Thoracic outlet syndrome (TOS) is characterized by pain, paresthesias, weakness, and/or pallor in the upper limb(s) caused by compression of the brachial plexus and/or subclavian vessels within the thoracic outlet region. These structures can be compressed between the anterior and middle scalene muscles or by an anatomical variant, such as scalenus minimus or cervical rib. The separation into vascular and neurogenic is too artificial since most patients have a component of both. Patients who present with this classic constellation of symptoms and corroborating exam/diagnostic findings, and fail conservative measures, are offered a thoracic outlet decompression surgery. Several approaches have been designed to treat TOS, including supraclavicular, infraclavicular, transaxillary, and posterior. In our hands, supraclavicular anterior scalenectomy has provided very good results with minimal morbidity. In certain cases, particularly with refractory and/or recurrent TOS, pectoralis minor release may be considered via an infraclavicular approach. Except for venous TOS, first rib resection is rarely needed. We prefer to classify TOS as venous (VTOS) and non-venous (NVTOS).