BACKGROUND Therapeutic options for treatment of hyperthyroidism caused by Graves' disease remain controversial. There are three main options: thiourea drugs, radioactive iodine ablation, and thyroidectomy. Each treatment has significant advantages and potential problems. METHODS The present study is a retrospective analysis of our experience with total thyroidectomy in Graves' disease. Sixty-two patients underwent this procedure in 11 years' time and were followed for a minimum of 2 years after surgery. All had measurement of total thyroxine, T3 uptake, and radioactive iodine (RAI) uptake and scanning. Sixty-three percent of all patients had some element of hyperthyroid eye signs. All patients were rendered euthyroid with pharmacologic therapy prior to surgery. Postoperatively, the patients were evaluated for improvement in eye signs, incidence of recurrent laryngeal nerve injury, and hypoparathyroidism. RESULTS None of the patients in this study have developed recurrent hyperthyroidism. All patients are maintained on levothyroxine. None of our patients incurred bilateral vocal cord paralysis. One patient (1.6%) demonstrated an immobile vocal cord more than 1 year following surgery. Ten patients (16%) demonstrated impaired mobility of one vocal cord in the immediate postoperative period. Nine of these patients recovered full vocal cord mobility within 6 months after surgery. Only one patient (1.6%) still required calcium and vitamin D therapy 1 year following surgery. However, in the immediate postoperative period, 23 patients (37%) required supplemental calcium and vitamin D. In 12 patients, calcium and vitamin D was discontinued within 1 month. In an additional 6 patients, calcium and vitamin D were discontinued within 4 months; 3 patients, within 6 months; and 1 patient, within 12 months after surgery. Incidental papillary carcinoma was found in 3 patients (5%). CONCLUSIONS Total thyroidectomy for Graves' disease is an effective and safe therapy. When performed by an experienced head and neck surgeon, it carries a low morbidity rate. It should be presented to patients as a therapeutic option within the context of a comprehensive discussion of the risks and benefits of radioactive iodine, pharmacologic therapy, and surgery.