The standard treatment of chronic venous hypertension and venous ulceration consists of elevation and compression bandaging in nurse-led community clinics. Since the 1930s, surgeons have been developing various techniques to alleviate chronic venous hypertension. These can be broadly divided into perforator and superficial venous surgery. Parallel developments in imaging techniques have led to a better understanding of venous flow haemodynamics. Large well conducted randomised controlled studies have demonstrated the beneficial effect of superficial venous surgery but, so far, there is a lack of similarly strong evidence in favour of perforating veins surgery. The purpose of this review is to evaluate the available evidence for or against these two forms of treatment.