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Purpose: The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life. Methods: A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12 months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale. Results: The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26 months (IQR 15–37). The median EQ-5D utility index score was 0.91 (0.89–1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life. Conclusions: Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients. [ABSTRACT FROM AUTHOR]