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The treatment approach to lower limb lymphedema is similar to that described above in that conservative treatment is initiated immediately after diagnosis. For mild cases, limb elevation may be sufficient to reduce the swelling and, for severe cases, the treatment with complete decongestive physiotherapy (CDP) is more intense. In addition, some practitioners treat patients with heat therapy, which consists of hot water immersion, microwave, and electromagnetic irradiation. Modalities may be combined but continued compression remains essential.

Pharmacologic treatment with benzopyrones is also effective for lower limb lymphedema but clinical trials are still lacking. Benzopyrones may also be effective for:

• Reducing edema
• Reducing the temperature of the limb
• Increasing softness of the skin
• Reduction of sensations such as heaviness
• Notably fewer incidences of secondary infection

As with conservative treatment, any pharmacologic therapy done is prescribed in combination with CDP. Some small studies indicate that CDP together with medication may be more effective than CDP alone.

Surgery is reserved for refractory cases and is always followed by the wearing of compression garments to prevent recurrence of swelling. The three types of surgical techniques are similar to those used for upper limb lymphedema and include:

• Debulking procedures - these are performed as one or two stage procedures of subcutaneous excision and skin grafting. The Charles method, where only the affected area of the limb is excised, may be performed or a modification of the Homan procedure, where the entire limb undergoes a two stage excision, may be performed. Surgery is effective for leg function, shape, and reduction of frequency of cellulitis. One of the complications which may occur as a result of debulking is the development of edema of the foot. Cosmetic outcome is thought to be better following two-stage excision.

  The major complications of debulking include infection, necrosis of the skin graft,and foot edema.

• Bypass or microsurgical procedures - this surgery is performed on individuals who have not responded to intense medical therapy. Some procedures seem to be more effective for secondary than primary lymphedema. The various techniques include:

  • lymphatic-venous anastomosis - a surgical connection is created between lymphatic and venous vessels
  • lymphovenous bypass - one small study showed a reduction of arm circumference of more than 5 cm. in 70% of patients followed for 6 months with reduction of incidence of cellulitis.

• Prophylactic surgery is performed on some patients who undergo extensive lymph node removal in the pelvic area and who are, therefore, at increased risk of developing lymphedema. In these cases, omentoplasty, may be performed. The omentum is a fold in the peritoneum (tissue that lines the abdomen) that surrounds abdominal organs and is very rich in lymphatics. The surgery helps the abdominal lymph drain into the peritoneal cavity where the omentum helps to absorb the lymph reducing the severity or in some cases the formation of lymphedema of the lower limbs. One study showed that while 50% (5 patients) of the control group developed lymphedema, only 16% (2 patients out of 12) of the surgical group developed postsurgical lymphedema.