Background: Hemifacial spasm (HFS) is a common disorder and has a significant impact on the quality of life. Microvascular decompression (MVD) is an effective and safe treatment option for patients with HFS, however the effectiveness and safety of MVD in elderly patients with HFS is not clear. Methods: We enrolled 699 HFS patients who underwent MVD from February 2008 to December 2011 at the Samsung Medical Center in Seoul, Korea. Subjects were divided into two groups: an elderly group (patients who were 60 years old or older) and a younger group. We compared demographic and clinical data, surgical outcome and complications after MVD between the groups. Results: The elderly group had more severe spasms and higher grade indentation than the younger group. Multiple offending vessels were more commonly detected in the elderly group. Although the improvement was similar 6 months after MVD between the groups, complications were more common in the elderly group even after controlling for possible confounding factors. In particular, ear problems including hearing loss were more common in the elderly group. Conclusion: MVD is an effective treatment option in elderly patients with HFS. However, surgeons should be pay attention to potential complications in elderly patients with HFS.