BACKGROUND: The hang-back loop suspension surgical technique for rectus muscle recession offers potential advantages over the conventional rectus muscle recession, including better exposure at the site of scleral sutures, shorter procedure duration, and lower risk of scleral perforation. Previous reports suggest that the hang-back technique for lateral rectus recession for exotropia results in poorer surgical success and may require a different surgical dosage. METHODS: We compared strabismus in a nonrandomized series of 55 children with exotropia treated with conventional surgery or hang-back surgery. Those in the hang-back (suspension) recession group were on average 2.5 years younger and had 8(Delta) more preoperative exotropia at distance. RESULTS: Surgical outcomes were not significantly different in the two treatment groups. Multivariate logistic regression suggests that outcomes are at least equivalent to conventional surgery after adjusting for age, severity, and other preoperative factors likely associated with outcome. CONCLUSIONS: The hang-back surgical technique was as effective as conventional lateral rectus recession surgery for children with exotropia.