The primary functional support for the medial eyelid is from the deep attachments of the orbicularis muscle to the posterior lacrimal crest and lacrimal diaphragm. A dehiscence of the deep medial canthal attachments can alter the position of the lower eyelid with subsequent tearing, medial ectropion, and ocular exposure. In this study, medial palpebral tendon reconstruction was performed on seven lower eyelids with medial instability or ectropion and a dehiscence of the medial palpebral tendon. A periosteal flap left attached to the posterior lacrimal crest was used to replace the attenuated or absent medial palpebral tendon. After a mean follow-up of 7 months, 86% (6/7) of the eyelids had acceptable cosmetic and functional results. The use of a periosteal flap to replace a dehiscence of the medial palpebral tendon has several advantages. The periosteal flap is readily available, strong, and autogenous. The lower eyelid and punctum are pulled tightly against the globe. Lastly, the procedure may be repeated or combined with other ectropion procedures.