Large substernal goiters have presented a challenge to surgeons since the beginning of thyroid surgery. With the widespread use of cross-sectional imaging and high-resolution ultrasound, more thyroid pathology is identified every year. In the setting of compressive symptoms, refractory hyperthyroidism, cosmetic concerns, malignancy, or even prophylaxis, thyroidectomy is indicated for large substernal goiters. Our aims are to present (1) the rationale and an algorithm for a concise preoperative assessment for thyroidectomy and (2) a detailed stepwise description of the procedure-emphasizing safety-for a large substernal goiter. This description is complemented by a medical artist's illustrations to emphasize the salient points of dissection. With sound surgical technique, thyroidectomy, although still sometimes quite challenging, may be performed safely, with rare need for median sternotomy, providing great relief to the patient. © 2009 Elsevier Inc. All rights reserved.