- Email: [email protected]
Inception and Evolution of the Components Separation Technique: Personal Recollections
241
CLINICS IN PLASTIC SURGERY Clin Plastic Surg 33 (2006) 241–246
Inception and Evolution of the Components Separation Technique: Personal Recollections Oscar M. Ramirez, &
a,b,c
MD
Acknowledgments
During my early years of general surgical training (around 1979), I began investigating the feasibility of transferring muscle units to cover defects in the body in a sliding fashion. Joseph Orlando, an attending plastic surgeon at The Franklin Square Medical Center, was very receptive to this new concept of muscle transfer, and he was instrumental in applying this principle to clinical practice, as I did not have plastic surgery patients of my own. The first unit moved using this principle was the gluteus maximus flap [1]. The basic premise of this technique was to mobilize the muscle, keeping either its origin or insertion intact, and to slide the nonattached segment of the muscle toward the defect requiring coverage, taking advantage of the muscle’s intrinsic elasticity. The motor innervations and the main vascular pedicles were kept intact. This allowed moving and reattaching one end of the muscle without sacrificing function, critical in ambulatory patients. The work on the gluteus maximus muscle generated many variations of flaps, useful to cover numerous wounds around the lower trunk and pelvis [2–4]. In July 1882, I moved to the University of Pittsburgh for plastic surgical training. There I met another fan of the gluteus maximus flap: Dennis Hurwitz. Together, we continued the anatomi-
&
References
cal investigations of this muscle, and we refined and expanded the use of this muscle. The success obtained with this muscle stimulated me to continue my anatomy laboratory investigation searching for other muscle units that could be amenable to the sliding technique with complete preservation of muscle function [5,6]. This laboratory investigation continued in 1984 when I moved to Baltimore to initiate my private practice with Joseph Orlando and Lee Dellon. Simultaneously, Dr. John Hoopes invited me to participate in the academic affairs of the Johns Hopkins University, initially as a clinical instructor and subsequently as a clinical assistant professor of plastic surgery. By mid-August of 1985, the chief resident in plastic surgery, Ernie Ruas, called me to consult on a difficult abdominal wall defect. This was in a 39-year-old African American man who in the past had sustained a retroperitoneal duodenal rupture in an altercation. He had developed gross peritonitis requiring a prolonged abdominal procedure with massive bowel edema, making closure of the abdominal wall impossible. Sepsis with retroperitoneal abscess required flank incisions for drainage. Furthermore, he required an interpositional inferiorly based right rectus abdominus muscle flap to cover an exposed gastro–duodenal anastomosis
a
Johns Hopkins University School of Medicine, Baltimore, MD, USA The University of Maryland School of Medicine, Baltimore, MD, USA c Esthetique Internationale Plastic Surgery Center, 2219 York Road, Suite 100, Timonium, MD 21093, USA E-mail address: [email protected] b
0094-1298/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2005.12.011
242
Ramirez
and avoid a fistula formation. The abdomen was closed with a Marlex (Ethicon, San Angelo, Texas) mesh and a split-thickness skin graft over the granulating bed. Several months later, he developed ulceration and breakdown of the skin graft over the mesh, which progressed to infection of the entire Marlex mesh. On Aug. 26, 1985, the patient was taken to the operating room, where he had a complete removal of the Marlex mesh. The resultant
defect measured 18 cm in width by 35 cm in height. The abdomen was closed with the components separation technique. The epigastric region was closed by approximation of the left rectus with its attached internal oblique transversus abdominus muscles to the right internal oblique transverse muscle flaps. The left rectus was separated from its attachment to the lower ribcage, creating basically a recto–pectoralis flap to facilitate closure. The mid-
Fig. 1. (A) Preoperative artistic rendering of a small defect on the midline of the abdomen. This can be located either in the upper, middle, or lower third of the abdomen. (B) Postoperative representation of the closure without relaxing incisions. (C ) Cross-sectional view of the small abdominal defect. (D) The recti muscles are being separated from the posterior rectus sheath. These are approached from their medial border exclusively. A lateral approach will disrupt the normal anatomical innervation of these muscles. Bilateral advancement is more effective than a more extensive unilateral advancement. (E ) Schematic view of the final repair without relaxing incisions. Abbreviations: EO, external oblique; IO, internal oblique; TA, transversus abdominus.
