Recurrence after conservative resection of pleomorphic adenoma is a rare and late phenomenon that poses a difficult management problem. All recurrences at 6 years after capsular dissection were detected clinically (recurrence rate 3.2%). Magnetic resonance imaging failed to detect early occult recurrences after conservative surgery and thus a “single shot” imaging modality for follow up is not recommended. Regular ultrasound and magnetic resonance imaging have been used after surgery for early detection of a recurrence. The pickup rate is low so the additional cost and effort of radiological surveillance is not justified. Follow up after parotid surgery for pleomorphic adenoma remains clinical. There may be a benefit in regular surveillance imaging of high risk patients (prior enucleation or resection after recurrence).