Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 3361–3370

Components separation technique of the

abdominal wall: Which muscle release
produces the greatest reduction in tension
on the mideline?
Leandro Dario Faustino a, Lydia Masako Ferreira a,
Oscar M. Ramirez b, Fábio Xerfan Nahas a,∗
a
Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP,
Brazil
b
Division of Plastic Surgery, Cleveland Clinic, Fort Lauderdale, FL, United States

Received 8 October 2020; accepted 24 May 2021

KEYWORDS Summary Background: The components separation technique (CS) is used for the reconstruc-
Reconstructive surgical tion of complex abdominal wall defects. Release and undermining of the rectus abdominis
procedures; muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline,
Abdominal wall; reducing recurrence of ventral hernia, but causes major changes in the physiology of abdom-
Ventral hernia; inal wall. The purpose of the study was to determine which muscle release and undermining
Rectus abdominis; produces the lowest tension on the midline.
Abdominal oblique Methods: Twenty fresh cadavers were dissected and the anterior and posterior layers of the
muscles rectus sheath were isolated in the midline. The forces necessary to advance the layers of the
rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above
and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after
release and undermining of the right RAM and left EOM; and after release and undermining
of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for
the different muscles involved, layers of the rectus sheath, measurement points, and stages of
separation.

The study was performed at the Division of Plastic Surgery of the Federal University of São Paulo, São Paulo, Brazil. Presentation in
meetings: None
∗ Corresponding author at: Rua Botucatu, 740, 2o. andar, Vila Clementino, CEP 04023-062

E-mail address: fabionahas@outlook.com (F.X. Nahas).

https://doi.org/10.1016/j.bjps.2021.05.015
1748-6815/© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
 L.D. Faustino, L.M. Ferreira, O.M. Ramirez et al.

Results: Tension on the abdominal midline after the release and undermining of both the RAM
and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM
alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05).
Conclusion: Release and undermining of the EOM by CS led to lower tension on the abdominal
midline compared to that associated with the release of the RAM alone.
© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.

