
Hernia Repair With Open
Component Separation
Ibrahim Khansa and Jeffrey E. Janis
DEFINITION
■ Traditional component separation, now termed “anterior component
separation,” involves separating the external oblique muscle from the
remaining components of the abdominal wall.
■ This requires two steps:
■ Incision of the external oblique aponeurosis
■ Delamination of the external oblique muscle from the underlying internal
oblique muscle
■ A third step (optional) is entry into and development of the retrorectus space.
■ “Posterior component separation,” also known as a transversus abdominis
release (TAR), is another type of component separation. It requires two steps:
■ Entering and developing the retrorectus space
■ Transection of the posterior lamella of the internal oblique and transversus
abdominis
■ Delamination of the transversus abdominis and transversalis fascia
ANATOMY
■ The layers of the lateral abdominal wall, from superficial to deep, are the
external oblique, internal oblique, and transversus abdominis muscles,
transversalis fascia, and peritoneum.
■ The segmental intercostal nerves to the abdominal wall musculature travel in

the layer between the internal oblique and transversus abdominis muscles.
■ Vascular perforators to the abdominal wall skin emerge from the deep
epigastric vessels.
■ They are arranged into a medial and a lateral row.
■ The medial row is dominant, especially the periumbilical perforators.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Assess if any indications for urgent surgery are present.
■ Bowel obstruction
■ Incarceration/strangulation
■ Infected mesh
■ Assess effect of hernia on the patient.
■ Ability to carry out activities of daily living
■ Pain at hernia site
■ Difficulty with defecation
■ On physical examination, look for:
■ Peritoneal signs
■ Reducibility of hernia
■ Edges of fascial defect
■ All scars on the abdomen (which will affect vascularity)
■ Presence of skin graft
■ Presence of a fistula
■ Presence of an ostomy
IMAGING
■ CT scan of the abdomen is useful to delineate:
■ The size, extent, and borders of the fascial defect
■ Whether component separation has been performed previously
■ The integrity of the musculofascial components (may have been previously
resected)
■ An estimate of the loss of domain
■ Presence and position of prior mesh, if applicable
■ The thickness of soft tissue between the hernia (sac) and overlying skin
SURGICAL MANAGEMENT
Preoperative Planning

■ Assess suitability of the patient for major surgery.
■ Smokers and tobacco users should completely abstain for at least 4 weeks
preoperatively and 4 weeks postoperatively.1,2
■ Nutrition should be optimized before surgery (prealbumin greater than 15
mg/dL, albumin greater than 3.25 g/dL).2,3
■ Diabetes should be well controlled (HbA1c ≤ 7.4%).2
■ Body mass index should be 42 or less, and preferably less than 40.2
■ After hernia dissection and lysis of adhesions, assess whether component
separation is needed:
■ Apply Kocher clamps on the medial edge of the rectus complex on each side.
■ Attempt to simulate midline reapproximation of the rectus complexes by
bringing the two sides toward each other.
• If too much tension is present, which may result in fascial cheese wiring or
inability to obtain primary musculofascial reapproximation, start with
unilateral component separation and reassess.
• If still there is too much tension after unilateral component separation,
perform bilateral component separation.
Positioning
■ Supine with arms abducted 90 degrees and all pressure points padded
Approaches
■ Multiple approaches are possible for component separation.
■ Anterior component separation through the hernia defect itself:
• Open
• Minimally invasive
■ Anterior component separation through separate lateral incisions: Endoscopic
■ Posterior component separation: Transversus abdominis release (TAR)
T E C H N I Q U E S
■ Open Anterior Component Separation
■ Identify the medial rectus reflection on each side.
■ Using Bovie electrocautery, dissect from medial to lateral just above the

anterior rectus sheath along the anterior rectus fascia. Multiple vascular
perforators may be encountered depending on the extent of the dissection.
■ In the classic open anterior component separation, these perforators are
sacrificed and wide skin flaps are developed.
■ In more modern perforator-sparing anterior component separation
approaches, they are identified and preserved or remain undissected by
limited undermining and preservation of composite tissue to decrease
complication rates.
■ Identify the semilunar line either by palpating the lateral rectus complex
margin between your fingers (intraperitoneal) and thumb (extraperitoneal) or
by displacing the rectus muscle laterally.
■ This latter maneuver, described by the senior author as the “tube of
toothpaste maneuver” (TECH FIG 1A), accentuates the indentation of the
semilunar line, making it more visible.4
■ Once the semilunar line is fully exposed, make an incision in the external
oblique aponeurosis 2 cm lateral to the semilunar line (TECH FIG 1B).
■ Enter the plane between the external oblique and internal oblique muscles.
This plane is identified by the presence of an avascular layer between the two
muscles.