Components Separation
dle and lower abdominal wall defect was closed by reapproximating the left rectus internal oblique transversus abdominus muscle to the remaining portion of the right rectus internal oblique transversus abdominus muscle. The external oblique muscles were advanced independently as well as the overlying skin flaps. He was seen last 4 months postoperatively with a well-healed abdominal wound. This case and others were published in September 1990 [7].
During one of my early presentations on this technique, I asked John McGraw what would be an appropriate name for the method. He suggested what now has become a household name in abdominal wall reconstruction: components separation. In 2000, in conjunction with another chief resident of plastic surgery at the Johns Hopkins University, John Girotto, we wrote a review article, summarizing many years of experience. This was published as a chapter in the book of Abdominal
Fig. 2. (A) Preoperative rendition of a moderate-sized defect on the midline of the abdomen. (B) Postoperative view of the reconstruction with small relaxing incisions. The resultant secondary defect usually is patched with Vicryl mesh. (C ) Cross-sectional view of a moderately sized defect. (D) Separation of some of the components of the abdominal wall musculature. The rectus muscle is separated from the posterior rectus sheath. This is done as far as laterally possible but respecting the segmental neurovascular pedicles to the muscle. The relaxing incisions are interrupted ones but allow the composite rectus internal oblique/transversus abdominus to be advanced to the midline. (E ) Secure closure of the recti muscles in the midline. The relaxing incisions defects are closed with pieces of Vicryl mesh. If the secondary weakness is self-evident, a Marlex mesh should be applied or the external oblique readvanced independently. Abbreviations: EO, external oblique; IO, internal oblique; TA, transverse abdominus.
243
244
Ramirez
Wall Hernias: Principles and Management, edited by Robert Bendavid and colleagues, published in 2001 [8]. Throughout the years, I have seen a plethora of publications on components separation. I have made some modifications such as in closing ab-
dominal wall defects following pedicle TRAMF breast reconstruction. This is called the rectus sharing technique [9,10]. A video of this work is available at the videotape library of the American Society of Plastic Surgeons. The latest application of the components separation principle is the ante-
Fig. 3. (A) Large preoperative defect that usually extends from xyphoid to pubis and horizontally measures at least two thirds of the vertical length. (B) Artistic demonstration of the closure. The large relaxing incision is closed partially by readvancement of the external oblique muscle and the application of Marlex mesh. (C ) Cross-sectional view of the large defect. The muscles usually are scarred down, retracted, and contracted. (D) A more aggressive separation of the components of the abdominal wall musculature. The rectus, as usual, is separated from the posterior rectus sheath. The anterior rectus sheath may have moderate to large amounts of scar tissue. This can be released with scoring incisions to allow a horizontal stretching of the rectus muscle. The external oblique muscle is released at the level of the fascial component of the muscle. Dissection laterally in the external oblique–internal oblique interface is done to allow easier advancement of the composite rectus internal oblique/transversus abdominus muscles. (E ) Upon closure of the recti in the midline, the internal oblique/transversus abdominus muscles tend to bulge. If readvancement of the external oblique does not allow closure of this secondary defect, I strongly suggest gapping the defect with a permanent type of material such as Marlex mesh.
