Morel-Lavallée Lesion Contour Deformity: Quilting Sutures to Prevent Recurrent Seroma after Resection.

INTRODUCTION

Closed degloving injuries are often overlooked in the acute setting and may not be apparent until later presentation as an evolving contour deformity.[1] Trauma with an oblique shearing force can avulse skin and subcutaneous tissues from the underlying fascia, creating a potential space for seroma accumulation, and subsequent Morel-Lavallée lesion. Morel-Lavallée first described posttraumatic seroma in 1853, reporting several patients who sustained traumatic injuries of the lumbosacral region, buttocks, and thigh.[2]

CASE REPORT

Case 1

A 60-year-old man presented with fluctuant masses of his right buttock and thigh, on a background history of trauma to the area when he was run over by a bus many years ago (Fig. 1). Computed tomography scan demonstrated multiple communicating cystic collections (44 × 20 × 12 cm), consistent with a Morel-Lavallée lesion. The lesion and capsule were excised and 2-0 Vicryl quilting sutures placed between the flap and fascia. After surgery and compression, drain output was nearly 5 L over 10 days. A small seroma occurred after drain removal but settled with conservative management. There has been no recurrence after nearly 3 years postsurgery.

Fig. 1.

Contour deformity of the right buttock and thigh as described in case 1.

Case 2

A 56-year-old man presented with increasing swelling and pain in his left thigh, 11 days after a car drove over his thighs and pelvis. Approximately 1600mL of serosanguineous fluid was aspirated, and over the next month he represented several times for drainage of a presumed “simple seroma.” Computed tomography scan subsequently showed a 38 × 11 × 10 cm multiseptated fluid collection. The encapsulated lesion was resected, and the flap was quilted with 3-0 Vicryl sutures (Fig. 2). Postoperatively, a bandage was used for compression, and drain output over 4 days was 300 mL. Some seroma reaccumulation was evident at day 10 and 1 month after surgery, but at 10 months postsurgery there was no recurrence.

Fig. 2.

Intraoperative surgical resection of the left thigh Morel-Lavallée lesion described in case 2, demonstrating the extent of the surrounding fibrous capsule.

DISCUSSION

Following closed degloving, a large dead space is created between the deep fascia and avulsed subcutaneous tissues. Ongoing discordant movement between the surfaces of these tissue planes prevents tissue adherence, thereby promoting seroma accumulation and pseudocyst formation. The presence of an encapsulated lesion, or pseudocyst, implies that conservative management with repeated aspiration will be ineffective. However, seroma may also recur after surgical resection, as simple excision addresses the pseudocyst but does not adequately treat the main issues of dead space and discordant movement between tissue layers.

Quilting sutures aim to eliminate dead space and reduce motion between adjacent tissue planes, as demonstrated in elective surgical procedures that feature controlled degloving.[3,4] Wide undermining in latissimus dorsi muscle flap harvest and mastectomy results in a dead space with potential movement between tissue layers, and the use of quilting sutures in these procedures is associated with reduced risk of postoperative seroma and reduced total seroma volume.[3,4] The utility of quilting sutures for seroma prevention has also been explored in a series of 22 patients with degloving injuries.[5]

In addition to resection and compression, routine use of quilting sutures is a useful surgical adjunct to close dead space, reduce movement and promote adherence between tissue layers, and prevent reaccumulation of seroma in resected Morel-Lavallée lesions.

STATEMENT OF CONFORMITY

The authors confirm that the principles outlined in the Declaration of Helsinki have been followed.