Purpose: Unilateral long-standing superior oblique palsy may lead to superior rectus overaction/contracture requiring surgery of multiple extraocular muscles to correct the hypertropia. We review our technique of tucking the superior oblique combined with immediate postoperative adjustable suture recession of the ipsilateral superior rectus. Methods: Twelve patients during the course of 2.5 years with longstanding vertical diplopia unrelated to closed head trauma or systemic disease who underwent our surgical technique were identified. The hypertropia in all patients was largest across the lower field (Knapp class 5) or nasal and lower fields (Knapp class 4). Outcome measures were primary-position hypertropia and vertical diplopia. Results: The mean preoperative hypertropia in primary gaze measured 17.8 PD (range, 4 to 30). The mean 2-week postoperative vertical deviation was 1.3 PD (range, 4 PD hypotropic to 6 PD hypertrophic). The mean 6-week postoperative vertical deviation was 1.9 PD (range, 2 PD hypotropic to 12 PD hypertrophic). Diplopia in primary and down gaze, which was universally present before surgery, resolved in 11 of the 12 patients (92%). Conclusions: This combination of procedures appears to be a highly successful choice for treatment of unilateral long-standing superior oblique palsy. Advantages for both patient and surgeon include adequate exposure through a single conjunctival incision, elimination of risks to the contralateral eye, and immediate intraoperative suture adjustment of the ipsilateral superior rectus.