Components Separation
rior rectus sheath partitioning that I use in my abdominoplasty operation [11]. A full article dealing with the technique by Kenneth Shestak is elsewhere in this issue. I will only add the five principles that explain the success and effectiveness of the operation:
enough, because the collagen deposition after its absorption will provide a structural support similar to a fascial layer. Large relaxing incisions, however, will require a more permanent material [Fig. 3]. Lastly, a good preoperative preparation helps to facilitate surgery and this includes:
• •
•
• •
•
Principle 1. Translation of the muscular layer of the abdominal wall to enlarge its tissue surface Principle 2. Separation of muscle layers that allows maximal individual expansion of each muscle unit Principle 3. This expansion is facilitated by its des-encasement of some muscle unit from its fascial sheath envelope that restricts its horizontal mobilization. Principle 4. The abdominal wall musculature in around 70% of its surface is covering hollow viscous. This can be more easily compressed than solid structures, particularly after a good bowel preparation. Likewise, false and floating ribs can be pushed to some extent by the action of the muscle pull. Principle 5. Provided that all the muscle elements (although retracted or scarred down) are in place, bilateral mobilization works more effectively than unilateral advancements. This also will equilibrate the forces of the entire abdominal wall and centralize the midline.
I will add some technical points of importance. A graduated approach of mobilization should be followed [8]. Minor defects can be closed by only skin separation from the abdomen similar to an abdominoplasty procedure, and muscle approximation can be accomplished by mobilization of the medial borders of the recti muscle and elevation of this from the posterior rectus sheath only [Fig. 1]. Medium-sized defects might require significant lateral-to-medial traction of the external oblique/ internal oblique/transversus muscle complex, which will require recti muscle separation from its posterior sheath up to near the junction to the linea semicircularis, and in some cases minor interrupted releasing incisions of the fascia of the external oblique muscle [Fig. 2]. Large defects will require varying degrees of longer external oblique muscle fascia release. In both cases of fascial release, particularly in the lower quadrants, a Vicryl or Prolene mesh can be applied to restore the continuity of the muscle layer and avoid areas of muscle wall weakness or potential hernias. Because this mesh will be covered internally by a muscle and externally by a thick panniculus, there is no risk of exposure to bowels or extrusion to the skin surface. In repairing small areas of relaxing incisions, the Vicryl mesh may be
• •
Use of an abdominal binder to gradually compress the abdominal cavity. Additionally, the patient should perform chest-breathing exercises. Do this for at least 4 to 6 weeks. If any possibility of loss of domain is anticipated, get a pulmonary consultation and have him/her do spirometric evaluations with the abdomen at maximal compression. Liquid diet for 2 or 3 days preoperatively and a good bowel preparation that includes antibiotics to diminish the formation of gas and stool allows easy closure, less tension on the diaphragm, and less tension on the vena cava. These two last effects will decrease the risk of pulmonary complications and venous thrombosis respectively. They also will diminish postoperative pain, discomfort, and the risk of ileus paralyticus.
Acknowledgments My thanks to Dr. Mimis Cohen and the countless surgeons who have used and published their experiences on the components separation method for abdominal wall reconstruction.
References [1] Ramirez OM, Orlando J, Hurwitz D. The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg 1984;74:68–75. [2] Ramirez OM, Hurwitz DJ, Futrell JW. The expansive gluteus maximus flap. Plast Reconstr Surg 1984;74:757–68. [3] Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus flap: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg 1987;40:1–10. [4] Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores. Ann Plast Surg 1987; 18:295–302. [5] Ramirez OM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg 1987;80:799–806. [6] Ramirez OM, Granick M. The sliding myocutaneous flap method: a method of wound repair with preservation of function. In: Hinderer U, editor. Transactions of the 10th Congress of the International Confederation of the IPRAS, volume II. Amsterdam: Elsevier; 1992.
245
246
Ramirez
[7] Ramirez OM, Ruas E, Dellon A. Component separation method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–26. [8] Ramirez OM, Girotto JA. Closure of chronic abdominal wall defects: the components separation technique. In: Bendavid R, Abrahamson J, Arregui M, et al, editors. Abdominal wall hernias. Principles and management. New York: Springer Verlag, New York; 2001. p. 487–96.
[9] Ramirez OM. Rectus sharing technique for repair of abdominal wall following rectus abdominus breast reconstruction. Plastic Surgery Forum 1990;13:167–9. [10] Ramirez OM. Discussion: abdominal wall closure after selective aponeurotic incision and undermining. Ann Plast Surg 1998;41:615–7. [11] Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000;105:425–35.
