The purpose of this article is to review surgical management for dermal ulceration that results from chronic venous insufficiency. Efficacy is gauged by freedom from recurrent ulceration, an objective clinical monitor. Accurate preoperative diagnosis and postoperative assessment of the venous circulation is enhanced by reliable non-invasive examinations. A recently developed clinical classification unifies reporting criteria and has been widely subscribed. Standard surgical ablation of incompetent saphenous and other superficial veins significantly improves clinical and hemodynamic outcome. Perforator incompetence alone is rarely the cause of ulcerative disease, but adjunctive ligation of communicating veins is considered important to the effective elimination of chronic venous insufficiency. New endoscopic techniques reduce morbidity associated with long incisions from the open subfascial procedure. In a more advanced role, deep venous reconstruction is infrequently performed, but is quite durable. Free-tissue transfer appears to be effective after 2 years of observation. Post-thrombotic chronic venous insufficiency continues to confer a more severe prognosis, which emphasizes the importance of accurate and precise diagnosis. Investigation of patients with ulcerative chronic venous insufficiency should be actively pursued, since individualized surgical management will effectively reduce recurrence of ulceration.