Reappearance of symptoms of cranial nerve dysfunction is not uncommon after successful microvascular decompression (MVD). The purpose of this study was to report two quite unusual cases of recurrent and newly developed hemifacial spasm (HFS) caused by a new conflicting artery more than 20 years after the first successful surgery. In Case 1, the first MVD was performed for HFS caused by the posterior inferior cerebellar artery (PICA) when the patient was 38 years old. After 26 symptom-free years, HFS recurred on the same side of the face due to compression by the newly developed offending AICA. In Case 2, the patient was first operated on for trigeminal neuralgia by transposition of the AICA at 49 years old, but 20 symptom-free years after the first MVD, a new offending PICA compressed the facial nerve on the same side, causing HFS. These two patients underwent reoperation and gained satisfactory results postoperatively. Reappearance of symptoms related to compression of the root exit zone (REZ) by a new offending artery after such a long symptom-free interval since the first effective MVD is rare. Here, we describe two such unusual cases and discuss how to manage and prevent such reappearance of symptoms after a long time interval.