Injury to the recurrent laryngeal nerve (RLN) is a known complication of thyroid surgery that can have a significant impact on a patient’s quality of life. Primary repair is recommended in the setting of a transected RLN identified during thyroid surgery and is the only management strategy that prevents muscle atrophy and preserves muscle tension and bulk, resulting in long-term vocal improvement. Primary repair alone should not be performed if immediate vocal improvement is desired, given the recognized delay in vocal outcomes associated with primary repair. There are no vocal outcome or safety differences among re-innervation techniques, and technique selection should be dependent on anatomic limitations and surgeon expertise. Limited data suggest that primary repair be recommended for younger patients, and used with caution in older patients.