Venous ulcers indicate the most severe forms of venous insufficiency and typically involve both the deep (including perforators) and superficial vein systems. Extreme reflux and venous hypertension result in changes in the microcirculation of the skin eventually leading to severe ulceration. Anatomic involvement at these stages generally involves the saphenous system, the perforators (typically the Cockett perforators), and the deep system (typically the femoral, superficial femoral and/or the profunda). A smaller subset of the population has deep system-only involvement (<5%) and an even smaller portion perforator-only incompetence.