Again, it has been already pointed out that it is desirable to complete the operation on the lip simultaneously with the reposition of the median projection; the effect of this more serious step is manifestly to increase the shock to the little patient, who is probably not in the most vigorous condition of health from its inability to take nutriment in the usual way, and at any rate renders the occurrence of primary union less likely. This fact may perhaps explain the much higher death-rate after operation amongst German surgeons than in this country. The prominent condition of the under lip (Fig. 75, p. 147) can be remedied later on by excising a 𝖵-shaped portion from its centre, resulting in marked improvement to the facial expression, especially in patients operated on after infancy. To my own mind the disadvantages of the retention of the incisive bone so clearly outweigh the _prima-facie_ advantages, that in my practice I have followed the usual course adopted by the majority of British surgeons in removing the bone at the earliest opportunity. By this removal the operation on the lip can be more successfully accomplished, and as regards the profile effect the later introduction of a dental plate with artificial incisors will greatly improve the appearance, and enable the patient to bite in a satisfactory manner, far more so, in fact, than with the mobile os incisivum. After removal of the bone and union of the lip, the approximation of the maxillæ to one another has been repeatedly observed and accurately noted. Whether this is due to the insensible pressure of the united lip or to increased osseous development is a matter of but slight importance; probably both agents contribute to this desirable effect. If, however, the maxillæ are considerably drawn together, the “bite” or dental adjustment between the upper and lower jaws becomes uneven, _i. e._ the upper teeth fall within the lower so that during mastication, side-to-side movements of the mandible, as seen in horses and cows, become needful. After the child has recovered from this preliminary operation of extirpation of the incisive bone, and the raw surface left by its removal has cicatrised, the soft parts of the lip are then dealt with. This cannot be well undertaken before the tenth to the fourteenth day. The operation, so far as the lateral segments are concerned, should be carried out according to the principles enunciated for the single harelip operation. A free detachment of the lip from the maxillæ by undercutting should be the first step, and this must be accomplished thoroughly in these bilateral cases. The edges will then require preparation by curved incisions made from above downwards as far as the muco-cutaneous junction, and then prolabial flaps are formed by cutting upwards and inwards at an angle of 60° to the preceding (Fig. 54 A).