The Underreported Benefits of Surgical Intervention for Chronic Sequelae of Closed Degloving Injuries: A Case Series

Abstract

Background:

Chronic closed degloving injury (CCDI) symptoms may result from fibrous capsule formation or traumatic fat displacement, often leading to contour deformity and debilitating pain. Although minimally invasive therapies are common first-line treatments, limited data exist on definitive management.

Methods:

A retrospective review identified 7 patients who underwent surgery for CCDI more than 2 months postinjury during a 3.8-year period. The analysis includes patient demographics, injury characteristics, outcomes of contour correction, symptom relief, and complications.

Results:

All patients presented with contour deformity, and 6 reported pain. Capsulectomy was the most frequently performed procedure (71%, n = 5). No patients had clinically significant residual fluid more than 5 cm³ within a capsule. Among those who underwent capsulectomy, 40% (n = 2) reported significant improvement and 60% (n = 3) achieved complete pain resolution with restored function. Two patients who underwent lipectomy alone sought correction of contour deformity without significant pain complaints. Of all contour deformities, 67% (n = 6) fully resolved, 11% (n = 1) improved, and 22% (n = 2) persisted.

Conclusions:

Significant preoperative pain was associated with the presence of a fibrous capsule despite the resolution of fluid collection. Not previously discussed in the literature, the involvement of large sensory nerves at the Scarpa or muscle fascia plane may help explain the degree of pain and subsequent relief. Surgical management was highly effective in addressing pain, neuropathy, and soft-tissue deformity associated with CCDI. These findings support surgery as a definitive treatment option for CCDI symptoms.

Takeaways

Question: What are the outcomes of surgical intervention for chronic closed degloving injuries (CDIs) with persistent pain and deformity?

Findings: This retrospective case series provided a new understanding of the role of the scar capsule and internal fat avulsion in the pathology of symptomatic chronic CDI. Capsulectomy achieved complete or significant pain relief, as well as improvements in functional capacity, in all patients. Contour deformity secondary to fat displacement without capsule was more difficult to fully correct than capsule-only pathology.

Meaning: Surgical intervention provides highly effective, definitive treatment for symptomatic chronic CDI, challenging traditional conservative management approaches and offering significant improvements in quality of life.

INTRODUCTION

Closed degloving injuries (CDIs), often also referred to as Morel-Lavallee lesions, are understudied soft tissue injuries in which the skin and adipose layer separate from the muscle or Scarpa fascia layer due to traumatic shearing forces from high-energy or crush mechanisms.¹ The potential space often fills with fluid or blood from disrupted perforating vessels and lymphatics, as well as displaced fat. The thickness and mobility of soft tissue layers in the thighs, hips, and buttocks increase the frequency of closed deglovings in these anatomical areas. With subtle radiographic and clinical findings, these injuries are easily overlooked due to accompanying polytrauma; delayed presentation occurs in approximately 33% of patients.² Once a CDI enters the chronic stage, a fibrous capsule forms, which creates a pathology that differs from the acute stage,³ necessitating a different treatment approach. Current literature demonstrates a consensus that chronic CDIs that have formed a capsule must be surgically excised, although this is reflected in a small number of case studies, small cohorts, and literature reviews. Furthermore, there are no investigations quantifying the outcomes of specific surgical techniques. This retrospective study sought to detail the sequelae of chronic CDI and outcomes of operative intervention. With promising results and a low recurrence rate (13%), this study may serve as a pilot in exploring definitive treatment methods for a condition underreported in the literature.

METHODS

A retrospective cohort study of the surgical interventions and outcomes of 7 patients treated at a level 1 trauma center between 2021 and 2024 was performed. All patients who presented to an ambulatory plastic surgery clinic were reviewed for inclusion based on diagnosis codes including injury, deformity, and/or pain in the back, buttock, or thigh anatomical locations. Exclusion criteria included age younger than 18 years, positive pregnancy status or incarcerated individuals, as well as those with sequelae attributable to open degloving injuries, unclear original injury precipitating symptomatic sequelae, or those less than 2 months from the original degloving injury. Data were abstracted via chart review of the initial injury encounter, operative notes, and follow-up clinic notes at 2 weeks, 6 weeks, and 5 months. The analysis includes patient demographics, procedures performed, outcomes, and postoperative complications.

