Identifying the exact cause for persistent and recurrent neurogenic thoracic outlet syndrome (NTOS) is challenging even with high-resolution imaging of the thoracic outlet. Improvement can be achieved with redo first rib resection, although the posterior first rib remnant is one of several potential points of brachial plexus compression. In approaching reoperative surgery for NTOS, the aim is to provide complete thoracic outlet decompression as guided by the patient’s history, physical examination, and adjunctive imaging. This may involve resection of the posterior first rib remnant, scar tissue encasing the brachial plexus, elongated C7 transverse process, cervical rib, and/or pectoralis minor tendon.