Perforator-sparing anterior components separation (ACS) is an important abdominal wall reconstruction technique for surgeons to have in their armamentarium. This technique can be applied to obtain musculofascial midline reapproximation while maintaining maximal blood supply to the abdominal skin flaps, significantly lowering wound healing complications. Patient selection, education, optimization, and postoperative care are critical to success of any abdominal wall reconstruction. Utilizing a multi-disciplinary team allows for a comprehensive evaluation and prehabilitation protocol. Postoperative care should be data driven and strictly adhered to during the acute hospital stay and at home in order to minimize the rates of short- and long-term complications. The surgery outlined in this chapter is based on key anatomic principles, a foundation of prior ACS developments and a core set of surgical principles: (1) minimizing perforator disruption, (2) direct supported mesh reinforcement of primary fascial reapproximation, (3) no-touch mesh placement techniques, (4) transfascial suture mesh fixation, (5) dead space obliteration, and (6) aggressive resection of marginal soft tissue. As with any surgical technique, perforator-sparing ACS has its limitations and technical challenges which need to be fully understood and considered while planning and executing the abdominal wall reconstruction in order to maximize overall success.