Outcomes are separated into the categories of deformity correction and symptomatic relief. Perioperative anatomic correction was measured by the dimensions of tissue removed, documentation of deformity resolution, and patient satisfaction. Symptomatic relief was measured via chart abstraction of patient reports of somatic pain, nerve pain, and ability to function in activities of daily living.

RESULTS

Patients sought care for chronic CDI for both pain (n = 6) and contour deformity (n = 7). The average time between the date of injury and surgery was 1.6 years. Before presentation, 1 patient had undergone interventional radiology drain placement twice, 1 patient had been offered but had not undergone aspiration, and 2 patients used compression. Four patients sought and were declined definitive surgical intervention at least once before inclusion in this cohort with the most common reason being a lack of likely improvement in symptoms, followed by the risk of soft tissue damage and scarring. The most frequently performed procedure was complete capsulectomy (45%) (Table 1).

Table 1.

Patient and Injury Characteristics: Baseline Characteristics and Demographics of Patient Cohort and Procedures

	Average	SD
Age at procedure, y	45.16	6.175189
Time from injury, y	1.64	0.915802
Follow-up duration, d	138	91.8
BMI, kg/m2	27.5	5.866375
Sex, n (%)	n = 7
Male	2 (29)
Female	5 (71)
Race, n (%)
White	6 (86)
Black or African American	1 (14)
Tobacco use <1 y of surgery, n (%)
Y	3 (43)
N	4 (57)
Diabetes, n (%)
Y	0 (0)
N	6 (86)
Prediabetic	1 (14)
Mechanism of injury, n (%)
Motor vehicle accident	3 (44)
Golf cart fell off cliff	1 (14)
Car versus bike	1 (14)
Snowmobile versus tree	1 (14)
Crush injury	1 (14)
Involved area of limb (n = 9), n (%)
Posterior thigh	1 (11)
Anterior thigh	1 (11)
Lateral thigh	4 (45)
Buttock	2 (22)
Flank	1 (11)
Procedure (n = 11), n (%)
Capsulectomy	5 (45)
Suction lipectomy	2 (18)
Scar revision	1 (9)
Fat graft	1 (9)
Percutaneous scar release	1 (9)
Direct lipectomy	1 (9)
Preoperative functional limitations (n = 9), n (%)
Standing	1 (11)
Sitting	1 (11)
Walking	3 (33)
Running	2 (22)
Sleeping	1 (11)
Work	1 (11)
Acute complications (<10d)
Yes	2 (22)
No	7 (78)
Acute complications type (n = 9*), n (%)
Dermatitis	1 (11)
Cellulitis (tx abx)	1 (11)
Late complications (10d<)
Yes	4 (44)
No	5 (56)
Late complications type (n = 9*), n (%)
Incomplete resolution of contour	3 (33)
Focal sensory neuropathy	4 (44)

^*Total number of CDIs with late complications (2 patients had 2 CDIs).

Zero patients had clinically significant residual fluid within this capsule (>5 mL). All patients who underwent capsulectomy reported significant improvement (40%, n = 2) or complete resolution (60%, n = 3) of pain. All patients noted improved or full return of activities of daily living function.

Complete resolution of neuropathy and pain was achieved with lipectomy alone in 2 patients who did not have a fibrous capsule. Within that group, 1 patient underwent direct lipectomy and closure, and the other underwent liposuction and percutaneous scar release. One patient who presented with painless contour deformity achieved resolution of contour deformity following lipectomy alone. Among all contour deformities, 67% of the lesions achieved complete resolution, 11% improved, and 22% had persistent deformity (Table 2).

Table 2.

