Lymphatic supermicrosurgery, supermicrosurgical lymphaticovenular anastomosis (LVA), is becoming a useful option for the treatment of compression-refractory lymphedema. One of the most important points in LVA is to make as many bypasses as possible for better treatment results. We report a progressive lower extremity lymphedema (LEL) case successfully treated with a ladder-shaped LVA. A 67-year-old female with secondary LEL refractory to conservative treatments underwent LVA. A ladder-shaped LVA was performed at the left ankle. In the ladder-shaped LVA, 3 lymphatic vessels and 1 vein were anastomosed in a side-to-side fashion; 2 lymphatic vessels next to the vein were anastomosed to the vein, and the other lymphatic vessel was anastomosed to the nearby lymphatic vessel. Using ladder-shaped LVA, 6 lymph flows of 3 lymphatic vessels could be bypassed into a vein. Six months after the LVA operation, her left LEL index decreased from 212 to 195, indicating edematous volume reduction. Ladder-shaped LVA may be a useful option when there are 3 lymphatic vessels and 1 vein in a surgical field. © 2013 Wiley Periodicals, Inc. Microsurgery 34:404–408, 2014.