This study aims to investigate the operative efficacy, surgical complication rate, and surgical strategy of microvascular decompression (MVD) for hemifacial spasm (HFS).Clinical data of 46 patients with HFS who underwent MVD were retrospectively analyzed.During surgery, it was found that the facial nerve root exit zone was compressed by the following arterial vessels: anterior inferior cerebellar artery in 24 patients (52.17%); posterior inferior cerebellar artery in 14 patients (30.43%); vertebral artery and a small artery in 7 patients (15.22%); and vertebral artery in 1 patient (2.18%). Symptoms of 38 patients were immediately remitted completely after surgery and symptoms of 8 patients were significantly reduced. Main complications included dizziness and tinnitus in 9 patients, hearing loss in 5 patients, cerebrospinal fluid leakage in 1 patient, and infection in 2 patients. No patient died during surgery.MVD is the preferred choice for treating idiopathic hemifacial spasm, and hearing impairment is the main complication. Skilled microsurgical techniques, as well as identifying and completely decompressing offending vessels, are the key to ensuring a successful microvascular decompression.