Outcomes: The Primary Outcomes of Surgical Intervention for Chronic CDI

	n (%)
Pain (n = 6*)
Resolved	4 (67)
Improved	2 (33)
Functional limitation(s) attributed to lesion (n = 7)
Resolved	6 (86)
Improved	1 (14)
Preoperative neuropathy (n = 9)
Resolved	3 (33)
Improved	1 (11)
N/A	5 (56)
Deformity (n = 9)
Improved	1 (11)
Resolved	6 (67)
Unchanged	2 (22)
Tissue volume excised, cm³	Average	SD
Capsulectomy	1041	591
Lipectomy	325	25

^*One patient did not endorse pain.

Complication rates were based on the total number of CDIs that were treated with surgical intervention. Two patients had 2 concurrent CDIs, whereas 5 patients had 1 CDI, for a total of 9 CDIs. Acute complications arose in 2 out of 9 CDIs. These included dermatitis (n = 1) and cellulitis (n = 1), both of which resolved completely within the follow-up period. Late complications developed in 4 out of 9 CDIs. These included incomplete resolution of soft tissue deformity (33%) and focal sensory neuropathy (44.4%) (Fig. 1).

Fig. 1.

A1/A2 and C1/C2 denote separate, concurrent CDIs in patients A and C. Orange and green indicate positive and negative complication status, respectively. *A1/A2 and C1/C2 denote 2 different CDIs in a single patient.

Two of the 3 persistent contour deformities occurred in the same patient. The 2 patients with persistent contour deformities were positive for risk factors for postoperative complications including high body mass index (BMI) (32.44 kg/m²) and active smoking status. Postoperative focal sensory neuropathy manifested as new paresthesia or anesthesia adjacent to the operative site; neuropathic symptoms were mild and reported to be a significant improvement from preoperative neuralgia.

Two patients underwent surgical revisions after initial operative treatment; 1 patient underwent secondary lipectomy and fat grafting, achieving contour improvement with incomplete resolution; a second patient underwent repeat capsulectomy for persistent pain with resolution of discomfort.

DISCUSSION

Treatment of acute CDIs via methods such as compression and aspiration, if performed in a timely manner, can be highly effective.⁴ Treatment of chronic CDIs is more complex due to the development of a fibrous capsule, deep soft tissue scarring, and/or the traumatic displacement of adipose tissue.⁵ In addition, chronic CDIs may be underrecognized and therefore undertreated due to the lack of data on this condition. The most commonly reported sequelae from chronic CDI are contour deformity and pain,^6,7 the severity of which can be completely debilitating for patients. This was reflected in this study’s cohort, in which 6 out of 7 patients reported associated pain, 4 out of 7 reported neuropathy symptoms, and all patients had associated contour deformity (Fig. 2).

Fig. 2.

A photograph of a 35-year-old woman with contour deformity sequelae from chronic CDI of the right lateral thigh. A, Preoperative, 794 days (2.2 y) after the initial injury.

Historically, the published first-line management for chronic CDI included conservative therapies such as compression and observation, or serial aspirations, but these are no longer recommended as standalone measures due to inefficacy, leading to a prolonged treatment course.⁸ Currently, first-line treatments for smaller lesions without fibrous capsules include minimally invasive options such as percutaneous drain, sclerotherapy, or aspiration.⁹ Per Nickerson et al¹⁰ and Barcavage et al,⁸ indications for operative management include CDIs that meet any of the following criteria: greater than 50 mL fluid upon aspiration, unresponsive to other forms of treatment, or the formation of a fibrous capsule. In practice, surgeons may not see a high volume of patients presenting with chronic CDIs; posttraumatic pain symptoms with unclear etiology, lack of an established standard of care, and subtle contour deformity may lead to hesitation in offering operative management. Emerging data continue to reveal operative management as a safe and effective option for definitive treatment of symptomatic chronic CDI, particularly in the role of eliminating the fibrous capsule and associated pain, as well as improvement of contour deformity.

All patients who endorsed a chief complaint of significant localized pain (6 out of 7 patients) had immediate, significant reduction or resolution of pain following open excision of the fibrotic capsule, supporting the efficacy of capsulectomy in pain relief (Fig. 3). During the injury, the translation of shearing forces through the soft tissues leads most commonly to separation of the skin and adipose layer either at the level of Scarpa fascia or muscle fascia (Fig. 4).