CLINICS IN PLASTIC SURGERY Clin Plastic Surg 33 (2006) 241–246
Inception and Evolution of the Components Separation Technique: Personal Recollections Oscar M. Ramirez, &
a,b,c
MD
Acknowledgments
During my early years of general surgical training (around 1979), I began investigating the feasibility of transferring muscle units to cover defects in the body in a sliding fashion. Joseph Orlando, an attending plastic surgeon at The Franklin Square Medical Center, was very receptive to this new concept of muscle transfer, and he was instrumental in applying this principle to clinical practice, as I did not have plastic surgery patients of my own. The first unit moved using this principle was the gluteus maximus flap [1]. The basic premise of this technique was to mobilize the muscle, keeping either its origin or insertion intact, and to slide the nonattached segment of the muscle toward the defect requiring coverage, taking advantage of the muscle’s intrinsic elasticity. The motor innervations and the main vascular pedicles were kept intact. This allowed moving and reattaching one end of the muscle without sacrificing function, critical in ambulatory patients. The work on the gluteus maximus muscle generated many variations of flaps, useful to cover numerous wounds around the lower trunk and pelvis [2–4]. In July 1882, I moved to the University of Pittsburgh for plastic surgical training. There I met another fan of the gluteus maximus flap: Dennis Hurwitz. Together, we continued the anatomi-
&
References
cal investigations of this muscle, and we refined and expanded the use of this muscle. The success obtained with this muscle stimulated me to continue my anatomy laboratory investigation searching for other muscle units that could be amenable to the sliding technique with complete preservation of muscle function [5,6]. This laboratory investigation continued in 1984 when I moved to Baltimore to initiate my private practice with Joseph Orlando and Lee Dellon. Simultaneously, Dr. John Hoopes invited me to participate in the academic affairs of the Johns Hopkins University, initially as a clinical instructor and subsequently as a clinical assistant professor of plastic surgery. By mid-August of 1985, the chief resident in plastic surgery, Ernie Ruas, called me to consult on a difficult abdominal wall defect. This was in a 39-year-old African American man who in the past had sustained a retroperitoneal duodenal rupture in an altercation. He had developed gross peritonitis requiring a prolonged abdominal procedure with massive bowel edema, making closure of the abdominal wall impossible. Sepsis with retroperitoneal abscess required flank incisions for drainage. Furthermore, he required an interpositional inferiorly based right rectus abdominus muscle flap to cover an exposed gastro–duodenal anastomosis
a
Johns Hopkins University School of Medicine, Baltimore, MD, USA The University of Maryland School of Medicine, Baltimore, MD, USA c Esthetique Internationale Plastic Surgery Center, 2219 York Road, Suite 100, Timonium, MD 21093, USA E-mail address: [email protected] b
0094-1298/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2005.12.011
242
Ramirez
and avoid a fistula formation. The abdomen was closed with a Marlex (Ethicon, San Angelo, Texas) mesh and a split-thickness skin graft over the granulating bed. Several months later, he developed ulceration and breakdown of the skin graft over the mesh, which progressed to infection of the entire Marlex mesh. On Aug. 26, 1985, the patient was taken to the operating room, where he had a complete removal of the Marlex mesh. The resultant
defect measured 18 cm in width by 35 cm in height. The abdomen was closed with the components separation technique. The epigastric region was closed by approximation of the left rectus with its attached internal oblique transversus abdominus muscles to the right internal oblique transverse muscle flaps. The left rectus was separated from its attachment to the lower ribcage, creating basically a recto–pectoralis flap to facilitate closure. The mid-
Fig. 1. (A) Preoperative artistic rendering of a small defect on the midline of the abdomen. This can be located either in the upper, middle, or lower third of the abdomen. (B) Postoperative representation of the closure without relaxing incisions. (C ) Cross-sectional view of the small abdominal defect. (D) The recti muscles are being separated from the posterior rectus sheath. These are approached from their medial border exclusively. A lateral approach will disrupt the normal anatomical innervation of these muscles. Bilateral advancement is more effective than a more extensive unilateral advancement. (E ) Schematic view of the final repair without relaxing incisions. Abbreviations: EO, external oblique; IO, internal oblique; TA, transversus abdominus.
