Purpose: To compare functional and surgical outcomes of a subperiosteal midface lift with and without the placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction. Design: Retrospective, comparative, interventional case series. Participants: Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye Institute in a 5-year period. Methods: Medical record review of all patients who underwent surgery for lower eyelid retraction by a subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were taken in all patients. Main Outcome Measures: Change in margin reflex distance 2 (MRD2), measured from the pupillary margin to the upper margin of the lower eyelid; patient discomfort; and surgical complications. Results: Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a better lower eyelid position, with improvement of lower eyelid height of 1.4 mm (P<0.001, 1-sample t test). Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD2 postoperatively as compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm, respectively; P = 0.02, Wilcoxon Mann-Whitney). One patient needed reoperation secondary to symptomatic lower eyelid retraction postoperatively. Conclusions: The subperiosteal midface lift is effective in correction of lower eyelid retraction of various causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.