Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.