Introduction Patients and Methods

The components separation technique (CS), introduced by
Ramirez et al.1 in 1990, consists of separating the rectus
abdominis muscle (RAM) from its posterior sheath, starting
from the xiphoid process and extending to the arcuate line,
and at the same surgical procedure, releasing the external
oblique aponeurosis, separating the external oblique mus-
cle (EOM) muscle from the internal oblique muscle (IOM).
Once the RAM and EOM are mobilized, a musculoaponeu-
rotic flap is created that can be medially transposed, yield-
ing up to 10 cm of bilateral muscle advancement. Thus, CS
allows the closure of complex abdominal wall defects up to
20 cm in width2 with a significant decrease in medial ten-
sion in both the anterior and posterior layers of the rectus
sheath.3 Recurrence rates of ventral hernia ranging from
62% (primary repair) to 32% (mesh repair)4 have been re-
duced to an average of 5% in a series of patients by using
CS.5
However, some studies have revealed that CS may be as-
sociated with high complication rates if performed as orig-
inally described, with the separation of the RAM and EOM
combined with dissection of a large amount of skin and sub-
cutaneous fat, and failing to preserve the perforating ves-
sels. Surgical wound infections have been reported in 8% to
40% of cases; suture dehiscence, in 8% to 43%; skin necrosis,
in 6% to 20%; seroma formation and hematomas, in 7% to
9%; and pulmonary complications, in 7% of cases.6-8 Several
CS variations have been described to reduce complication
rates.5 , 9-12
In an article published in 2006, Ramirez13 proposed some
modifications to the technique described by him and ac-
knowledged that a gradual and stepwise approach to muscle
release appears to be the best way to treat defects at differ-
ent levels of complexity and to minimize complications.13
The author postulated that the ideal procedure would be to
first mobilize the RAM to close minor defects, and when this
becomes insufficient, the EOM should be mobilized. How-
ever, no experimental study or clinical trial has satisfacto-
rily demonstrated that this muscle release sequence is the
most effective. Thus, following the tendency towards a less
invasive CS, the question that remains is which muscle re-
lease and undermining will produce the lowest tension on
the abdominal midline.
The primary objective of this study was to identify which
muscle release and undermining using the CS technique is
associated with the lowest force necessary to advance the
rectus sheath to the abdominal midline. The secondary ob-
jectives were to evaluate the resulting reductions in tension
on the anterior and posterior layers of the rectus sheath and
at supraumbilical and infraumbilical levels.
This was a primary, interventional, experimental, cross-
sectional, analytical, self-controlled, non randomized,
open, single center study. The methodology described was
based on the Anatomical Quality Assurance (AQUA) check-
list: Guidelines for reporting original anatomical studies.14
The sample was obtained and studied at the Death Veri-
fication Service (SVOC; “Serviço de Verificação de Óbitos da
Capital” in Brazilian Portuguese) of the city of São Paulo.
The sample size was calculated based on previous studies
on the same line of research and a self-controlled design
was used for sufficient statistics, with each study partici-
pant serving as his or her own control to prevent bias when
comparing different participants.
Inclusion criteria were non fixed human cadavers of any
race or sex, age range from 20 to 70 years, and those ob-
tained within 24 h of death.
Exclusion criteria were death by trauma, violent death,
before abdominal surgery, presence of abdominal wall her-
nias, peritoneal adhesions, peritoneal diseases, and un-
known time of death.
Anatomical dissection
The cadaver was placed in the supine position. An incision
was made in the abdominal midline through the skin and
subcutaneous tissue extending to the aponeurosis, where
the linea alba was identified. The subcutaneous tissue was
bilaterally separated from the anterior layer of the RAM
and EOM sheaths, defining an area limited superiorly by the
costal margins, laterally by the anterior axillary lines, and
inferiorly by the inguinal ligament. A longitudinal incision
from the costal margins down to the arcuate line was made
in the anterior aponeurosis close to the linea alba to gain
access to the posterior rectus sheath.
The necessary force to advance the anterior and poste-
rior layers of the rectus sheath separately to the abdominal
midline were measured bilaterally at two levels located 3
cm above (supraumbilical level) and 2 cm below the umbili-
cus (infraumbilical level) and at 3 different stages: (stage 1)
before any muscle release; (stage 2) after release and un-
dermining of the right RAM and left EOM; and (stage 3) after
release and undermining of the left RAM and right EOM, so
that in this stage all muscles were released.
For tensile force measurements, 8 stitches of 2-0
polyglactin (Vicryl, Ethicon Inc., Somerville, NJ) were
placed at the medial edges of the RAM. Four symmetrical
stitches were made at the anterior rectus sheath, two at the
supraumbilical, and two at the infraumbilical level. In the

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 3361–3370

Figure 1 Separation of muscle components of the abdominal wall. Location of the 8 stitches for tensile force measurements at the
supraumbilical and infraumbilical levels. Measurement points: (1) right anterior superior point; (2), right posterior superior point;
(3), left anterior superior point; (4), left posterior superior point; (5), right anterior inferior point; (6), right posterior inferior point;
(7), left anterior inferior point; and (8), left posterior inferior point.

