Liposuction Treatment of a Subacute Morel-Lavallée Lesion: A Case Report

Introduction. A Morel-Lavallée lesion (MLL) is a rare and aesthetically concerning condition caused by a shearing force between subcutaneous fat and underlying fascia. Subsequent seroma formation occurs after the initial trauma of a crush injury, ligamentous sprain, or abdominal liposuction. Misdiagnosed lesions lead to inadequate treatment and are a source of chronic pain. Case Report. The case of a 33-year-old woman who presented with a large, painful subacute MLL of the left thigh after being run over by a truck 3 weeks prior is reported. Physical examination revealed severe hyperesthesia and fluctuance of the left thigh. After confirmation of the fluid collection by X-ray and computed tomography angiogram, the authors performed liposuction of the cavity and seroma wall to evacuate and treat the lesion. Postoperative care consisted of a temporary drain, thigh compression, and oral antibiotics. Immediate reduction in size was appreciated intraoperatively with no reaccumulation of fluid at postoperative visits on week 1 and week 6. The pathology report confirmed seroma etiology, and all cultures of the fluid returned negative. At the end of her postoperative course, the patient reported a reduction in pain and no recurrence of her symptoms. Conclusions. This case of MLL was diagnosed early and successfully treated with liposuction, resulting in an acceptable cosmetic outcome. It is the authors’ hope that this case report will lead to earlier diagnosis and proper treatment of MLLs.

A Morel-Lavallée lesion (MLL), first described by Maurice Morel-Lavallée in 1853, is a rare internal degloving injury as a result of traumatic shearing forces between the subcutaneous fat and underlying deep fascia.^1,2 These lesions are often seen after low-velocity crush injuries or high-velocity blunt force trauma.² Consequently, the disruption in blood supply and lymphatics in the fat allow a dead space seroma to develop.² If misdiagnosed, they become a source of chronic pain for patients. 

The authors describe the case of a 33-year-old woman, who after being run over by a truck, presented with a subacute MLL that was successfully treated with liposuction. The authors present the case of an early diagnosis of a subacute MLL and definitive treatment with liposuction; it is their hope this case may provide insight into an area lacking in the literature.

A 33-year-old woman with a history of poor wound healing presented to the emergency department (ED) at the University of Texas Medical Branch in Galveston with worsening left thigh swelling, pain, and cellulitis after being run over by a truck 3 weeks prior. At the time of initial injury, she was evaluated at an outside hospital and discharged with direction to follow up with her primary care physician. Her leg swelling and pain continued to progress, prompting her visit to the ED at the authors' hospital. On physical examination, she exhibited severe hyperesthesia of the left thigh and palpable fluid collection. A femur X-ray did not show any bony abnormality. A computed tomography (CT) angiogram of her lower extremity demonstrated a large isodense fluid collection in the superficial soft tissue and fat of the left thigh (21.4 cm x 13.7 cm x 3.8 cm) and 2 smaller collections in the superficial soft tissues of the anterior medial left shin (5.6 cm x 0.8 cm) and within the fascia of the anterior thigh compartment muscles (8.3 cm) (Figure 1). The fluid collections were presumed to be subacute MLLs related to her recent trauma. Bedside decompression with a 14-gauge needle was performed and 800 mL of clear amber fluid was evacuated. Compression was applied and cultures were obtained, which were negative for organisms. There were no local or systemic signs of infection. The seroma reaccumulated over the next day, prompting the need for definitive surgical intervention. Figure 2 shows the left thigh preoperatively. 

Surgical technique
A number 15 blade was used to make an incision measuring 1 cm over the lower lateral left thigh slightly superior to the knee. A long tonsil was used to enter the seroma cavity and, immediately, clear amber-colored fluid poured out. A suction tip was then inserted, and the cavity was decompressed of fluid. Tumescent solution of 1 L of normal saline mixed with 1 mg of epinephrine was injected into the subcutaneous tissues of the left thigh, fat posterior to the cavity, and cavity itself. A total of 1 L of tumescent solution was used. The cavity was measured and found to be 24 cm x 15 cm in size. A 3-mm liposuction cannula was inserted into the cavity and used to disrupt the capsule membrane and necrotic fat surrounding the cavity. Pieces of the capsule were noted in the liposuction cannister in addition to fat. Immediate reduction in the size of the lesion was appreciated intraoperatively (Figure 3). After evacuation of the cavity, a temporary drain was placed and the left thigh was dressed with a soft roll, Kerlix (Cardinal Health), and ACE Bandage (3M) under moderate compression from the foot to upper thigh. 

Postoperative course
The patient tolerated the procedure well and was discharged on postoperative day 3 in good condition with an oral course of minocycline 100 mg twice daily for 7 days. The patient was seen at 1-week follow-up, and then at 6 weeks. At the 6-week follow-up, she was doing well and showed no reaccumulation of fluid (Figure 4). At the end of her postoperative course, she had a reduction in pain and no recurrence of symptoms. 

Ethics
Written informed consent was obtained from the patient included in this article. This study was exempt from Institutional Review Board approval. 

