Sixty-one patients with substernal goiter--42 women and 9 men (female:male ratio 2.2:1), mean age 57.5 years--underwent surgical resection in the General and Thoracic Surgery Division of the Surgery Department of the University of Catania from January 1980 to March 1999. Six patients (9.8%) had previously undergone cervicotomy. Forty-nine patients (80.3%) had symptoms (2 with acute respiratory failure); 22.9% had metabolic symptoms. Fifty-one patients (83.6%) had cervicomediastinal goiter, 8 (13.1%) migrated mediastinal goiter and 2 (3.3%) ectopic goiter. Forty-one cases (69.5%) were prevascular and 18 (30.5%) retrovascular; of the latter 5 were pre-visceral and 13 retrovisceral. Fifty-one thyroidectomies (6 subtotal) were performed, as well as 5 mediastinal excisions to complete removal and 4 resections confined to the mediastinal component. The 51 patients with cervicomediastinal goiter underwent cervicotomy in 42 cases (82.4%), cervicosternotomy in 7 cases (13.7%) and cervicosternothoracotomy in 2 cases (3.9%). The 8 migrated mediastinal goiters were removed via sternotomy in 6 cases, cervico thoracotomy in 1 and thoracotomy in 1. This latter approach was also used for the 2 ectopic goiters. The goiter presented signs of neoplastic degeneration in 2 cases (3.2%). Postoperative complications were: recurrent nerve palsy in 5 cases (1 bilateral definitive, 1 monolateral definitive, 3 monolateral transient), respiratory failure in 2, mediastinal hematoma in 1 and hypocalcemia in 8 (transient in 6). There was one postoperative death due to cardiorespiratory failure after cervicosternotomy. Surgical excision of substernal goiters is the best choice of treatment in view of the very low postoperative mortality and morbidity.