projection of the previously described stitches, four sym-
metrical stitches were made at the posterior rectus sheath,
two at the supraumbilical, and two at the infraumbilical
level, as given in Figure 1. The stitches were tied forming a
loop of 10 mm in diameter, so that a hook could be used to
pull the thread. The abdominal midline was marked with a
2-0 nylon thread (Ethilon, Ethicon Inc., Somerville, NJ) at-
tached from the xiphoid process to the pubis. The distance
from each stitch to the midline was recorded. The force ap-
plied on each stitch to advance the rectus sheath to the
midline was measured using a portable digital force gauge
(Dinamômetro Crown DAC, Técnica Industrial Oswaldo Fili-
zola Ltda, São Paulo, Brazil) combined with an appropriate
metal hook (Figure 2a).
At the end of each separation stage, the stitch at each
measurement point was pulled twice to the midline by the
hook attached to the force gauge and the average tensile
force was recorded for each point. The average of the two
measurements was used in each point as the value of trac-
tion. The traction coefficient (TC) was then calculated by
dividing the average tensile force for each measurement
point by the distance from the point to the midline.
In stage 1, traction measurements were performed be-
fore the separation of any of the muscular components of
the abdomen.
During stage 2, release and undermining of the right RAM
was carried out at the RAM group, whereas the left EOM was
released and undermined in the so-called EOM group. In the
right hemiabdomen (RAM group), the posterior layer of the
rectus sheath was separated (Figure 2b), whereas in the left
hemiabdomen (EOM group), the EOM was separated from its
adjacent muscle, the IOM (Figure 3a).
For the right hemiabdomen (RAM group), at stage 3, the
EOM was separated from its adjacent internal oblique mus-
cle (IOM), thus completing the CS procedure by first mobi-
lizing the RAM and then the EOM. For the left hemiabdomen
(EOM group), the posterior layer of the rectus sheath was
then separated, also completing the three stages of CS by
first mobilizing the EOM and then the RAM. The general ap-
pearance of the abdomen at the end of the CS procedure
(stage 3) in both the right and left hemiabdomen is exhib-
ited in Figure 3b.
The force applied on the 8 measurement points to ad-
vance the rectus sheath to the midline was measured at
the end of each stage and TC values were calculated and
recorded. Laparotomy was then performed through a mid-
line incision from the xiphoid process to the pubic symph-
ysis for inspection of the abdominal cavity. The abdominal
wall and viscera were examined for any pathological condi-
tion that could limit the mobilization of wall components or

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 L.D. Faustino, L.M. Ferreira, O.M. Ramirez et al.

Figure 2 Separation of muscle components of the abdominal wall. (a) Measurement of tensile force using a digital force gauge;
and (b) right hemiabdomen after release and undermining of the rectus abdominis muscle (RAM group, stage 2).