TECH FIG 1 • A. “Tube of toothpaste” maneuver: the
rectus complex is displaced laterally in order to
accentuate the linea semilunaris. B. Marking of the
external oblique aponeurotomy in classic “Ramirez-
style” open anterior component separation. C.
Elevation of the external oblique muscle off the
underlying internal oblique muscle in an areolar,
avascular plane, up to the midaxillary line in classic
“Ramirez-style” open anterior component separation.
D. Closure of the anterior rectus sheath after bilateral
classic “Ramirez-style” open anterior component
separation. Note the degree of medial advancement
obtained.
■ Using a blunt dissection instrument (such as a plastic Yankauer suction),
bluntly dissect the plane superiorly and inferiorly. Then use Bovie

electrocautery to continue the external oblique aponeurotomy from the iliac
crest inferiorly to 6 cm above the costal margin superiorly.
■ Superiorly, the aponeurosis is more muscular, and care must be taken to
obtain adequate hemostasis as the muscle is incised.
■ Apply two Allis clamps to the medial edge of the cut external oblique
muscle, and lift it off the underlying internal oblique muscle.
■ Place a wide malleable on the internal oblique to push it posteriorly, and use
Bovie electrocautery or a spreader-dissector to dissect the plane between the
external and internal oblique muscles from medial to lateral (TECH FIG
1C).
■ This plane should be dissected laterally until sufficient release is
performed, varying between the anterior axillary line and posterior axillary
line, if needed.
■ Near the posterior axillary line, the vascular pedicle to the external oblique
muscle will be encountered along its undersurface and should be preserved.
■ This technique allows advancement of 5, 10, and 3 cm in the epigastric,
waistline, and suprapubic areas, respectively, on each side (TECH FIG 1D).5
■ If needed, the retrorectus space can be entered by incising along the medial
rectus reflection, identifying the rectus muscle, and keeping the anterior
rectus sheath and muscle together as a complex, as well as dissecting the
space between the muscle and the posterior sheath.
■ Segmental neurovascular bundles (which enter laterally) should be
visualized and preserved.
■ This maneuver theoretically adds 2 cm to the amount of possible
advancement in addition to the numbers listed above.5
■ After hernia repair is complete by primarily reapproximating the
musculofascia, a closed suction drain should be placed into the space
developed between the external and internal oblique muscles.
■ Tension-free closure should be performed in layers with absorbable sutures:
■ Three-point sutures incorporating each side of Scarpa fascia and the
underlying closed anterior rectus fascia
■ Deep dermal sutures
■ Running subcuticular suture
■ Open anterior component separation requires widely undermined skin flaps,
which can lead to seroma formation. The risk of seroma can be decreased by:
■ Closed suction drain placement in the midline, as well as at the external

oblique aponeurotomy site
■ Progressive tension sutures between the underside of Scarpa fascia and the
anterior rectus sheath
■ Spraying fibrin glue
■ Minimally Invasive Anterior Component
Separation6 (Video 1)
Video p5-c007
■ Identify the rectus complex on each side.
■ Using Bovie electrocautery, create a 5-cm-wide tunnel from medial to lateral
just superficial to the anterior rectus sheath, located about 4 to 5 cm inferior
to the costal margin.
■ This tunnel is meant to spare most vascular perforators to the abdominal
wall, especially the periumbilical perforators, by preserving composite
tissue.
■ Continue medial to lateral dissection within the subcutaneous tunnel until 2
cm lateral to the semilunar line.
■ The semilunar line can be identified using the same “tube of toothpaste”
techniques described above4 (see TECH FIG 1A).
■ Once the semilunar line is identified, make a limited incision in the external
oblique aponeurosis 2 cm lateral to the semilunar line.
■ Enter the plane between the external oblique and internal oblique muscles.
00:00 / 00:00

This plane is identified by the presence of a fatty avascular layer.
■ Using a blunt dissection instrument (such as a plastic Yankauer suction),
bluntly dissect the plane superiorly and inferiorly.
■ Now that the trajectory of the anticipated external oblique aponeurotomy is
known by transposing the plastic Yankauer suction tip anteriorly, dissect a
precise, narrow vertical subcutaneous tunnel overlying the planned location
of the external oblique aponeurotomy (2 cm lateral to the semilunar line).
■ This is made with a combination of a narrow Deaver retractor, Bovie
electrocautery, and spreader-dissector.
■ Then use Bovie electrocautery to continue the external oblique
aponeurotomy under direct visualization from the iliac crest inferiorly to 6
cm above the costal margin superiorly.
■ Superiorly, the aponeurosis is more muscular, and care must be taken to
obtain adequate hemostasis as the muscle is cut.
■ Apply two Allis clamps to the medial edge of the cut external oblique
muscle, and lift it off the underlying internal oblique muscle.
■ Place a wide malleable on the internal oblique to push it posterior, and use
Bovie electrocautery or a spreader-dissector to dissect the plane between the
external and internal oblique muscles from medial to lateral.
■ This plane should be dissected laterally, as needed, to anywhere between
the anterior and posterior axillary lines.
■ Near the posterior axillary line, the vascular pedicle to the external oblique
muscle will be encountered along its undersurface and should be preserved.
■ If needed, the retrorectus space can be entered by incising along the medial
rectus reflection, identifying the rectus muscle, and keeping the anterior
rectus sheath and muscle together as a complex, dissecting the space between
the muscle and the posterior sheath.
■ Segmental neurovascular bundles (which enter laterally) should be
visualized and preserved.
■ This maneuver theoretically adds 2 cm to the amount of possible
advancement in addition to the numbers listed above.
■ After hernia repair is complete by primarily reapproximating the
musculofascia, a closed suction drain should be placed into the space
developed between the external and internal obliques.

