Background: Subcutaneous emphysema (SE) after pulmonary resection is troublesome and has been poorly studied. Methods: A retrospective review was made of a prospective database. Patients who underwent pulmonary resection and in whom clinically detected SE were studied. Results: Of 4,023 patients between January 1999 and June 2006, 255 patients (6.3%) had clinically apparent SE. Predictors of developing SE by multivariate analysis were preoperative forced expiratory volume of air in 1 second (FEV1%) less than 50%, having an air leak, and having had a previous thoracotomy. Despite maximizing chest tube suction, 85 patients (33%) had recalcitrant SE. These patients with recalcitrant SE were more likely to have a lower median FEV1% (p = 0.037), a previous ipsilateral thoracotomy, and have undergone a lobectomy (p < 0.001). Recently, 64 of the 85 patients underwent single-incision, video-assisted thorascopic surgery with pneumolysis and chest tube placement, which successfully resolved the SE within 24 hours in all patients except 1. These 64 patients had a significantly shorter hospital stay (6 versus 9 days, p = 0.02) and less time with recalcitrant SE than the other 21 patients. Conclusions: Subcutaneous emphysema is more likely in patients who have an FEV1% less than 50% and who undergo a redo thoracotomy. Recalcitrant SE emphysema (SE that persists despite increasing chest tube suction) is more likely in patients who undergo lobectomy and is best treated by video-assisted thorascopic surgery with pneumolysis between the leaking lung, which is usually partially adhered to the previously opened intercostal space. This directs the air leak back into the pleural space and out of the subcutaneous space. This procedure shortens the duration of SE and hospital stay. © 2008 The Society of Thoracic Surgeons.