Figure 3 Separation of muscle components of the abdominal wall. (a) Left hemiabdomen after release and undermining of the
external oblique muscle (EOM group, stage 2); and (b) complete abdomen at the end of components separation (stage 3) in both
groups.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 3361–3370
Table 1 Sample characteristics (n = 19)
Characteristics
Time since death (hours)
Age (years)
Weight (kg)
Height (cm)
BMI (kg/cm2)
Xiphoid-pubis distance (cm)
Distance between ASICs (cm)
Waist circumference (cm)
Diastasis recti - supraumbilical level (cm)
Diastasis recti - infraumbilical level (cm)
SD, standard deviation; BMI, body mass index; ASICs, anterior superior iliac crests.
cause changes in intra-abdominal pressure. All dissections
and measurements were performed by the same surgeon.
Statistical analysis
Descriptive analyses were used to determine means and
standard deviations (SD) for anthropometric characteristics,
gender, and race of the study participants.
For each stage, comparisons among mean TC values were
made in four different experimental situations: 1) right
hemiabdomen (RAM group) versus (vs.) left hemiabdomen
(EOM group); 2) anterior vs. posterior layer of the rectus
sheath; 3) supraumbilical vs. infraumbilical level; and 4)
separation stage 1 vs. stage 2 vs. stage 3. Mean percent-
age reductions in TC values were also calculated for each
experimental situation and among separation stages.
Analysis of variance (ANOVA) with repeated measures
was performed with data from the experimental situations
1, 2, and 3. Paired Student’s t-test was conducted for com-
parisons among separation stages (experimental situation
4). All tests were carried out at a significance level α of
0.05 (p ≤ 0.05) with a confidence interval of 95%.
Statistical analysis was performed using the Statistical
Package for the Social Sciences (SPSS) version 20.0 (SPSS
Inc., Chicago, IL, USA), Minitab 16 (Minitab Inc., State Col-
lege, PA), and Excel software (Office 2010, Microsoft Corp.,
Redmond, WA).
Results
Thirteen cadavers were men, 13 were White, 5 were of
mixed race, and 2 were Black. A cadaver was excluded from
the study because of an intestinal tumor with multiple peri-
toneal adhesions that was diagnosed after laparotomy. The
characteristics of the sample are summarized in Table 1.
Significant reductions in mean TC values were observed
among the stages at all measurement points (Table 2).
Significant differences in mean TC values between the
RAM and EOM groups were also found in stages 2 and 3,
with the force necessary to advance the rectus sheath to
the midline being higher in the RAM group. In both groups,
the mean TC decreased after each stage of the CS procedure
(Figure 4).
3365
Mean Range SD
4 2-18 3.524
62 58-70 5.851
60 49-82 10.484
165 154-185 9.720
21.6 16.7-30.0 3.597
34 28-41 3.596
29 22-38 4.161
82 54-105 13.493
2.2 1.7-4.5 0.694
1.8 0.7-3.1 0.686
Significant reductions in TC of 35% and 42% were ob-
served from stage 1 to stage 2 in the RAM and EOM groups,
respectively (p <0.001), with the greatest reduction oc-
curring in the EOM group (Figure 5). When considering the
different muscle release sequences performed in the RAM
group (release of the RAM followed by the EOM) and EOM
group (release of the EOM followed by the RAM), no sig-
nificant difference in mean TC reduction was observed be-
tween groups from stage 1 to stage 3 (Figure 5).
Mean percent reductions in TC values from stage 1 to
stage 2 calculated for the anterior and posterior layers
of the rectus sheath in both groups are demonstrated in
Figure 6. Release of the EOM alone resulted in a greater
reduction in TC for the anterior layer of the rectus sheath
(percent reduction, 48%) compared to that associated with
the release of the RAM alone (percent reduction, 36%;
p = 0.007). No significant difference in mean TC reduction
was observed for the posterior layer of the rectus sheath
at the end of stage 2 (Figure 6). Mean percent reductions
in TC values of 66% and 54% were detected for the anterior
and posterior layer of the rectus sheath, respectively, from
stage 1 to stage 3.
Mean percent reductions from stage 1 to stage 2 in TC
values at the supraumbilical and infraumbilical levels were
greater in the EOM group compared to those in the RAM
group (p = 0.04), but no significant difference was found
within the groups (Figure 5). Percent reductions from stage
1 to stage 3 in TC values of up to 48% and 41% were de-
tected at the supraumbilical and infraumbilical levels, re-
spectively. (Figure 7)
Discussion
The technique used in this study employs a digital force
gauge for the measurements of forces that are necessary
to advance the layers of the rectus sheath to the midline.
It is broadly supported by cadaver15 , 16 and in vivo studies17
and has been applied to variations of CS, including poste-
rior approaches.18 , 19 The study sample was representative
of the local population, but the body mass index (BMI) was
lower than that of the samples from previous studies.18 , 20
Nahas et al.9 investigated the relationship between BMI and
abdominal wall compliance and found that changes in BMI
were not correlated to changes in tensile forces necessary
 L.D. Faustino, L.M. Ferreira, O.M. Ramirez et al.

Table 2 Mean TC values for each measurement point at all the separation stages (n = 19)
Point Separation stage Mobilized muscle Mean TC (kgf/cm) 95% CI SD p-value
1- RAS 1 None 1.0236 0.2814 0.6421 <0.001
2 RAM 0.6912 0.1859 0.4241
3 RAM + EOM 0.3539 0.1232 0.2812
2- RPS 1 None 1.1658 0.2734 0.6238 <0.001
2 RAM 0.7461 0.1953 0.4456
3 RAM + EOM 0.5512 0.1546 0.3527
3- LAS 1 None 0.8857 0.1822 0.4157 <0.001
2 EOM 0.4563 0.1584 0.3614
3 EOM + RAM 0.3236 0.1296 0.2957
4- LPS 1 None 1.0655 0.2541 0.5799 <0.001
2 EOM 0.6556 0.2089 0.4767
3 EOM + RAM 0.4748 0.1697 0.3873
5- RAI 1 None 1.3093 0.6164 1.4065 <0.001
2 RAM 0.8100 0.1665 0.3800
3 RAM + EOM 0.4626 0.1516 0.3460
6- RPI 1 None 1.3217 0.5168 1.1792 0.003
2 RAM 0.9143 0.2854 0.6511
3 RAM + EOM 0.6581 0.2040 0.4655
7- LAI 1 None 1.1104 0.3012 0.6873 <0.001
2 EOM 0.5853 0.1939 0.4425
3 EOM + RAM 0.3447 0.1503 0.3429
8- LPI 1 None 1.1142 0.2848 0.6498 <0.001
2 EOM 0.7343 0.2430 0.5545
3 EOM + RAM 0.4422 0.1863 0.4250
Paired Student’s t-test (significance, p < 0.05).
TC, tensile force coefficient; CI, confidence interval; SD, standard deviation; RAM, rectus abdominis muscle; EOM, external oblique muscle;
RAS, right anterior superior point; RPS, right posterior superior point; LAS, left anterior superior point; LPS, left posterior superior point;
RAI, right anterior inferior point; RPI, right posterior inferior point; LAI, left anterior inferior point; and LPI, left posterior inferior point.

