An 11-year-old girl underwent left levator excision and fascia lata brow suspension for Marcus-Gunn jaw-winking ptosis. The SO tendon was inadvertently cut when the levator palpebrae superioris was severed above the Whitnall ligament, and repair was attempted during the procedure. She visited 1 week later with vertical and torsional diplopia associated with a right head tilt and face turn to the right side, and she was found to have signs consistent with left SO palsy. Strabismus surgery was performed 1 year after the procedure; preoperatively, she had a left hypertropia of 20 prism diopters (PD), which increased to 25 PD on both right gaze and left tilt (Figure 1). This hypertropia increased significantly from upgaze (5 PD) to downgaze (25 PD), and there was a V-pattern with 8 PD of exotropia on upgaze and 8 PD of esotropia on downgaze. Motility examination showed SO underaction of −3 and IO overaction of +4 in the left eye. Testing of subjective torsion using double Maddox rod showed excyclotropia of 8° in primary position, which increased to 14° on downgaze. The left IO was transposed nasal to the inferior rectus muscle, with its posterior border reattached to the sclera 2 mm below the medial rectus insertion and the anterior border reattached 2 mm nasal to this point (Figure 2C). Postoperatively, the abnormal head posture was corrected. She was orthophoric in both primary position and downgaze, although there was a 6-PD left hypotropia on upgaze with limitation of elevation, more in adduction (Figure 2A and D). She was diplopia free except in upgaze, and the excyclotorsion was eliminated in primary position, with excyclophoria of 3° only in downgaze (Figure 2B). These results were stable at 11 months.