Superior oblique muscle palsy (4th cranial muscle palsy) is the most common acquired Extraocular muscle weakness and the most common Extraocular muscle palsy responsible for vertical strabismus and abnormal head position.Yet its surgical treatment is controversial.Some prominent Strabismus surgeons in the past have advocated only a simple stepwise approach to this condition consisting of weakening of the ipsiLateral inferior oblique followed bV recession of the contralateral inferior rectus for any residual hyperdeviation.Unfortunately this algorithm often is not ideal and does not optimally correct the torsional component or torticollis present in many patients At the UniversitY of Michigan we have developed an improved approach to patients with superior oblique palsy of different etiologies that results in improved functional and cosmetic results with fewer procedures This presentation will present this improved approach and emphasize how it can be used to treat all patients with this problem.Step by step surgical slides will be also be presented to illustrate the techniques required to accomplish this improved result and how to select the optimal technique for each patient.