Initiating primary reconstruction after abrative surgery for head and neck malignancy using free flap transfer on 1974, we applied the same technique of microvascular anastomosis to the repair of the recurrent laryngeal nerve (RLN) in 1975. The first application of RLN reconstruction was for a patient suffering from papillary thyroid carcinoma invading RLN just at the laryngeal entrance. Since then, more than 140 RLNs were repaired under microscope using 10-0 monofilament nylon suture. End-to-end, nerve transplantation, or anastomosis to the ansa cervicalis were performed resulting in similar acceptable outcome. RLN was reconstructed even in the larynx. The average mean maximal phonation time (MPT) after 5 months was 14.7sec. The results, together with strategy for bilateral RLN palsy resulting as the drawback of RLN repair, will be presented.