Recurrent thyroid carcinoma is relatively common, yet few guidelines exist to aid in surgical disease management. In this course, we will discuss the pre-surgical work up of patients requiring repeat surgery with emphasis on the common locations of disease involvement. The anatomic relationships in the paratracheal space and upper mediastinum will be reviewed. Management of the strap muscles, recurrent laryngeal nerve, trachea, larynx, esophagus and major vessels will be addressed. Multiple ways to approach and identify relevant anatomy will be reviewed with applications to both revision surgery and complex initial surgery.