Despite our improved knowledge of the lymphatic system, lymphedema remains an incurable disease. Its pathogenesis is still poorly understood, but fortunately the majority of patients can be satisfactorily managed by conservative means. Surgical intervention is offered only in cases of refractory disease and does not offer a surgical cure. At the present time, there are five major surgical options: lymphangioplasty, buried dermal flap, lymphaticovenous shunts, the Charles procedure, and the staged subcutaneous excision beneath flaps. Lymphangioplasty is usually limited to those patients with limited life expectancy, because the beneficial effects are transient. The most frequently used procedures--the buried dermal flap, the Charles procedure, and the subcutaneous excision beneath flaps--offer patients symptomatic improvement, primarily through the excision of lymphedematous subcutaneous tissue. Much controversy still exists as to the efficacy and future applicability of both the enteromesenteric bridge and microlymphatic surgery, which are currently under investigation. Long-term follow-up will be necessary. The discouraging fact remains that no procedure cures lymphedemia; however, we believe that, at this time, the subcutaneous excision beneath skin flaps offers the most reliable and consistently beneficial means of surgically managing the symptoms of lymphedema.