■ Endoscopic Anterior Component Separation
Through a Separate Incision7
■ Make a 1-cm vertical incision 5 cm medial to the anterior superior iliac
spine, and dissect down to the anterior rectus sheath (TECH FIG 2A).
■ Create a vertical subcutaneous tunnel over the midaxillary line, using the
Spacemaker balloon (Snowden Pencer, Franklin Lakes, NJ) (TECH FIG
2B).
■ Use the port to insert a 10-mm, 30-degree, angled laparoscope (TECH FIG
2C).
■ Under direct endoscopic vision, make a 0.5-cm incision 2 cm below the
costal margin and another 0.5-cm incision 3 cm superomedial to the original
incision.
■ Use the additional ports to insert laparoscopic cautery and forceps.
■ Retract the external oblique muscle laterally while performing an external
oblique aponeurotomy 1 to 2 cm lateral to the semilunar line.
■ Then dissect in the plane just deep to the external oblique muscle from
medial to lateral (TECH FIG 2D).
■ Modifications of this technique have also been described, with the use of
laparoscopic instruments.8

TECH FIG 2 • Endoscopic anterior component
separation, as described by Lowe et al.7
■ Transversus Abdominis Release9,10
■ Identify the medial edge of the rectus complex on each side.
■ Use Bovie electrocautery to incise the medial rectus reflection to enter the
retrorectus space (TECH FIG 3A).
■ Note any small pre-existing rents in the medial aspect of the posterior
rectus sheath through which the fibers of the rectus muscle are visible. If
present, these constitute an ideal entry point into the retrorectus space.
■ Apply a Kocher or Babcock clamp to the anterior rectus sheath/rectus
muscle complex and retract it anteriorly and laterally while retracting the

posterior rectus sheath posteriorly and medially.
■ Using a combination of blunt dissection (Kittner) and Bovie electrocautery,
or with a spreader-dissector, dissect on top of the posterior rectus sheath from
medial to lateral, developing the space by elevating the rectus muscle and
underlying fat.
■ The deep inferior epigastric vessels must be protected during this
dissection.
■ The retrorectus fat must be elevated with the muscle, leaving behind the
shiny white posterior rectus sheath. This facilitates protection of the deep
inferior epigastric vessels.
■ Continue this dissection laterally until the semilunar line is encountered.
Segmental intercostal nerves to the rectus muscle will be visible and should
be preserved. Blunt dissection can be performed around the nerves.

TECH FIG 3 • A. Transverse abdominis release steps:
(1) enter retrorectus space. (2) Elevate rectus
abdominis muscle and fat off the posterior rectus
sheath. (3) Incise posterior leaflet of internal oblique
aponeurosis medial to the intercostal nerves. (4)
Transect transversus abdominis muscle. (5) Dissect
extraperitoneal plane deep to transversus abdominis
muscle. B. Dissection plane in posterior component
separation. C. Transection of transversus abdominis
muscle fibers in transversus abdominis release (TAR)

or “posterior component separation.” D. Extended
retromuscular plane after TAR. Note the degree of
medial advancement obtained.
■ Dissect this retrorectus plane superiorly up to the costal margin (or even
posterior to it) and inferiorly to the pubic bone.
■ Care must be taken inferior to the arcuate line, as the posterior rectus
sheath consists of only the transversalis fascia at this point and is very thin.
■ Starting as superior as possible, and 0.5 cm medial to the intercostal nerves
to the rectus muscle, incise the posterior lamella of the internal oblique
aponeurosis. This will demonstrate the transverse muscular fibers of the
transversus abdominis muscle (TECH FIG 3B).
■ Using a right angle clamp, spread the fibers of the transversus abdominis
muscle to separate them from the underlying fascia.
■ Then, using Bovie electrocautery, incise the transversus abdominis muscle.
Make sure the transversalis fascia and peritoneum are not injured. A saline-
moistened bowel towel protector is also helpful.
■ Continue this dissection from superior to inferior until the full length of the
transversus abdominis muscle is incised.
■ Apply two Allis clamps to the cut edge of the transversus abdominis muscle
and enter the underlying avascular plane. This plane can be dissected from
medial to lateral using a combination of blunt dissection (Kittner) and cautery
(TECH FIG 3C).
■ The dissection can be taken superior to the dome of the diaphragm,
inferiorly to the pubic bone and Cooper ligaments, and laterally to the
psoas muscles.
■ The posterior component separation allows advancement of 4 to 8 cm on
each side (TECH FIG 3D).9
PEARLS AND PITFALLS
Techniques
■ Anterior component separation is only complete after the external
oblique muscle has been completely elevated off the underlying
internal oblique muscle laterally to the level of the anterior axillary,

