Recurrent pain after microvascular decompression (MVD) in trigeminal neuralgia is an inevitable fact in a subset of patients that neurosurgeons have to face despite meticulous surgical technique. This phenomenon, its epidemiology, and possible etiological factors have been described in the literature, but there is no consensus on the best treatment in such a scenario. Posterior fossa re-exploration is an effective and safe surgical modality that enables a tailored approach to the responsible factors for recurrence. Indeed, such a patient-specific proceeding avoids manipulation of the trigeminal nerve, such as pinching or combing, lowering the risk for hypesthesia. Posterior fossa re-exploration may provide pain relief in the majority of patients also at long-term, comparable to index case surgery. In this chapter, we present an overview of recurrence after MVD and describe surgical techniques for posterior fossa re-exploration and its outcome.