Components Separation
dle and lower abdominal wall defect was closed by reapproximating the left rectus internal oblique transversus abdominus muscle to the remaining portion of the right rectus internal oblique transversus abdominus muscle. The external oblique muscles were advanced independently as well as the overlying skin flaps. He was seen last 4 months postoperatively with a well-healed abdominal wound. This case and others were published in September 1990 [7].
During one of my early presentations on this technique, I asked John McGraw what would be an appropriate name for the method. He suggested what now has become a household name in abdominal wall reconstruction: components separation. In 2000, in conjunction with another chief resident of plastic surgery at the Johns Hopkins University, John Girotto, we wrote a review article, summarizing many years of experience. This was published as a chapter in the book of Abdominal
Fig. 2. (A) Preoperative rendition of a moderate-sized defect on the midline of the abdomen. (B) Postoperative view of the reconstruction with small relaxing incisions. The resultant secondary defect usually is patched with Vicryl mesh. (C ) Cross-sectional view of a moderately sized defect. (D) Separation of some of the components of the abdominal wall musculature. The rectus muscle is separated from the posterior rectus sheath. This is done as far as laterally possible but respecting the segmental neurovascular pedicles to the muscle. The relaxing incisions are interrupted ones but allow the composite rectus internal oblique/transversus abdominus to be advanced to the midline. (E ) Secure closure of the recti muscles in the midline. The relaxing incisions defects are closed with pieces of Vicryl mesh. If the secondary weakness is self-evident, a Marlex mesh should be applied or the external oblique readvanced independently. Abbreviations: EO, external oblique; IO, internal oblique; TA, transverse abdominus.
243
244
Ramirez
Wall Hernias: Principles and Management, edited by Robert Bendavid and colleagues, published in 2001 [8]. Throughout the years, I have seen a plethora of publications on components separation. I have made some modifications such as in closing ab-
dominal wall defects following pedicle TRAMF breast reconstruction. This is called the rectus sharing technique [9,10]. A video of this work is available at the videotape library of the American Society of Plastic Surgeons. The latest application of the components separation principle is the ante-
Fig. 3. (A) Large preoperative defect that usually extends from xyphoid to pubis and horizontally measures at least two thirds of the vertical length. (B) Artistic demonstration of the closure. The large relaxing incision is closed partially by readvancement of the external oblique muscle and the application of Marlex mesh. (C ) Cross-sectional view of the large defect. The muscles usually are scarred down, retracted, and contracted. (D) A more aggressive separation of the components of the abdominal wall musculature. The rectus, as usual, is separated from the posterior rectus sheath. The anterior rectus sheath may have moderate to large amounts of scar tissue. This can be released with scoring incisions to allow a horizontal stretching of the rectus muscle. The external oblique muscle is released at the level of the fascial component of the muscle. Dissection laterally in the external oblique–internal oblique interface is done to allow easier advancement of the composite rectus internal oblique/transversus abdominus muscles. (E ) Upon closure of the recti in the midline, the internal oblique/transversus abdominus muscles tend to bulge. If readvancement of the external oblique does not allow closure of this secondary defect, I strongly suggest gapping the defect with a permanent type of material such as Marlex mesh.