midaxillary, or posterior axillary line, depending on the patient.
External oblique aponeurotomy alone does not constitute
component separation.
■ Minimally invasive techniques for anterior component separation
have been proven to have lower rates of wound healing problems
compared to techniques with wide undermining.
■ When dissecting the retrorectus space, the fatty layer should be
elevated with the rectus muscle, leaving behind the white posterior
rectus sheath. This is very important to protect the deep inferior
epigastric vessels from iatrogenic injury.
■ When performing a posterior component separation/TAR, start as
superiorly as possible (where the transversus abdominis has the
most muscle fibers and is easier to identify) and proceed inferiorly.
Visualization
■ When performing minimally invasive component separation,
adequate visualization can only be obtained if the surgeons wear a
headlight or use a lighted retractor.
Outcomes
■ Even in cases in which fascial reapproximation is not possible
despite component separation, and where a bridged mesh repair is
therefore necessary, the defect size should be reduced using
component separation, as this has been shown to reduce recurrence
rates.11
■ Mesh decreases recurrence rates in all cases and should be used in
defects larger than 4 cm.
POSTOPERATIVE CARE
■ DVT prophylaxis: Patients should ambulate the evening of surgery and then at
least 5 times daily thereafter.2
■ Pulmonary toilet: Patients should use incentive spirometry 10 times every hour
while awake.2
■ Analgesia: The use of neuraxial blocks, intraoperative local anesthetic
infiltration in the transversus abdominis plane, and postoperative use of
nonopioid analgesics (gabapentin, celecoxib, ibuprofen, acetaminophen)
reduce narcotic requirements, which improves mental status and pulmonary
function and accelerates return of bowel function.
OUTCOMES
■ Minimally invasive techniques of component separation have lower rates of
wound healing problems than techniques with wide undermining.
■ Ghali et al. compared minimally invasive technique to traditional component

separation and found lower rates of skin dehiscence (11% vs 28%), seroma
(2% vs 6%), abdominal bulge (4% vs 14%), and hernia recurrence (4% vs
8%).12
■ Saulis et al. compared minimally invasive technique to traditional component
separation and found lower rates of wound necrosis/infection (2% vs 20%).13
■ Lowe et al. compared minimally invasive technique to traditional component
separation and found lower rates of wound infection (0% vs 40%) and
dehiscence (0% vs 43%).7
■ In cases in which fascia cannot be reapproximated and a bridged mesh repair
is planned, component separation should still be performed to reduce the defect
size.11
COMPLICATIONS
■ Surgical complications
■ Surgical site occurrences
• Cellulitis
• Abscess
• Hematoma
• Seroma
• Dehiscence/necrosis
• Fistula
■ Hernia recurrence
■ Bulge
■ Abdominal compartment syndrome
• Suspect is intraoperative peak airway pressure increases by 12 mm Hg or
more above baseline6 or if intraoperative plateau pressure increases by 6 cm
H2O (4.4 mm Hg) or more.14
■ Medical complications
■ Pulmonary (atelectasis, pneumonia, reintubation)
■ Urologic(urinary tract infection)
REFERENCES
1. Sorensen LT. Wound healing and infection in surgery: the pathophysiological
impact of smoking, smoking cessation, and nicotine replacement therapy: a
systematic review. Ann Surg. 2012; 255:
1069-1079.

2. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce
postoperative complications in plastic surgery. Plast Reconstr Surg.
2016;137:351-360.
3. Kudsk KA, Tolley EA, DeWitt RC, et al. Preoperative albumin and surgical
site identify surgical risk for major postoperative complications. J Parenter
Enteral Nutr. 2003;27:1-9.
4. Janis JE, Khansa I. Evidence-based abdominal wall reconstruction: the maxi-
mini technique. Plast Reconstr Surg. 2015;136:1312-1323.
5. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for
closure of abdominal-wall defects: an anatomic and clinical study. Plast
Reconstr Surg. 1990;86:519-526.
6. Butler CE, Campbell KT. Minimally invasive component separation with
inlay bioprosthetic mesh (MICSIB) for complex abdominal wall
reconstruction. Plast Reconstr Surg. 2011;128:698-709.
7. Lowe JB, Garza JR, Bowman JL, et al. Endoscopically assisted “components
separation” for closure of abdominal wall defects. Plast Reconstr Surg.
2000;105:720-729.
8. Rosen MJ, Jin J, McGee MF, et al. Laparoscopic component separation in the
single-stage treatment of infected abdominal wall prosthetic removal. Hernia.
2007;11:435-440.
9. Gibreel W, Sarr MG, Rosen M, Novitsky Y. Technical considerations in
performing posterior component separation with transverse abdominis muscle
release. Hernia. 2016;20:449-459.
10. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis
muscle release: a novel approach to posterior component separation during
complex abdominal wall reconstruction. Am J Surg. 2012;204:709-716.
11. Itani KMF, Rosen M, Vargo D, et al. Prospective study of single-stage repair
of contaminated hernias using a biologic porcine tissue matrix: the RICH
study. Surgery. 2012;152:498-505.
12. Ghali S, Turza KC, Baumann DP, Butler CE. Minimally invasive component
separation results in fewer wound-healing complications than open component
separation for large ventral hernia repairs. J Am Coll Surg. 2012;214:981-989.
13. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator
preservation significantly reduces superficial wound complications in
“separation of parts” hernia repairs. Plast Reconstr Surg. 2002;109:2275-2280.
14. Blatnik JA, Krpata DM, Rosen MJ, et al. Predicting severe postoperative
respiratory complications following abdominal wall reconstruction. Plast

