Chest wall defects continues to be a challenge faced by reconstructive surgeons and are often the results of oncological resections, trauma or congenital malformations. The primary goals of chest wall reconstructions includes are to obliterate dead space, restore chest wall rigidity and stability, and protect intrathoracic organs. Previous literature focuses on various approaches for sternum, ribs, or soft tissues reconstructions. The descriptions of costal margin reconstruction remains limited. We present a case of total costal margin reconstruction in a 24 year old female following partial Ravitch Pectus repair for an acquired mild pectus carinatum deformity. She presented 2 years after her initial surgery with an unstable thoracic cage construct associated with large chest wall deformity, left chest pain and recurrent 7th rib fractures. The reconstruction design takes in consideration of the patient’s slim physique, negative Rhesus status, and the thoracic cage biomechanical requirement for future pregnancy plans. Virtual surgical planning, customized fixation plates, and multiple allografts were designed for her reconstruction. Her pain management were optimized perioperatively to minimize pain-associated respiratory complications. The patient continues to progress well in the postoperative period. We describe the challenges faced in a total costal margin reconstruction requiring multidisciplinary involvement throughout the patient’s journey from preoperative to through to postoperative inpatient and outpatient managements. Designs and materials for costal margin reconstruction continues to leverage advancing technological developments. The patient’s has ongoing postoperative reviews with longer-term outcome available at the time of this presentation.