Background: The long-term outcomes of total facial nerve decompression (TFND) in severe idiopathic recurrent facial palsy (IRFP) are still unknown.Aims/objectives: To explore the long-term follow-up results of TFND in IRFP.Materials and methods: Twenty-eight patients suffering from severe IRFP were enrolled. Patients were offered conventional therapy or TFND and were categorized into control or operation group. The follow-up lasted for at least 6 years. Comparison was made in terms of relapse of facial palsy as well as outcomes of facial nerve.Results: There were 16 participants in operation group, whose follow-up lasted for 10.4 ± 1.3 years. In contrast, there were 12 participants in control group, who were followed up lasted for 11.2 ± 1.2 years. No participants suffered relapse in the operation group while seven out of 12 participants (58.3%) encountered relapse with regard to control group (p < .05). In terms of facial nerve results, 16 out of 18 participants (88.9%) reached satisfactory outcomes of facial nerve (HB grade I or II) while only four out of 12 participants (33.3%) achieved satisfactory outcomes in control group (p < .05).Conclusions and significance: In terms of severe IRFP, TFND can defend patients from relapse in a long period, and enhance recovery of facial nerve.