Reconstr Surg. 2012;130:836-841.

8
CHAPTER
Ventral Hernia: Component
Separation Technique
Mark W. Clemens and Charles E. Butler
DEFINITION
■ The component separation technique is a type of rectus abdominis muscle
advancement flap that reconstructs ventral hernia and large abdominal wall
defects.
■ Component separation is a fascial release of the external oblique fascia with
creation of musculofascial advancement flaps.
■ The general indications for performing a component separation of the
abdominal wall include a deficiency of the abdominal wall fascia, which would
require a bridged repair without fascial release.
■ Ramirez and colleagues’ description of the surgical technique of component
separation moves the rectus musculofascia medially, to close midline defect by
releasing the external oblique aponeuroses and posterior rectus sheath
bilaterally.1
■ Myofascial advancement techniques, or component separation, takes
advantage of the laminar nature of the abdominal wall and the ability to release
one muscular or fascial layer to enable medial advancement of another.
ANATOMY
■ The lateral abdominal wall musculature is composed of three layers, with the
fascicles of each muscle directed obliquely at different angles to create a strong
envelope for the abdominal contents.
■ Each of the muscles forms an aponeurosis that inserts into the linea alba, a
midline structure joining the two sides of the abdominal wall.
■ The external oblique muscle is the most superficial muscle of the lateral
abdominal wall.

■ The deepest muscular layer of the abdominal wall is the transversus abdominis
muscle with its fibers coursing horizontally. These three lateral muscles give
rise to aponeurotic layers lateral to the rectus abdominis muscle, which
contribute to the anterior and posterior layers of the rectus sheath.
■ The transversus abdominis muscle inserts into the transversus abdominis
aponeurosis to form the posterior rectus sheath and continues as a muscular
component laterally in the upper abdomen. This feature is important when
considering the technical aspects of a posterior component separation.
■ At the midline, the two anterior rectus sheaths form the tendinous linea alba.
On either side of the linea alba is the rectus abdominis muscle, the fibers of
which course vertically and run the length of the anterior abdominal wall.
■ The arcuate line, located 3 to 6 cm below the umbilicus, delineates the point
below which the posterior rectus sheath is absent and is composed of the
transversalis fascia and peritoneum.
■ The abdominal wall receives the majority of its innervation from the 7th to
12th intercostal nerves and the first and second lumbar nerves.
■ The lateral abdominal muscles receive their blood supply from the lower three
to four intercostal arteries, the deep circumflex iliac artery, and the lumbar
arteries. The rectus abdominis muscles are perfused by the superior epigastric
artery (a terminal branch of the internal mammary artery), the inferior
epigastric artery (a branch of the external iliac artery), and the lower intercostal
arteries.
PATHOGENESIS
■ Indications for abdominal wall reconstruction include tumor ablation,
congenital anomalies, and trauma.
■ Abdominal defects and hernias may result from genetically impaired collagen
formation, deposition, organization with sequelae from injury, failed
laparotomy closures, or failed hernia repairs.
■ Risk factors for the development of hernias included tobacco use and a strong
family history of hernia, which suggests a genetic predisposition.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most common presentation to reconstructive surgeons is an incisional
hernia as sequelae to a previous laparotomy.
■ There are three general indications to repair an incisional hernia: the hernia is
symptomatic, causing pain or alterations in the bowel habits; the hernia results

