To describe recurrence patterns in patients with recurrent respiratory papillomatosis (RRP) following surgical intervention. Single-center, retrospective, longitudinal case series. Initial and follow-up laryngoscopic examinations of seven previously untreated adult-onset RRP patients were reviewed. Patients were followed longitudinally for periods ranging from 3 months to 7 years. Lesion locations were recorded using a twenty-one region laryngeal schematic, and maps were generated to illustrate the distribution of disease before and after cold-knife or potassium-titanyl-phosphate laser intervention. Univariate and multivariate analyses were employed to examine variables affecting recurrence patterns. Across all patients, a statistically significant correlation between initial distribution and primary recurrence was observed. Seventy-five percent of new lesions were adjacent to regions with preexisting disease; 83% of new glottic lesions were adjacent to preexisting glottic lesions, and 66% of supraglottic lesions were adjacent to preexisting supraglottic regions. No statistically significant differences in recurrence rate were observed across sites. In previously untreated patients with adult-onset recurrent respiratory papillomatosis, lesions tended to recur either in the same regions or regions adjacent to those affected at the time of initial surgery. 4 Laryngoscope, 129:1993-1997, 2019.