Figure 4 Mean tensile force coefficient (TC) for both groups for the three separation stages.
∗
p = 0.005; ∗∗ p = 0.028.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 3361–3370

Figure 5 Mean percentage reduction in tensile force coefficient (TC) between stages for both groups. ∗ p <0.001; P1, stage 1; P2,
stage 2; P3, stage 3.

Figure 6 Mean percent reduction in tensile force coefficient (TC) from stage 1 to stage 2 for the anterior and posterior layers of
the rectus sheath in both groups. ∗ p = 0.007.

for the medial advancement of musculoaponeurotic com-
ponents of the abdominal wall. Similarly, Hope et al.20 ob-
served no correlation between BMI and width of the hernia
defect. Despite the low BMI of the study sample, it is be-
lieved that increases in BMI may have a low impact on the
medial tension of our sample.
Our results revealed that the classical CS, as initially
proposed by Ramirez et al.1 , reduced tension on the ab-
dominal midline by 56% on average, which is in agreement
with previous studies.3 , 9 Classical CS also resulted in reduc-
tions in TC of 66% and 54% for the anterior and posterior
layers of the rectus sheath, respectively, and reductions in
TC of up to 48% and 41% at supraumbilical and infraumbili-
cal levels, respectively, indicate greater reductions in ten-
sion on the anterior layer of the rectus sheath and at the
supraumbilical level. The undermining of subcutaneous tis-
sue probably decreases tension on the suture line. However,
an extensive undermining may damage perforating vessels,
reduce superficial blood flow, and result in complications,
such as necrosis and surgical site infection. Nahas et al.9
addressed this issue and suggested that the subcutaneous
undermining should be limited by the semilunar line – that