in a significant protrusion that affects the patient’s quality of life; and the
hernia poses a significant risk of bowel obstruction (such as a large hernia with
a narrow neck).
■ Acquired hernias typically occur after surgical incisions and thus are
commonly referred to as incisional hernias.
■ Epigastric hernias occur from the xiphoid process to the umbilicus, umbilical
hernias occur at the umbilicus, and hypogastric hernias occur below the
umbilicus in the midline.
■ Although not a true hernia, diastasis recti can present clinically as a bulge in
the midline. In this condition, the linea alba is stretched, resulting in bulging at
the medial margins of the rectus abdominis muscles. There is no fascial ring or
true hernia sac. Unless significantly symptomatic, diastasis recti does not need
to be corrected surgically.
■ Previous rectus abdominis muscle flap harvest does not preclude the future use
of component separation techniques.2
IMAGING
■ Preoperative computed tomography to examine the defect characteristics and
abdominal wall anatomy and vascularity is helpful for surgical planning.
■ Computed tomography (CT) allows for visualization of intra-abdominal
organs, and the abdominal wall, three-dimensional data sets, and multiplanar
reformation capabilities.
■ CT scans may assist in detecting fluid collections, bowel obstruction,
incarceration, strangulation, and traumatic wall hernias.
■ Magnetic resonance (MR) imaging also permits the detection of soft tissue
defects and abdominal wall hernias though this modality does not usually offer
further sensitivity and therefore may be cost-prohibitive.
SURGICAL MANAGEMENT
Preoperative Planning
■ Physical examination should be performed to assess the patient’s general
condition, the abdominal wall integrity, and the extent and location of any
abdominal wall abnormalities.
■ The presence of scars that compromise blood supply could become an obstacle
to raising reliable tissue flaps.
■ Routine laboratory tests and a nutritional workup are advised.

■ Patients should be marked in the preoperative holding area, and it is beneficial
to evaluate patients in a recumbent and supine position for complete evaluation
of abdominal wall defects.
■ Markings may delineate anatomical boundaries such as the pelvis, midline,
and costal margin as well as the fascial extent of any intra-abdominal defects.
■ Bowel preps may be beneficial in patients with anticipated violation of the
gastrointestinal tract.
■ Intravenous antibiotics are initiated in the holding area.
Positioning
■ Patients are placed supine on the operative table, sedated, and intubated.
■ The abdomen is widely draped and prepped to expose the patient’s flanks and
from the pelvis to the midsternal area.
■ Patients should receive sequential compression devices and or compression
hoses for deep vein thrombosis prophylaxis.
■ Patients requiring greater exposure should have room temperatures maintained
above 75°F to minimize postoperative infections.
Approach
■ All approaches to abdominal wall closure should be aimed at re-establishment
of the abdominal domain integrity with complete fascial coaptation.
■ All attempts should be made to avoid a bridged mesh repair because there is a
clear trend toward higher recurrence rates compared with when the fascia can
be reapproximated over a mesh repair.
■ Component separation release can be done by open or minimally invasive
component separation. A minimally invasive component separation can be
performed in various ways, but all of the techniques (to a certain degree)
maintain the blood supply to the skin from the underlying rectus abdominis
muscles.
T E C H N I Q U E S
■ Open Component Separation
■ An open component separation is performed by raising large subcutaneous

flaps to expose the external oblique fascia3 (TECH FIG 1).
■ The cutaneous perforators emerging from the anterior rectus sheath are
ligated and divided to facilitate exposure of the linea semilunaris in its
entirety. These flaps are carried laterally past the linea semilunaris.
■ An anatomically precise external oblique aponeurotomy is made 1 to 2 cm
lateral to the linea semilunaris on the lateral aspect of the external oblique
aponeurosis from several centimeters above the costal margin to the pubis. It
is important to confirm that the incision is not carried through the linea
semilunaris, as this would result in a full-thickness defect of the lateral
abdominal wall, which is challenging to repair.
■ The external oblique aponeurosis is then bluntly separated in the avascular
plane away from the internal oblique aponeurosis to the midaxillary line,
allowing the internal oblique and transversus abdominis muscles with the
rectus abdominis muscle or fascia to advance medially as a unit.
■ These techniques, when performed bilaterally, can yield up to 20 cm of
mobilization in the midabdomen.
■ Once the mesh inset and fascial closure are performed, the subcutaneous
skin flaps are advanced and closed at the midline.

TECH FIG 1 • Open component separation.
Subcutaneous flaps are elevated off the anterior
rectus sheath to expose the external oblique
aponeurosis. The external oblique aponeurosis is
released from the inguinal ligament inferiorly to above
the costal margin superiorly. This allows exposure of
the internal oblique muscle fibers once the external
aponeurosis is incised.
■ To reduce subcutaneous dead space, interrupted quilting sutures should be
placed between the Scarpa fascia and musculofascial repair.
■ This technique also decreases shear stress, which is thought to contribute to
postoperative seroma formation, and decreases the total drain output,
allowing the surgeon to place fewer drains and leave them in for a shorter
period.

■ After paramedian skin perfusion is critically assessed, a vertical
panniculectomy may be performed so that the skin is reapproximated in the
midline without redundancy.
■ Laparoscopic Component Separation
■ Laparoscopically, component separation is performed through a 1-cm
incision below the tip of the 11th rib overlying the external oblique muscle.4,5
■ The external oblique muscle is split in the direction of its fibers, and a
standard bilateral inguinal hernia balloon dissector is placed between the
external and internal oblique muscles and directed toward the pubis (TECH
FIG 2).6
■ Three laparoscopic trocars are placed in the space created, and the dissection
is carried from the pubis to several centimeters above the costal margin.
■ The linea semilunaris is carefully identified, and the external oblique
aponeurosis is incised from beneath the external oblique muscle at least 2 cm
lateral to the linea semilunaris.
■ The muscle is released from the pubis to several centimeters above the costal
margin.
■ This procedure may be performed bilaterally depending on the width of the
defect and the amount of advancement required.

