Minimally Invasive Dual Negative-Pressure Strategy for Extensive Morel–Lavallée Lesions

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J Wound Manag Res. 2026;22(2):123-127

Publication date (electronic) : 2026 June 30

doi : https://doi.org/10.22467/jwmr.2026.03601

Jeeyoon Kim, Haejin Seo, Eun Young Rha, Jongweon Shin

Department of Plastic and Reconstructive Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding author: Jongweon Shin, MD, PhD, Department of Plastic and Reconstructive Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul 03312, Korea, E-mail: psjwshin@gmail.com

Received 2026 March 13; Revised 2026 April 22; Accepted 2026 April 27.

Abstract

Introduction

Morel–Lavallée lesions (MLLs) are closed degloving injuries caused by shearing forces that separate the subcutaneous tissue from the underlying deep fascia, creating a potential space prone to persistent hemolymphatic fluid accumulation [1]. When inadequately treated, this residual cavity may progress to chronic encapsulation, recurrent seroma formation, infection, skin necrosis, and delayed wound healing [1,2]. In published literature, treatment failure and recurrence have been attributed primarily to inadequate dead-space elimination rather than to initial fluid volume alone [3]. Despite a growing consensus on this therapeutic principle, the optimal management strategy for large or subacute MLLs remains poorly defined and highly heterogeneous. Early percutaneous drainage may be effective in selected acute lesions; however, its reliability diminishes once a persistent cavity or pseudocapsule has formed [4]. In contrast, open debridement with meticulous suture-based dead-space closure can achieve durable cavity obliteration but often requires wider incisions and may increase soft-tissue morbidity or compromise residual vascularity [5]. Consequently, current treatment strategies reflect a trade-off between minimal invasiveness and dependable dead-space elimination, and no standardized technical framework has been universally adopted [2]. To address these limitations, several approaches combining drainage and negative-pressure wound therapy (NPWT) have been introduced, ranging from limited-incision evacuation with external NPWT to more invasive techniques incorporating cavity manipulation or quilting sutures [6-8]. Although these methods share the objective of dead-space control, they differ in technical complexity and degree of soft-tissue disruption, and sustained cavity collapse remains challenging in large or subacute lesions.

Recognizing that durable dead-space obliteration is central to preventing recurrence, we describe a dual negative-pressure configuration that integrates internal closed-suction drainage with externally applied NPWT over the entire dead-space footprint. While both components have been used individually in prior approaches, their coordinated application establishes a unified pressure-mediated environment that enables simultaneous intracavitary evacuation and uniform tissue apposition. This configuration facilitates sustained cavity collapse without extensive dissection or routine pseudocapsule excision, providing a minimally invasive and reproducible strategy for controlling dead space in large or subacute MLLs. This study was reviewed and exempted from full review by the Institutional Review Board of Eunpyeong St. Mary’s Hospital, The Catholic University of Korea (IRB No. PC25ZISE0200). The requirement for informed consent was waived by the IRB; identifiable images were published only with additional written permission when applicable.

Idea

The dual negative-pressure strategy was applied in two patients with extensive subacute MLLs of the thigh.

A 40-year-old woman presented 3 weeks after blunt trauma with a 3×2 cm eschar and surrounding fluctuance on the medial thigh. Magnetic resonance imaging demonstrated a well-defined subcutaneous fluid collection measuring 20×11×2 cm (Fig. 1). Following a limited incision incorporating the necrotic skin, hemolymphatic contents were evacuated and selective debridement of nonviable debris was performed. As the pseudocapsule was intraoperatively found to be thin, incompletely organized, and mechanically collapsible, excision was not performed. Two closed-suction Jackson–Pratt drains were positioned in the medial and lateral dependent compartments. After layered wound closure, external NPWT was applied over the entire cutaneous footprint of the dead space using a commercially available system (Curasys; CGBio Co., Ltd.) in continuous mode at −125 mmHg, thereby establishing a coordinated dual-compartment negative-pressure environment (Fig. 2). External NPWT was maintained for 6 days and removed after confirmation of stable wound appearance and decreased drainage. The internal drains were removed sequentially on postoperative day (POD) 8 and POD 10 once the daily output remained ≤15 mL for 2 consecutive days. The wound healed uneventfully without recurrent fluid collection. At 6 months, stable contour restoration was observed (Fig. 3). No recurrence was identified during 3 years of follow-up.

Fig. 1

Preoperative findings of extensive Morel–Lavallée lesion. (A) A 40-year-old woman presented 3 weeks after blunt trauma with a necrotic skin lesion on the medial aspect of the left thigh. (B) Magnetic resonance imaging demonstrated a well-defined subcutaneous fluid collection, measuring 20 ×11 ×2 cm (arrows), between the fascia and subcutaneous tissue, consistent with an extensive Morel–Lavallée lesion.

Fig. 2

Dual negative-pressure technique for dead-space management. (A) Limited excision of the necrotic skin was performed, allowing evacuation and selective debridement of nonviable debris from the underlying cavity through the same incision, followed by primary layered closure. (B) Two closed-suction Jackson–Pratt drains were positioned in the medial and lateral dependent compartments of the lesion cavity. External negative-pressure wound therapy was applied to completely cover the cutaneous footprint of the dead space at −125 mmHg in continuous mode.

