Medial ectropion of the lower lid responds poorly to standard ectropion procedures. This region contains the initial parts of the nasolacrimal excretory system, which must be functionally reestablished. A new surgical approach to medial ectropion consists of a Z-plasty transposition skin flap from the upper to the lower lid, a plication of the lower crus of the medial canthal tendon, and a punctoplasty. The posterior and superior contraction forces in the transposition flap enhance and maintain the result. Seven lids have been successfully operated on with this technique from the functional and cosmetic point of view.