Background: Incomplete removal of the first rib in operations intended to decompress the thoracic outlet is often seen after the single transaxillary approach (often leaving a posterior stump) or supraclavicular techniques (leaving an anterior stump). The former may also cause neurogenic and vascular injuries because the exposure is often poor in attempting complete removal of the first rib posteriorly and the surgeon faces a significant struggle. Study Design: A new operative procedure is described entailing two stages using two separate incisions: a transaxillary and posterior incision done at the same sitting that accomplishes complete removal of the first rib with less risk. This combined approach is done with the help of a new arm holder device during the transaxillary stage followed by a small incision behind the trapezius ridge for posterior access to the rib. Results: I present 33 patients in whom this operation was implemented, with a cure rate of 79%, improvement in 15%, and unchanged in 6%, with no complications or mortality. Technical details are presented. Conclusions: A double-incision approach is recommended as a safer and more effective method to accomplish complete removal of the first rib than are single transaxillary supraclavicular techniques in cases with thoracic outlet obstruction.