Fig. 3.

Photograph of the excised specimen from chronic CDI capsulectomy of the buttock.

Fig. 4.

Computed tomography axial image showing a residual deflated capsule from a CDI at the right gluteal Scarpa fascia plane (white arrow) in a patient with debilitating pain symptoms at presentation.

Fluid fills this potential space, and if it persists, a fibrous capsule then forms, which remains as the symptomatic source even if the fluid is fully resorbed. Whether it occurs within Scarpa fascia or muscle fascia, symptomatic relief may reflect relieved pressure on large sensory nerves adjacent to, or entrapped directly within, the fibrotic capsule. The prevalence of neuropathic complaints such as numbness, tingling, or burning pain that radiated down the lower extremity (71%) that were relieved immediately postoperatively supports this etiology. Beyond capsulectomy, direct lipectomy with repositioning of displaced adipose tissue was also effective for pain relief. One patient without fibrous capsule formation had localized pain that was triggered by running, as well as neuropathy at rest, which resolved following direct lipectomy and closure. Symptoms in this case could be explained by increased tension on subcutaneous nerves from local adipose tissue displacement. As there were no CDIs that contained a significant amount of fluid, pressure from residual fluid volume was unlikely to be a contributing factor to symptoms.

Operative management of chronic CDI, as well as its symptomatic sequelae, which includes focal neuropathy, pain, and contour deformity, has demonstrated promising results in the patients treated in this cohort. Surgical treatments proposed in existing literature include capsule evacuation, open debridement, minimally invasive techniques, or lipectomy.^5,9,11,12 In this study, capsulectomy and scar excision were performed with sharp or cautery dissection, in which the entire scar capsule was fully removed, followed by drain placement and layered closure. For contour deformity, direct or suction lipectomy, autologous fat grafting, and percutaneous scar release techniques were used for contour correction.

Contour deformities related to CDIs in this series presented with a primary complaint of unsightly bulges. In some cases, excision of the scar capsule was adequate for contour correction. However, in cases where scar capsule pathology was not present, direct subcutaneous excision was less successful. It is proposed that the underlying pathology may be described as internal fat avulsion, in which the displaced adipose tissue bulge is accentuated by a less appreciable depression and associated subcutaneous scarring. This pathology may see more complete resolution rates if treated with a combination of lipectomy, percutaneous scar lysis, and fat grafting of subtle depression. The experience within this case series demonstrated that these internal fat avulsion defects were significantly more difficult to fully correct than contour deformities related to residual scar capsule. It may be more challenging to achieve full contour correction in patients with elevated BMI after traumatic fat displacement.

The limitations of this study include the lack of a control group to directly compare outcomes with nonoperative management. The rarity of this condition is both a contributing factor to the small sample size and an important reason for disseminating techniques and challenges from a high-volume trauma center. Standardized objective measurements of focal neuropathy and contour deformities, as well as validated patient-reported outcomes tools for pain and neuropathic symptoms, may be beneficial in future research. Future studies may evaluate factors associated with the conversion from acute CDI to chronic CDI and the risk of chronic pain as a sequela of chronic CDI.

CONCLUSIONS

The outcomes of surgical interventions targeted at the persistent pathology after CDI, including capsulectomy for residual deflated fibrous capsules and suction or direct lipectomy with or without fat grafting for internal fat avulsion with displacement, demonstrated immediate improvement or complete resolution of the symptoms of chronic CDI postoperatively, including persistent pain or focal neuropathy. Significant preoperative pain was associated with the presence of a fibrous capsule despite the absence of residual fluid collection. Mechanical stress or entrapment of the large sensory nerves at the Scarpa or muscular fascial plane may help explain the severity of pain and subsequent relief for these patients. Surgical intervention was highly effective for treating sequelae of chronic CDI including pain, neuralgia, and soft tissue deformity, with attention directed, particularly in high-BMI patients, to increased challenges achieving full contour correction after traumatic fat displacement.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.