This study compared perioperative and oncological outcomes between modified subxiphoid video-assisted thoracoscopic surgery (VATS) thymectomy and median sternotomy thymectomy for locally advanced thymic malignancies. A propensity score–matched analysis of 144 patients revealed that the VATS approach resulted in shorter operative duration, less blood loss, faster recovery, and fewer complications, with no significant difference in complete resection rates. Survival analyses indicated similar recurrence-free and overall survival between the two groups. These findings suggest that modified subxiphoid VATS thymectomy is a safe and effective alternative for selected patients, although further prospective studies are needed for long-term evaluation.