In the author's experience, the rate of recurrence is lower (5%-10%) when a combined procedure (transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy) is performed as the primary operation. The author strongly believes this combined procedure accomplishes an excellent decompression of the thoracic outlet area and decreases the rate of recurrence and reoperation. In addition, spontaneous recurrence most likely is caused when scar tissue gradually builds up in the surgical area. For this reason, as mentioned previously, the author instructs and encourages patients to start postoperative exercises the day after surgery and to continue these exercises for at least 6 months and preferably 1 year to improve brachial plexus and subclavian vessel gliding and to minimize the harmful effects of scar tissue.