TECH FIG 2 • Laparoscopic component separation. A.
Access to the external oblique aponeurosis is
achieved through a small incision at the costal margin
through which a balloon dissector is placed. The
external oblique aponeurosis is then divided from the
pubis to above the costal margin. B. This minimally
invasive approach preserves the attachments of the
subcutaneous tissue (including myocutaneous

perforators) to the anterior rectus sheath throughout
its course.
■ Periumbilical Perforator-Sparing Technique
■ A periumbilical perforator-sparing technique of component separation may
be performed to preserve the blood supply to the anterior abdominal wall skin
near the midline and is based primarily on perforator vessels from the deep
inferior epigastric vessels.
■ Cadaver dissections and radiographic studies confirmed that the majority of
these vessels are located within 3 cm of the umbilicus. With preservation of
these vessels, ischemic complications involving the subcutaneous flaps are
significantly reduced.
■ To avoid injury to the periumbilical perforator vessels, a line is marked no
less than 3 cm cephalad and 3 cm caudal to the umbilicus.
■ The periumbilical perforator tunnels are begun at the epigastric and
suprapubic regions. Subcutaneous tunnels are created using lighted retractors
to identify the external oblique fascia.
■ The superior and inferior tunnels are connected using cautery and retractors
while maintaining the subcutaneous attachments of the periumbilical region.
■ The linea semilunaris is identified by palpation, and the external oblique is
incised 2 cm lateral to this junction.
■ The aponeurotomy is extended several centimeters above the costal margin
and to the pubic tubercle.
■ The external oblique muscle is separated from the internal oblique muscle in
an avascular plane toward the posterior axillary line for additional
advancement to the midline.
■ Minimally Invasive Component Separation
■ The MICS technique is designed to avoid division of the musculocutaneous
perforators overlying the rectus sheath and thus maintain perfusion to the
paramedian skin.7–9
■ After lysis of adhesions and identification of the fascial edges, bilateral, 3-
cm wide, subcutaneous access tunnels are created over the anterior rectus
sheath from the midline to the linea semilunaris at the level of the costal

margin (TECH FIG 3A).
■ Through these access tunnels, the external oblique aponeurosis is vertically
incised 1.5 cm lateral to the linea semilunaris (TECH FIG 3B).
■ The tip of a metal Yankauer suction handle (Cardinal Health, Dublin, OH),
without suction, is inserted through the opening in the avascular plane
between the internal and external oblique aponeuroses, separating them at
their junction with the rectus sheath.
TECH FIG 3 • Minimally invasive component
separation (MICS). A. Access to the external oblique
aponeurosis is achieved through a small tunnel from
the midline to the supraumbilical external oblique

aponeurosis. Vertical tunnels are created dorsal and
ventral to the planned release site of the external
oblique aponeurosis. Periumbilical perforators and the
subcutaneous tissue overlying the anterior rectus
sheath are left undisturbed. B. The external oblique
aponeurosis is then divided from the pubis to above
the costal margin. The external oblique aponeurosis in
the upper abdomen is released with electrocautery as
the muscle is transected at, and superior to, the costal
margin. C. Scissors are generally used to release the
external oblique aponeurosis inferiorly. This MICS
approach preserves the attachments of the
subcutaneous tissue (including myocutaneous
perforators) to the anterior rectus sheath throughout
its course.
■ The suction tip is advanced inferiorly to the pubis and superiorly to above
the costal margin.
■ Next, lateral dissection between the internal and external oblique muscles is
performed to the midaxillary line (TECH FIG 3C).
■ Minimal subcutaneous skin flaps are then elevated over the anterior rectus
sheath circumferentially to the medial row of rectus abdominis perforator
vessels, and a retrorectus or preperitoneal mesh inlay is generally used.
■ If a preperitoneal inset is used, the preperitoneal fat is dissected from the
posterior sheath circumferentially to allow the mesh to be inlaid directly
against the posterior sheath or rectus abdominis muscle (below the arcuate
line).
■ Mesh is inserted to the semilunar line with no. 1 polypropylene sutures via
the horizontal access tunnels and the cranial and caudal aspect of the defect.
■ Next, the myofascial edges are advanced and reapproximated over the mesh
with sutures placed through the myofascia and mesh.
■ Interrupted resorbable 3-0 sutures are placed to affix the posterior sheath to
the mesh, thereby obliterating dead space and reducing the potential for fluid
collection.

