Background: It is our hypothesis that the extent of thyroid resection for benign nodular thyroid disease (NTD) should be based on the extent of disease. Methods: Patients operated on for benign NTD from 1990-2007 were divided into three groups, those who underwent lobectomy for unilateral NTD (Group 1), near-total or total thyroidectomy for bilateral NTD (Group 2), and reoperation for NTD initially treated at other institutions (Group 3). The incidence of recurrence was determined for Groups 1 and 2 and the timing of diagnosis was compared to Group 3. Potential risk factors for recurrent disease were examined. Results: 511 patients were operated on for benign NTD. Contralateral disease was excluded in Group 1 patients using ultrasound (45%) and/or intraoperative palpation. Five (2%) of 246 patients in Group 1 and one (0.4%) of 230 patients in Group 2 developed recurrent NTD after 8 / 5 and 4 yrs compared to a mean 19 / 11 yrs for the 35 patients in Group 3 following one to three previous thyroidectomies. Recurrent disease was diagnosed by physical exam in 22 (54%) and imaging in 19 (46%) patients. Thyroid hormone was required for post-surgical hypothyroidism in 70 (28%) patients in Group 1. Patients with recurrent disease were younger (38 / 18 yrs vs. 50 / 15 yrs, p 0.05), had a higher body mass index (BMI) (33.3 / 7.3 kg/m vs. 30.6 / 8.0 kg/m, p 0.05) and were more often African American (42.5% versus 34.7%, p 0.05). Conclusion: Thyroid lobectomy is optimal therapy when benign NTD is limited to one lobe, as evidenced by a 2% recurrence rate and maintenance of euthyroidism in 72% of patients. When NTD is bilateral, total thyroidectomy is indicated to eliminate recurrence, underscoring the importance of routine preoperative ultrasound. Young age, African American race and increased BMI are risk factors for recurrent NTD and warrant more aggressive follow up.