Purpose To report a surgical approach to managing hypotropia associated with thyroid eye disease (TED) that uses adjustable sutures. Methods The medical records of consecutive patients with TED and hypotropia who underwent adjustable suture inferior rectus muscle recession with or without superior rectus muscle recession of the hypertropic eye were reviewed retrospectively. The initial goal was undercorrection in primary gaze and no hyperdeviation in downgaze. Outcomes were rated according to the presence of diplopia in primary and reading positions as excellent (none), good (no diplopia with <10Δ correction), and poor (diplopia). Results Fifty-four patients were included. The initial median primary position deviation was 16Δ. Of the 54 patients, 39 (72%) underwent unilateral inferior rectus muscle recession; 15 (28%), bilateral; and 24 (44%), superior rectus muscle recession. On mean follow-up of 38 weeks, 35 patients (65%) had excellent results (30 aligned in primary and reading position, 5 of whom could fuse small deviations [average, 3Δ]); 17 (31%), good results (13 < 6Δ); and 2 (3.7%), poor results, but aligned after reoperation (6Δ overcorrection, 16Δ undercorrection). Of the 24 misaligned patients (ie, those with small deviations, good results, and poor results), 13 were undercorrected an average of 4.9Δ and 11 (20%) were overcorrected an average of 6.2Δ. Adjustment timing, number of muscles recessed, preoperative deviation, and previous orbital decompression did not affect outcomes. Conclusions In this series, patients with hypotropia and TED were effectively managed by the use of adjustable sutures and by surgeons operating on multiple muscles, anticipating drift toward overcorrection of the recessed inferior rectus muscle, and using prism for residual deviation.