This case demonstrates early identification of a subacute MLL and successful treatment with liposuction. Obtaining an accurate history is key in recognizing MLL. Providers should consider MLL in the incidence of crush injuries, blunt force trauma, polytrauma, and especially in those with pelvic injuries.² However, it is often missed during the acute period, as seen with the present case, due to the presence of more complex, distracting injuries requiring more immediate attention.³

Another key element in early detection is the presence of palpable fluctuance.² Several studies^1,2,4 have reported its presence as a reliable indicator of a MLL. Palpable fluctuance, in combination with other symptoms (eg, an enlarging and tender lesion, hyperesthesia, and increased skin mobility), were evident in this patient. Similar to the present findings, other studies^2,4 reported that the presence of these symptoms should raise concerns for a MLL. Suspected MLLs should be further evaluated using magnetic resonance imaging (the gold standard for identification of these soft tissue lesions).^1,2

Inadequate treatment of these lesions often results in poor cosmetic appearance and recurrence. Although there lacks a widely accepted treatment algorithm, multiple therapies have been described in the literature. The most commonly reported conservative therapy includes aspiration, elastic compression, bandaging, and sclerotherapy.^1,2,4-6 Further invasive therapy consists of complete excision and percutaneous drainage followed by compression.⁵ 

Currently, open debridement and drainage are the most reported treatments for larger MLLs or MLLs with evidence of necrosis.^2,7 Nickerson et al⁸ compared the rate of recurrence with the use of conservative treatment (observation ± compression), percutaneous aspiration, and operative management and found percutaneous aspiration in lesions containing more than 50 mL of fluid had the highest rate of recurrence (83%), followed by conservative management (19%) and operative management (15%). In an acute and a subacute MLL, the surrounding vasculature and soft tissue are compromised, further increasing the risk of postoperative complications, such as poor wound healing and necrosis with invasive procedures requiring extensive incisions.^7,9 Considering this, it is reasonable to choose a minimally invasive approach to mitigate such operative risks, especially in patients with a higher risk of complications. 

In the present case, the authors chose liposuction due to the patient’s history of poor wound healing, suboptimal nutrition, smoking, and the thin seroma wall visualized on imaging. Liposuction, commonly performed by plastic surgeons, is the removal of subcutaneous fat after infiltration of a wetting solution for up to 30 minutes followed by evacuation of the fat using a blunt cannula attached to suction.¹⁰ Wetting solutions available for infiltration can vary; however, the most commonly used is Klein’s solution, consisting of 1 L of normal saline, 1 mL of 1:1000 epinephrine, and 50 mL of 1% lidocaine.¹⁰ The purpose of these solutions is to provide volume replacement, hemostasis, and local pain control. The authors elected to not use wetting solution containing lidocaine in this patient as it could have masked hyper/hypoesthesia indicating early MLL recurrence or compartment syndrome in the early postoperative period. Smaller cannulas generate more resistance but allow for even fat removal and, therefore, are generally used in cosmetic liposuction.¹⁰ For the present case, the authors chose a larger 3-mm cannula for aggressive fat removal, capsule disruption, and large fluid evacuation. 

Unfortunately, to the best of the authors' knowledge, there are few reports describing the use of minimally invasive therapies and even fewer using liposuction.^7,11,12 Several reports^7,11,12 demonstrated its use in chronic MLL in which patients presented more than 1 year after the inciting trauma. In contrast, the present patient presented shortly after her trauma (3 weeks) and still achieved satisfactory aesthetic results without recurrence using liposuction. Liposuction effectively removes fat permanently in smooth contour MLL cases, but it may be less effective if fat necrosis and irregular contour is present.¹² In the case herein, fat necrosis was not present on CT or intraoperatively. Although a definitive mechanism has not been elucidated, 1 proposed mechanism is that liposuction debridement of the internal surface of the MLL allows for healing and eventual scarring to close the dead space.¹³ Liposuction, similar to open debridement, can remove viable and necrotic fat contents of MLLs but, with a decreased risk of skin necrosis in subacute lesions where vascular supply to overlying skin is already compromised. 

Morel-Lavallée lesions can occur after any shearing force and lead to painful and disfiguring conditions if left untreated. An accurate history, palpable fluctuance on physical exam, and appropriate imaging are critical in the early diagnosis of MLLs. Moreover, liposuction is a rare yet acceptable alternative option in the case of early presentation of a MLL in a patient with significant comorbidities in whom large invasive procedures are not optimal. Herein, the authors reported a case that was diagnosed early and successfully treated with liposuction, resulting in an acceptable cosmetic outcome. Given the limitations of a single case study and the paucity of reported cases in the literature, larger studies need to be conducted to further validate this treatment course for a MLL. 

Authors: Shana S. Kalaria, MD¹; Alexis Boson, BS²; and Lance W. Griffin, MD, FACS³

Affiliations: ¹Division of Plastic Surgery, University of Texas Medical Branch, Galveston, TX; ²School of Medicine, University of Texas Medical Branch; and ³Division of Trauma and Acute Care Surgery, Department of Surgery, University of Texas Medical Branch

Correspondence: Lance W. Griffin MD, FACS, Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1172; lwgriffi@utmb.edu 

Disclosure: The authors disclose no financial or other conflict of interest.