Lymphedema remains a disease with multiple treatment options, but rarely one with consistently successful outcome. Microsurgical treatment has slowly proven itself to be a promising, albeit technically demanding option. To facilitate and improve upon the operative results of this technique, we have undertaken the following in a select group of patients. Eighteen patients were evaluated over the past three years, seven of whom were deemed operative candidates. The preoperative evaluations included venous duplex ultrasound and lymphoscintigraphy. Pre-operative radioisotope injection, as in sentinal node mapping, followed by intraoperative vital blue dye injection was performed. The gamma probe was used to identify suitable lymphatics signaled by areas of highest uptake. These areas correlated with high concentration of blue dye. Postoperative management included elevation, wrapping and continued physical therapy. Suitable conduits were found in five of seven patients. Four out of these five patients had successful outcomes. Gradual decrease in extremity circumference, increased response to wrapping, increase sensation and patient comfort, and ultimately less dependence on wrapping defined successful outcomes. We believe that appropriate preoperative evaluation along with intraoperative localizing assistance of the gamma probe helped us optimize our results.