Large multinodular goiters can present as challenging surgical dilemmas. We present a 33-year-old female with a massive thyroid goiter compressing the trachea and extending below the aortic arch. She underwent resection using a medial approach thyroidectomy. The isthmus was transected and the right thyroid lobe exposed first. The thyroid lobe was rotated laterally to expose the medial tracheal attachments. The superior-medial and all of the inferior portions of Berry's ligament were divided, which allowed reflection of the right lobe superiorly and medially, leading to identification of the right RLN more laterally and deeply. The nerve was then traced as it entered the larynx. The remaining superior-lateral Berry's ligament was divided and the superior right lobe delivered from the neck.The left lobe was also approached in a medial-inferior fashion. After identification of the left RLN medially and transection of Berry's ligament away from the RLN, the left thyroid lobe with its substernal extension was delivered from the neck and mediastinum with minimal deep neck and mediastinal dissection. PTH and ionized calcium levels throughout the perioperative period were normal. The patient tolerated the procedure without postoperative hoarseness or hypocalcemia. Although large thyroid goiters with substernal extension are technically challenging, initial medial approaches can facilitate exposure and once the thyroid is no longer attached to the trachea, the substernal component can be delivered with minimal deep neck or substernal dissection. This technique can serve to minimize patient morbidity and reduce inpatient hospital stay from extensive neck and mediastinal dissection.