Components Separation
rior rectus sheath partitioning that I use in my abdominoplasty operation [11]. A full article dealing with the technique by Kenneth Shestak is elsewhere in this issue. I will only add the five principles that explain the success and effectiveness of the operation:
enough, because the collagen deposition after its absorption will provide a structural support similar to a fascial layer. Large relaxing incisions, however, will require a more permanent material [Fig. 3]. Lastly, a good preoperative preparation helps to facilitate surgery and this includes:
• •
•
• •
•
Principle 1. Translation of the muscular layer of the abdominal wall to enlarge its tissue surface Principle 2. Separation of muscle layers that allows maximal individual expansion of each muscle unit Principle 3. This expansion is facilitated by its des-encasement of some muscle unit from its fascial sheath envelope that restricts its horizontal mobilization. Principle 4. The abdominal wall musculature in around 70% of its surface is covering hollow viscous. This can be more easily compressed than solid structures, particularly after a good bowel preparation. Likewise, false and floating ribs can be pushed to some extent by the action of the muscle pull. Principle 5. Provided that all the muscle elements (although retracted or scarred down) are in place, bilateral mobilization works more effectively than unilateral advancements. This also will equilibrate the forces of the entire abdominal wall and centralize the midline.
I will add some technical points of importance. A graduated approach of mobilization should be followed [8]. Minor defects can be closed by only skin separation from the abdomen similar to an abdominoplasty procedure, and muscle approximation can be accomplished by mobilization of the medial borders of the recti muscle and elevation of this from the posterior rectus sheath only [Fig. 1]. Medium-sized defects might require significant lateral-to-medial traction of the external oblique/ internal oblique/transversus muscle complex, which will require recti muscle separation from its posterior sheath up to near the junction to the linea semicircularis, and in some cases minor interrupted releasing incisions of the fascia of the external oblique muscle [Fig. 2]. Large defects will require varying degrees of longer external oblique muscle fascia release. In both cases of fascial release, particularly in the lower quadrants, a Vicryl or Prolene mesh can be applied to restore the continuity of the muscle layer and avoid areas of muscle wall weakness or potential hernias. Because this mesh will be covered internally by a muscle and externally by a thick panniculus, there is no risk of exposure to bowels or extrusion to the skin surface. In repairing small areas of relaxing incisions, the Vicryl mesh may be
• •
Use of an abdominal binder to gradually compress the abdominal cavity. Additionally, the patient should perform chest-breathing exercises. Do this for at least 4 to 6 weeks. If any possibility of loss of domain is anticipated, get a pulmonary consultation and have him/her do spirometric evaluations with the abdomen at maximal compression. Liquid diet for 2 or 3 days preoperatively and a good bowel preparation that includes antibiotics to diminish the formation of gas and stool allows easy closure, less tension on the diaphragm, and less tension on the vena cava. These two last effects will decrease the risk of pulmonary complications and venous thrombosis respectively. They also will diminish postoperative pain, discomfort, and the risk of ileus paralyticus.
Acknowledgments My thanks to Dr. Mimis Cohen and the countless surgeons who have used and published their experiences on the components separation method for abdominal wall reconstruction.
References [1] Ramirez OM, Orlando J, Hurwitz D. The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg 1984;74:68–75. [2] Ramirez OM, Hurwitz DJ, Futrell JW. The expansive gluteus maximus flap. Plast Reconstr Surg 1984;74:757–68. [3] Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus flap: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg 1987;40:1–10. [4] Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores. Ann Plast Surg 1987; 18:295–302. [5] Ramirez OM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg 1987;80:799–806. [6] Ramirez OM, Granick M. The sliding myocutaneous flap method: a method of wound repair with preservation of function. In: Hinderer U, editor. Transactions of the 10th Congress of the International Confederation of the IPRAS, volume II. Amsterdam: Elsevier; 1992.
245
246
Ramirez
[7] Ramirez OM, Ruas E, Dellon A. Component separation method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–26. [8] Ramirez OM, Girotto JA. Closure of chronic abdominal wall defects: the components separation technique. In: Bendavid R, Abrahamson J, Arregui M, et al, editors. Abdominal wall hernias. Principles and management. New York: Springer Verlag, New York; 2001. p. 487–96.
[9] Ramirez OM. Rectus sharing technique for repair of abdominal wall following rectus abdominus breast reconstruction. Plastic Surgery Forum 1990;13:167–9. [10] Ramirez OM. Discussion: abdominal wall closure after selective aponeurotic incision and undermining. Ann Plast Surg 1998;41:615–7. [11] Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000;105:425–35.