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The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach.We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report.Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit).This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.