■ Closed suction drainage catheters are placed in each component separation
donor-site area, in the space between the rectus complex closure and mesh,
and in the subcutaneous space.
■ The remaining undermined skin flaps are sutured to the myofascia with
vertical rows of interrupted resorbable 3-0 quilting sutures to reduce dead
space and potential shear between the subcutaneous tissue and myofascia.
■ Posterior Component Separation
■ A posterior component separation is based on the retromuscular Rives-
Stoppa approach to ventral hernia repair.
■ The posterior component separation focuses on transversus abdominis
aponeurosis release.
■ By incising this myofascial aponeurosis, the surgeon exposes the
preperitoneal space. This provides substantial advancement of both the
posterior fascial flap and the anterior myofascial compartment.
■ The initial release is completed by incising the posterior rectus sheath
approximately 1 cm lateral to the linea alba, and the posterior rectus sheath is
separated from the overlying rectus muscle (TECH FIG 4A).
■ The transversus abdominis muscle is incised just medial to the intercostal
nerves, and the underlying transversalis fascia and peritoneum are identified
(TECH FIG 4B). This myofascial release is extended the entire length of the
posterior rectus sheath.
■ The potential space between the transversus abdominis muscle and the
peritoneum is developed as far laterally as necessary, even to the psoas
muscle if needed. This plane can be extended superiorly to the costal margin,
retrosternally above the xiphoid, and inferiorly into the space of Retzius.
■ The posterior sheath is then closed, to completely exclude any mesh from
the viscera. An adequately sized piece of mesh is then secured, similar to a
standard retromuscular repair but with greater overlap.

TECH FIG 4 • Posterior component separation. A. The
initial release is completed by incising the posterior
rectus sheath approximately 1 cm lateral to the linea
alba, and the posterior rectus sheath is separated
from the overlying rectus abdominis muscle.
Dissection is carried to the lateral border of the rectus
muscle, and the perforating intercostal nerves are
identified, marking the linea semilunaris. B. Next, the
transversus abdominis muscle is incised just medial to
the intercostal nerves, and the underlying
transversalis fascia and peritoneum are identified.
This myofascial release is extended the entire length
of the posterior rectus sheath. The potential space
between the transversus abdominis muscle and the
peritoneum is developed as far laterally as necessary.
PEARLS AND PITFALLS
Abdominal
compartment
syndrome
■ Although every attempt to re-establish the midline is advisable, not
all patients can tolerate the intraperitoneal compression required
(which can result in intraperitoneal hypertension, pulmonary

compromise, or abdominal compartment syndrome).
Seroma
formation
■ Adequate drainage of the skin flaps should be performed with
liberal use of drains and quilting sutures. Resection of a previous
hernia sac is important to prevent seroma formation.
Hernia
recurrence
■ All means necessary should be employed to avoid a bridged repair
as primary fascial coaptation is essential to minimize hernia
recurrence.
Mesh
explantation
■ Tissue-based bioprosthetic mesh has gained popularity for its lower
rates of mesh infection, fistula formation, and mesh explantation
than the rates reported with synthetic mesh.
Skin
coverage
deficiency
■ Pedicled muscle flaps and free flaps are important to assist in soft
tissue coverage for large abdominal wall defects.
POSTOPERATIVE CARE
■ In general, abdominal wall reconstruction patients have prolonged
postoperative healing periods due to the dynamic function and mobility of the
abdominal musculature.
■ Perioperative management of high-risk patients should include appropriate
deep venous thrombosis (DVT) chemoprophylaxis according to the Caprini
risk score.
■ Sequential compression devices and early ambulation should be utilized with
low molecular weight fractionated heparins administered postoperatively.
■ Perioperative antibiotics are indicated, and cases with violation of the
gastrointestinal tract should be offered broader coverage for anaerobic as well
as Gram-negative bacteria.
■ For ventral hernia, closed suction drains are used liberally and are kept in
place on average 1 to 2 weeks until less than 30 cc/day.
■ Abdominal wall reconstruction patients should refrain from strenuous
activities and exercises that isolate the abdominal core for at least 6 to 12
weeks.
■ Patients may gain comfort from the use of an abdominal binder for 3 months
and then with any expected heavy physical activity thereafter.
■ Routine follow-up includes a physical examination in an outpatient clinic,
often performed weekly for 1 month after discharge, then every 3 months for 1
year, and then annually thereafter.

OUTCOMES
■ Estimated incidences of hernia recurrence have a wide range from 2% to 54%,
depending on the type of repair (mesh 2% to 36% vs suture repair alone 25% to
54%), patient comorbidities, and surgical technique10 (FIGS 1 to 3).
■ The number of prior attempts of hernia repair is predictive of the relative risk
of recurrence. In a study of approximately 10 000 patients, 5-year reoperative
rate was 23.8% after a primary repair, 35.3% following a secondary repair, and
38.7% after a tertiary repair.
■ There are few comparative data to suggest the superiority of one myofascial
advancement approach over another, and likely, each has a role in abdominal
wall reconstruction. Open component separation often allows tension-free
closure of large defects, and recurrence rates as low as 20% have been reported
with the use of open component separation and mesh reinforcement in large
hernias.
FIG 1 • Abdominal wall reconstruction. A. A 67-year-old