Background: Reoperation for locally recurrent papillary thyroid cancer (PTC) is technically difficult and associated with higher morbidity. This study evaluated the use of same-day ultrasound guidance (SDUS) as an adjunct. Methods: We compared 2 cohorts of consecutive patients with a single impalpable focus of recurrent PTC. Group I (August 2001-January 2004) was explored based on results of imaging. Group II (April 2004-January 2007) had an additional SDUS, performed before incision with indelible skin marking directly over the lesion. Outcome measures included failure to resect, lesion size, and postoperative change in thyroglobulin. Results: In group I, in 3 of 6 cases the surgeon was unable to find the preoperatively imaged focus. By contrast, all 19 group II patients had successful resection of the lesion facilitated by SDUS (P < .01). SDUS resection was more likely to succeed even though group II lesions were smaller (mean 17 vs 11 mm; P = .009). Mean operative times did not differ but morbidity was lower (P < .01) in group II. Postresection serum thyroglobulin levels dropped to undetectable in 50% of evaluable cases. Conclusions: When focused resection of recurrent PTC is considered appropriate, SDUS guidance is an efficient and useful adjunct, allowing resection of lesions as small as 6 mm.