2. When the fissure, though single, extends upwards into the nose, the operation is more difficult, and the result frequently less satisfactory. The first thing to be done is to separate the lips from the gums, so as to make them more freely mobile. The whole edges of the cleft require refreshing. 3. _Double Harelip_, without bony deformity, and where the intervening portion of the skin is vertical, does not project, and can be made useful for the new lip. Such cases are not very common, but when they do occur the question arises, How are they to be managed--in two separate operations or at once? I believe, in every case, at once. The central wedge-shaped portion is not large enough to extend downwards as far as the prolabium, but still should not be removed altogether, as it may be of great use, especially in bearing the columna nasi, and allowing its full development. The edges should be pared in the same way, and to the same extent as in single harelip, with the addition that the intervening portion should have its edges completely removed, and be left in the form of a wedge, with its apex downwards. The highest suture should be passed through first one side, then the base of the wedge, and then the other side; the second one through both, and the apex of the wedge; and a third should unite the prolabium, not including the wedge. [Illustration: FIG. XXV.[105]] 4. _Double Harelip_ combined with fissures of the hard palate, and projection of a central bone. This is the analogue of the inter-maxillary bone in the lower animals, and bears the two middle incisor teeth, and projects very variously in different cases. In some it projects horizontally forwards in the most hideous manner, in others it lies at an angle more or less oblique; in very few does it maintain its proper position; when projecting forwards, and as the teeth also share in its projection, it entirely prevents approximation of the edges of the fissures by operation, so it must first be dealt with in one of two ways, either-- [Illustration: FIG. XXVI.[106]] (1.) It may be at once removed with bone-pliers, the piece of skin over it being saved. This is the best that can be done in cases of old standing after the first year or two, though attempts have been made to break the neck of the projecting portion, and thus permit of its being shoved back. (2.) By gradual pressure by a spring truss, strapping, or a bandage, it may be forced back. This is possible only in cases where the deformity has been comparatively slight, and the patient has been seen early. The edges must then be pared and approximated as directed above. One or two points about the operation for harelip require a special notice:-- 1. _When to operate._--Great differences in opinion exist. Some say not before two or three years, others within two or three days, or even _hours_, after birth.