3367
 L.D. Faustino, L.M. Ferreira, O.M. Ramirez et al.
Figure 7 Mean percent reductions from stage 1 to stage 2 in tensile force coefficient (TC) at the supraumbilical and infraumbilical
levels in both groups. ∗ p = 0.04.
beyond the semilunar line does not decrease closing tension
in CS.
Ramirez13 reviewed the CS technique and proposed a
gradual approach, and selected the release of the RAM as
the first step considering a less disruptive approach of the
abdominal wall. In 2012, Ramirez21 proposed classifying CS
into four types: 1) separation of the subcutaneous tissue
and RAM; 2) separation of the subcutaneous tissue and RAM
combined with relaxing incisions in the EOM aponeurosis; 3)
same as category 2, but completing the release and under-
mining of the EOM (classical CS); and 4) combining classical
CS with mesh. He also recommended that the release of the
RAM should precede the release of the EOM. However, as
demonstrated in our study, the tension on the midline was
reduced by 35% after the release of the RAM alone and 42%
after the release of the EOM alone, suggesting that a more
efficient approach should start with the undermining of the
EOM. The RAM should be first approached only in the im-
possibility of EOM release or when its release proved to be
insufficient to close the defect. The selective separation of
muscle components proposed here may optimize CS and re-
duce complication rates, endorsing a new paradigm for the
reconstruction of complex abdominal wall defects.16 , 22
A human cadaver model was used as in the original
CS study.1 Other cadaver studies have also proposed mod-
els15 , 23 , 24 and innovations in CS.9 , 10 , 25 , 26 Molecular struc-
tures and histochemical properties of muscle fibers are re-
liably maintained in fresh cadavers27 , the enzymatic activ-
ity of muscle cells remains preserved and postmortem ar-
tifacts are absent or minimal within 24 h of death.28 The
effects of anesthesia on the muscle response of living pa-
tients should also be considered. Tensile strength in pa-
tients undergoing anesthesia with neuromuscular blockers
may vary among patients and over the intraoperative pe-
riod, as the metabolism of the living patient changes the
3368
concentration of anesthetic agents over time. Both in vivo
studies with patients receiving neuromuscular blockade and
experimental studies may exhibit changes in muscle com-
pliance and intrinsic tension. Hence, this study presented a
self-controlled technique, in which each participant serves
as their own control in the different stages of dissection and
focused on the percentage reduction in medial tension and
less on the absolute values of TC. The values of percent-
age reduction in medial tension obtained after the release
of the EOM indicate that the selective separation of muscle
components may be worthwhile to consider in future in vivo
studies.
Shestak et al.2 are among the pioneers in the clinical use
of CS and reported that after the separation of the EOM,
the rectus sheath can be advanced to the midline up to 16
cm. Additional advancement of 2 cm can be obtained by
releasing the RAM from its posterior sheath. In the present
study, the release of the RAM alone resulted in higher ten-
sile forces and smaller advances of the rectus sheath to the
midline. Interestingly, the release of the EOM reduced the
tension on the anterior rectus sheath by 48% and only by 33%
on the posterior rectus sheath, which may be explained by
the fact that the anterior rectus sheath is mostly formed by
the EOM aponeurosis. Further studies are necessary to in-
vestigate the resulting medial tension after the release of
the EOM and RAM sheaths in posterior CS approaches.
After the pioneering studies, several other authors have
published their findings and modifications, and new exper-
imental models have emerged. Surprisingly, the fundamen-
tal question of this study (muscle release that produces the
lowest tension on the midline) has not yet been answered.
To answer this question, it was necessary to compare the
tension on the midline in different moments: before any
separation procedure, after the release of the RAM alone,
and after the release of the EOM alone. This enabled to
 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 3361–3370
quantify the individual contribution of each muscle group
to the reduction of tension on the midline.
The present study adds relevant information regarding
abdominal wall closure. As a cadaver study, conclusions
with regard to postoperative complications and clinical out-
comes could not be reached, and this may be considered
as a limitation. In open surgical approaches, access to the
EOM requires extensive undermining, which may result in
increased complications compared to the RAM approach. In
contrast, endoscopic and robotic approaches to the EOM do
not present this problem. The proposed technique for mea-
suring tensions in the different stages of dissection can be
used for comparisons between the different release proce-
dures associated with modifications of the classic CS, includ-
ing the posterior release of the transversus abdominis and
rectus abdominis muscles. Thus, our results provide new in-
sight for future cadaver and in vivo studies.
Conclusion
Release and undermining of the external oblique muscle
alone by components separation technique resulted in a
greater reduction in tension on the abdominal midline com-
pared to the release of the rectus abdominis muscle alone.
Tension reduction was also greater in the anterior layer than
in the posterior layer of the rectus sheath after the release
of both muscles. No significant difference in tension reduc-
tion was found between the supraumbilical and infraumbil-
ical levels within muscle groups.
Conflict of interest
None.
Funding
No funding was received for this study.
Ethics
This study was approved by the Research Ethics Commit-
tee of the Universidade Federal de São Paulo (Brazil). All
procedures involving human participants were performed in
accordance with the ethical standards of the institutional
or national research committee and with the World Medical
Association Declaration of Helsinki (June 1964) and subse-
quent amendments.
Consent for publication: The study was conducted after ob-
taining written informed consent from family members of
the deceased for the use of clinical data and photographic
records for scientific purposes and publication.
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