Several methods for correcting a severe varus deformity during total knee arthroplasty (TKA) have been reported. The tibial subperiosteal stripping of the superficial medial collateral ligament (MCL) can often lead to excessive release. Traditional pie-crusting of the superficial MCL using a blade also can lead to excessive release (iatrogenic transection). We established a selective and sequential medial release technique using the pie-crusting method with multiple needle punctures and investigated the effectiveness and safety of the technique during primary TKA. The deep MCL was released during exposure. Medial tightness in extension was balanced by release of the posterior portion of the superficial MCL and the structures of the posteromedial corner first. Next, medial tightness in flexion was balanced by pie-crusting with multiple needle punctures of the anterior portion of the superficial MCL with the trial implant or gap block in situ. Eighty-eight knees with varus alignment of =15° were effectively balanced with our technique. There were no complications, that is, no hematoma formation, conversion to a constrained implant, or late instability. The selective and sequential technique described was safe, reproducible, and effective in treating severe varus deformity during primary TKA.