Management of Morel-Lavallée Lesions
For Morel-Lavallée lesions, early percutaneous drainage with débridement is the preferred initial treatment for acute presentations, while chronic or recurrent lesions (particularly those yielding >50 mL on aspiration) should proceed directly to operative management with open débridement and cavity obliteration. 1, 2
Initial Assessment and Diagnosis
- Clinical presentation typically includes a palpable area of fluctuance at the injury site, most commonly in the thigh, trochanteric region, pelvis, or gluteal area following high-velocity trauma 3, 4
- Imaging confirmation should include ultrasonography showing hypoechoic fluid collection and/or MRI revealing fluid signal between subcutaneous tissue and underlying fascia 5, 4
- Distinguish acute from chronic lesions, as this fundamentally determines treatment approach—acute lesions (within days of injury) respond better to conservative measures, while chronic lesions (persisting >6 months) have high recurrence rates with aspiration alone 3, 5
Treatment Algorithm Based on Lesion Characteristics
Acute Lesions (Within 3 Days of Injury)
Proceed with early percutaneous drainage and débridement 1:
- Perform drainage through two 2-cm incisions (one distal, one superior-posterior) 1
- Use plastic brush to débride injured fatty tissue with pulsed lavage 1
- Place medium Hemovac drain, removing when drainage <30 mL per 24 hours 1
- This approach achieved successful resolution in 19 patients with no deep infections at 6-month follow-up 1
Aspiration Volume as Decision Point
If aspiration yields >50 mL of fluid, proceed directly to operative management 2:
- The Mayo Clinic study demonstrated that 83% of lesions yielding >50 mL on aspiration recurred, compared to only 33% of those with <50 mL 2
- This threshold has been adopted as a practice management guideline to avoid multiple failed aspirations 2
Chronic or Recurrent Lesions
Operative management is indicated for lesions persisting despite conservative treatment 3, 5:
- Doxycycline sclerodesis can be attempted: aspirate fluid, instill doxycycline, apply compressive elastic bandaging 3
- Radical surgical excision if sclerodesis fails after 4-5 attempts: excise the lesion and suture superficial to deep fascia to prevent shearing 5
- This prevents recurrence by eliminating the potential space 5
Management of Associated Fractures
- Percutaneous pelvic fixation can be performed safely during the same operative setting as Morel-Lavallée drainage 1
- Open procedures for pelvic or acetabular fractures should be delayed until at least 24 hours after drain removal to minimize infection risk 1
- Seven patients underwent simultaneous percutaneous posterior pelvic ring fixation and Morel-Lavallée treatment without wound complications 1
Common Pitfalls to Avoid
- Do not perform repeated aspirations without progression to definitive treatment—the percutaneous aspiration group had 56% recurrence rates versus 15% in the operative group 2
- Do not miss the diagnosis in patients with soft tissue swelling after high-velocity trauma, as delayed recognition increases infection risk if fracture fixation is performed 4
- Obtain wound cultures during initial drainage, though most are negative; three of sixteen cultures were positive in one series 1
- Counsel patients about long-term sequelae including persistent contour deformity, decreased skin mobility, and feeling of tightness even after successful treatment 3
Expected Outcomes
- Early percutaneous management achieved resolution without deep infection or need for skin débridement in all patients at minimum 6-month follow-up 1
- Doxycycline sclerodesis showed no recurrences during mean 50-month follow-up when combined with compression 3
- Surgical excision with fascial suturing prevented recurrence at 1-year follow-up 5