Fig. 3

Six-month postoperative outcome without recurrence. Six months postoperatively, the patient demonstrated stable wound healing without evidence of recurrent fluid collection. Symmetrical thigh contour was preserved with minimal scarring.

The same pressure-based configuration was applied in a 69-year-old man with hypertension and diabetes mellitus who presented 3 weeks after initial trauma with a large lesion extending from the inguinal region to the knee and a 7×5 cm area of overlying eschar (Fig. 4). After limited debridement through compromised skin and evacuation of the lesion cavity, pseudocapsule excision was not performed based on intraoperative findings similar to those in the first case. A dependent closed-suction drain was placed based on lesion configuration, followed by layered closure. External NPWT was applied using the same system and pressure settings (−125 mmHg, continuous mode). In this case, both the NPWT dressing and the internal drain were removed on POD 6 after satisfactory reduction of drainage. At 3 months postoperatively, the wound demonstrated stable healing without recurrence. Further long-term follow-up was not possible because the patient subsequently died from pneumonia-related sepsis unrelated to the surgical procedure.

Fig. 4

Extensive Morel–Lavallée lesion on clinical and computed tomography imaging. (A) A 69-year-old man presented after a fall with extensive ecchymosis and a 7×5 cm area of black eschar on the medial aspect of the left thigh. (B) Contrast-enhanced computed tomography demonstrated a large subcutaneous fluid collection, measuring approximately 30×8 cm (arrows), between the fascia and subcutaneous tissue and extending from the left inguinal region to the knee, consistent with an extensive Morel–Lavallée lesion.

Across both cases, durable dead-space control was achieved without pseudocapsule excision, quilting sutures, or additional fixation techniques. No secondary procedures for recurrent seroma, infection, or persistent cavity formation were required during the available follow-up period.

Discussion

In MLLs, clinical outcomes are determined primarily by the effectiveness of dead-space control rather than by fluid evacuation alone [3]. While early acute lesions may respond to simple evacuation, chronic lesions with a fibrotic pseudocapsule often require open debridement for durable cavity obliteration [4,5], reflecting a trade-off between minimal invasiveness and reliable dead-space control. The structural evolution of the lesion, particularly pseudocapsule formation, is central to this continuum. As previously described, pseudocapsule development is a time-dependent process driven by inflammatory and fibrotic changes within the lesion cavity [1,9]. Subacute lesions represent an intermediate stage in which the pseudocapsule is present but remains thin, incompletely organized, and mechanically compliant. Nonetheless, simple fluid evacuation is often insufficient to prevent recurrence, whereas routine capsular excision may result in unnecessary soft-tissue disruption. This intermediate state therefore represents a persistent therapeutic gap in which neither simple drainage nor aggressive surgical excision is optimal.

Several hybrid techniques incorporating NPWT have been proposed to address this challenge. Intralesional placement of fenestrated NPWT foam combined with drainage tubing has been shown to enhance cavity wall contact and facilitate continuous fluid evacuation [6]. Limited-incision evacuation followed by external NPWT has demonstrated favorable outcomes in selected cases, particularly where conventional compression is difficult to apply [7]. More invasive approaches incorporating mesh incisions, quilting sutures, and adjunctive NPWT have also been described, enabling effective dead-space obliteration in more advanced lesions, albeit at the cost of increased procedural complexity and direct pseudocapsule manipulation [8]. The strategy presented here differs conceptually in that coordinated negative pressure is applied simultaneously to two distinct compartments: intracavitary evacuation through internal closed-suction drainage, and uniform external compression through NPWT applied over the entire dead-space footprint. While each component has been described individually, their concurrent application establishes a unified pressure environment that promotes continuous fluid evacuation and broad tissue apposition, thereby facilitating more uniform and sustained cavity collapse. This may be particularly advantageous in extensive or subacute lesions where preservation of residual soft-tissue integrity is desirable. The rationale for this configuration is supported by experimental and clinical studies of NPWT. NPWT has been shown to enhance fluid removal, reduce interstitial edema, and induce macro- and micro-deformations that stabilize tissue interfaces [10-12]. In cavitary defects, pressure distribution occurs in a spatially graded manner, enabling effective cavity collapse while minimizing excessive stress on surrounding tissues [11]. Additionally, closed-incision NPWT has been associated with reduced wound drainage and postoperative complications in large soft-tissue resections, supporting its adjunctive role in dead-space management [13].

Within this framework, the dual negative-pressure configuration is most applicable to subacute lesions, in which the pseudocapsule remains mechanically collapsible but fluid evacuation alone is insufficient for durable dead-space control. In this setting, coordinated intracavitary drainage and external compression may provide a minimally invasive means of achieving sustained cavity collapse while preserving soft-tissue integrity.

Several limitations should be acknowledged. This report demonstrates technical feasibility without comparative evaluation against established surgical strategies. The small sample size limits generalizability, and further studies are required to determine the clinical impact of this approach. Careful patient selection remains essential, as chronically infected or extensively fibrotic lesions may still require formal open intervention. Longer-term follow-up was unavailable in one patient because of death unrelated to the procedure.

In conclusion, durable dead-space control remains central to successful MLL management. The described dual negative-pressure strategy integrates internal drainage with external NPWT to enable coordinated cavity collapse, offering a minimally invasive and reproducible option for the management of extensive or subacute MLLs.

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