Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. Surgical treatment is effective for most patients undergoing operative repair. However, in recent studies, the difficult-to-ignore early complications of surgical treatment can be as high as 62.5%. Among them, esophageal stricture occurring in 42-54% of patients, anastomosis leakage occurs at a rate of 22.7-26%, and the mortality rate can be as high as 29.4%. Here, we introduce our innovative experience repairing acquired TEFs with a thoracoacromial artery perforator flap, in which provides a clear surgical field of view, reliable reconstruction, and no serious complications during the perioperative period and no mortality or complications were observed within 180 days after the operation.Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation.Repair of acquired TEFs using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.2023 Journal of Thoracic Disease. All rights reserved.