Patients with persistent or recurrent trigeminal neuralgia (TN) after microvascular decompression (MVD) are frequently difficult to manage. This study aimed to analyze the safety and efficiency of repeat MVD, with the main focus on prognostic factors and long-term outcomes.We performed a retrospective study of 41 TN patients (19 men, 22 women) who underwent repeat MVD due to persistent or recurrent pain from January 2008 to January 2016. These patients were followed up from 12 to 96 months (mean, 42 ± 17.3 months). Univariate analysis by Spearman's rank correlation coefficient was used for analysis of prognostic factors.During the repeat MVD, compression of the trigeminal nerve was noted by an artery in 15 patients (36.6%), vein in 6 patients (14.6%), Teflon in 8 patients (19.5%), and no compression in 12 patients (29.3%). Twenty-one patients (51.2%) had already undergone 1 or more previous ablative procedures, either before the first MVD or between the surgeries. The complete pain relief rates of repeat MVD were 87.8% immediately after surgery and 75% at last follow-up. Thirteen patients (31.7%) had new or increased facial numbness after repeat surgery. Univariate analysis revealed 2 prognostic factors, negative finding during reoperation (P = .021) and no pain relief after the initial surgery (P = .038), that showed a negative influence on success rates after repeat MVD.Repeat MVD can still achieve an excellent outcome in patients with persistent or recurrent pain. However, the risk of facial numbness is increased. Surgeons should be selective in performing repeat MVD, priority should be given to patients who have a pain-free interval after initial MVD or show demonstrable compression on imaging studies.